“Insanity is doing the same thing and expecting a different result.” – Not Albert Einstein
If you’d ever like to thoroughly confuse and frustrate yourself, I recommend conducting some internet research on the concept of change. You’ll be taught that the only constant in life is change while you also learn that no one really changes. You’ll learn that change is stressful, and you’ll be shown how freeing change can be. If you google “change is easy”, you’ll have 5.2 billion results to read. If you google, “change is hard”, you’ll only have 4.9 billion results to review.
While this exercise certainly will not bring you any clarity, what does seem clear is that we just don’t know how to feel about change. We certainly want things to improve, but we seem to be very divided on whether change is worth the effort. Even if we determine that the cure won’t be worse than the disease, we then face the completely undefined task of how to change. This is true on a personal level and it is especially true in larger systems as well.
Change and Behavioral Health
The field of Behavioral Health (industry shorthand for Mental Health and Substance Abuse services), has wrestled with the idea of change for its entire history. In the 1840’s, Dorthea Dix lobbied for better living conditions for the mentally ill and successfully convinced the United States to fund 32 state psychiatric hospitals (1). This formalized the institutional inpatient care model, in which many patients lived in hospitals and were treated by professional staff.
Institutional inpatient care was considered the gold standard model of care for over 100 years. However, due to funding reductions and the realization that many of these asylum settings were serving to traumatize patients via isolation, harsh living conditions, and human rights violations, the institutional inpatient model was gradually replaced by a push for deinstitutionalization and outpatient treatment (2). This shifted the setting for care and the burden to community-based settings.
With institutions coming under attack and deinstitutionalization offering mixed results, what exists today is a system of transinstitutionalization where traditional isolated settings, administratively supervised outpatient settings, and social systems such as the criminal justice system are completely isolated but functionally interdependent (3). That is incredibly complex and difficult to describe. Can we imagine how overwhelming it must be to attempt to receive care in such a system? Maybe that is why on June 2, 2018, the New York Times described the current community-based mental health system is a “colossal failure.”
Like the mental health systems described above, systems of care for Addiction and Substance Abuse issues have also struggled to decide how to best help those in need. The issue of dealing with Addiction is essentially timeless. It is said that the first American essay on alcoholism was Anthony Benezet’s Mighty Destroyer Displayed from 1774. However, there is evidence that Native American tribes organized “sobriety circles” for generations prior to Benezet’s work (4). And if we are discussing original publications of addiction, what do we make of biblical passages such as Proverbs 23:20 which states, “Do not join those who drink too much wine or gorge themselves on meat, for drunkards and gluttons become poor, and drowsiness clothes them in rags.” Could that be the very first “just say NO” public service message?
If our awareness of the dangers of substance abuse is longer than our awareness of mental health issues, our attempts to offer change to those suffering is much shorter. Until recently, your options for Addiction treatment included hospitalization and self-help groups such as Alcoholics Anonymous and Narcotics Anonymous. Alcoholism wasn’t even defined as a disease until 1956. Addiction wasn’t even classified as a disease until 1987 (5). For the first 3 years, if Jeopardy host Alex Trebek had said “Drug Addiction is a disease” and you answered “True”, you would’ve lost!
Do We Actually Need More Change?
That’s a great question and I’m glad I asked it. Too often, people rush through the evaluation of the need for change and jump right into the millions of theories about how to change. With 5.2 billion articles telling you how easy it is to change and 4.9 billion articles telling you how difficult it will be, it seems prudent to evaluate whether we even need to embark on such a disconnected and confusing journey.
Entering “should I make a change” into google yields 8.2 billion results. That may be too many to review here so perhaps we should condense the evaluation down to 3 core questions:
- Is this a problem worth solving?
- Is what is currently being done working?
- Are there better options available?
Is this a problem worth solving?
On the surface, this may seem like a cold or impersonal question. This country has 43 million people who suffer from mental illness every year. It also has 10 million people who suffer daily from mental illnesses that are so debilitating and severe that these individuals cannot function (6). These numbers do not even include the 21.7 million people in the country who needed substance abuse and addiction treatment last year (7). It seems obvious that we have a problem that is so widespread and impacts so many lives that it demands better solutions.
One potential counter consideration comes to us from systems researcher Russell Ackoff who advises, “We fail more often because we solve the wrong problem than because we get the wrong solution to the right problem.” So, the question isn’t whether it is right to solve the problem of better behavioral healthcare. The question is whether better behavioral healthcare is the right problem to solve. To answer that, we must consider the second question first.
Is what is currently being done working?
For individuals, this may be the easiest question to answer. If you are someone who has battled addiction, gone through treatment, and now lives a happy and healthy life free from the influence of drugs, you will say that current methods do work. You will say that they saved your life. If you have stood by someone and loved them as they worked with a therapist to cope with anxiety or depression and have seen the remarkable changes that can take place, you will absolutely say that therapy saves lives. If you, or someone you love have participated in current systems of care and successfully improved, you will gladly support the work that is being done and maybe could not imagine your life without that support. All these individuals would be correct and each of these individuals would be in a significant minority.
The inconvenient truth of the behavioral health industry is that current methods do not produce lasting positive change for most people they serve.
People with serious mental illness account for a disproportionate share of suicides, homelessness, violence, and incarceration. 2 million mentally ill people go untreated every year. (8). Adults in the U.S. living with serious mental illness die on average 25 years earlier than others. An estimated 46% of homeless adults live with severe mental illness and/or substance use disorders. 70% of youth in juvenile justice systems have at least one mental health condition Approximately 41% of all prisoners have “a recent history” of a mental health condition (9).
