Access to Care Should Be Our Field’s Top Priority

Our gap in access to care exceeds that of other fields in healthcare. It may be our most fundamental problem. Effective treatments are useless for people who cannot receive them. Poor access in our field derives from many sources. Three key drivers deserve special attention: social stigma, subspecialty barriers, and social injustice. Every clinician and executive should be focused on our access problem.

Some people are unconvinced by statistics. Statements from prominent people are more persuasive for them. The CEO of one of the country’s largest healthcare systems made a simple statement: “there’s an alarming gap between the number of people who experience mental illness and those who receive care.”

Alarming is a fitting word, but it is noteworthy that he omits reference to substance use disorders (SUD) in his warning. This is a surprising oversight given that fewer than 20% of people in need get SUD treatment. Yet it reflects our field division into subspecialties. For example, the popular rallying cry, “no health without mental health,” should be, “no health without behavioral health.” We are one field.

There are multiple drivers for poor access in our field, but stigma is a powerful, insidious force suppressing access through shame. It is a durable impediment that merits a collaborative effort by our field, including mental health and SUD specialists. It requires a comprehensive plan, well beyond current efforts to replace moralistic with medical thinking. It is much more than a conceptual problem.

Gaps in the quality of care are often identified as departures in practice from established standards or evidence-based approaches. Yet our field has a glaring and widely prevalent quality gap that is rarely discussed. The troubling reality is that a majority of our clinicians think of themselves as mental health therapists with scant knowledge of SUDs.

This deficiency has long been accepted in our field based on history and tradition. It means many people starting therapy for mental health issues are unlikely to have their therapist recognize burgeoning SUD issues. This is a gap in quality that is essentially a gap in access. These people may find care, but not getting a critical issue addressed as needed is comparable to no care for that issue.

A similar problem is more aspirational than historical in nature. Behavior change is the essential remedy for many patients with chronic health conditions like diabetes and heart disease. Nutritionists and other health coaches have value, but these patients often need someone skilled in behavior change to help modify their unhealthy behaviors.

These patients need access to a therapist, though not necessarily formal therapy. Advice on diet and exercise is insufficient for many. They need access to clinicians with unique skills, and such access is difficult today. A good solution is to make health behaviors core to our field. Our clinicians would then routinely focus on the interconnections between mental health issues, SUDs, and health behaviors.

Poor access to care is not equally distributed. We find wide disparities linked to social groups. The Healthy People 2020 framework illuminates this. This government report reveals how health