Perhaps the most damning statistics of all are that despite the time, effort, and money, spent of raising awareness and reducing the stigma surrounding mental health, the percentage of adults with serious psychological distress who report seeing or talking to a mental health professional has declined. 42% in 2012, and 34% in 2018 (10). Additionally, there are 112 million people who currently live in underserved areas (defined by a ratio of 20,000 in need to every 1 provider). Only 27% of total Mental Health needs are currently being met (13).
Treating addiction and substance abuse disorders is not going much better. The 2015 National Survey on Drug Use and Health (NSDUH) data indicated that 8.1 percent or 21.7 million people aged 12 or older needed substance use treatment in the past year. Of those 21.7 million, only an estimated 2.3 million people aged 12 or older who needed substance use treatment received treatment at a specialty facility that year. This number represents 10.8 percent of the 21.7 million people who needed substance use treatment in the past year (11). This means that 19.4 million people who needed substance abuse treatment in one year, never even walked through the doors of a place where they could receive help.
Of course, entering treatment is just the first step in achieving sobriety. Successful completion of that program would be another step with sustained sobriety being the goal. So how did those 2.3 million people who needed and received substance abuse treatment fare? Only about 30% of those individuals remained clean and sober 6 months after completing their treatment (12).
This means that, each year, a group of people approximately the same size as the state population of Florida (our 3rd most populous state) needed substance abuse treatment. Each year, a group of people approximately the same size as the city population of Houston received substance abuse treatment. Six months after this treatment, a group of people approximately the same size as the number of people who attended the 8 Dallas Cowboys home football games last year were still sober. Well, the Cowboys saw 30,000 more people pass through their gates than people who remained sober, but the point remains.
Are there better options available?
Thankfully, perhaps mercifully, there are promising behavioral healthcare practices that have emerged. These successful approaches to care include prevention strategies, practice-based interventions that produce consistent success, and entirely new systems of care that have demonstrated the ability to reduce barriers to care and facilitate success. Perhaps chief among these emerging practices is the concept of Integrated Care.
While substance abuse, mental health, primary health, and psychopharmacology treatments have traditionally operated in separate but related systems, Integrated Care providers merge all these services into one system of care designed to meet patient needs with maximum collaboration while minimizing traditional barriers to care. In an Integrated System of Care, one agency meets each of these patient needs while benefiting from real time coordination of care and seamless treatment planning.
The Surgeon General’s Report on Alcohol, Drugs, and Health found Integrated Care for primary care, mental health, and substance use-related problems to produce the best outcomes and provide the most effective approach for supporting whole-person health and wellness (14). The Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources and Services Administration (HRSA), along with the National Council for Behavioral Health have stated that , “the solution lies in integrated care, the systematic coordination of general and behavioral healthcare. Integrating mental health, substance abuse, and primary care services produces the best outcomes and proves the most effective approach to caring for people with multiple healthcare needs” (15).
To review, we now know that improving behavioral healthcare services is a problem worth solving and the right problem to solve because the 43 million people currently suffering from Mental Health issues and the 21.7 million people currently fighting Addiction issues deserve better help than they have received. We know that we can do better because while individuals have turned their lives around under the current disconnected systems of care, those individuals are in the minority and their successes need to be replicated more often. Finally, we have a PATH to reliable and consistent success that shows great promise in Integrated System of Care.
We encourage you to review our website at www.pathihc.com to see what PATH Integrated Healthcare s doing today to ensure patient successes tomorrow. We also recommend that you look for future articles from The PATH that explore the concept of Integrated Systems of Care in greater detail.
1 – PBS Online’s “Timeline: Treatments for Mental Illness”. Retrieved February 10, 2020.
2 – Novella, E.J. (2010). Mental health care and the politics of inclusion: a social systems account of psychiatric deinstitutionalization. Theor Med Bioeth, 31: 411-427.
3 – Prins, S.J. (2011). Does Transinstitutionalization Explain the Overrepresentation of People with Serious Mental Illnesses in the Criminal Justice System? Community Ment Health J, 47: 716-722.
4 – http://www.williamwhitepapers.com/pr/AddictionTreatment&RecoveryInAmerica.pdf
5 – https://www.ncsbn.org/Understanding_the_Disease_of_Addiction.pdf
6 – https://mentalillnesspolicy.org/
7 – https://www.samhsa.gov/data/sites/default/files/report_2716/ShortReport-2716.html
8 – https://mentalillnesspolicy.org/
9 – https://www.nami.org/learn-more/mental-health-by-the-numbers
10 – https://www.healthsystemtracker.org/chart-collection/current-costs-outcomes-related-mental-health-substance-abuse-disorders/#item-eighteen-percent-adults-united-states-mental-behavioral-emotional-disorder
11 – https://www.samhsa.gov/data/sites/default/files/report_2716/ShortReport-2716.html
12 – https://americanaddictioncenters.org/rehab-guide/success-rates-and-statistics
13 – https://www.kff.org/other/state-indicator/mental-health-care-health-professional-shortage-areas-hpsas/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
14 – https://www.ncbi.nlm.nih.gov/books/NBK424848/
15 – https://www.integration.samhsa.gov/about-us/what-is-integrated-care
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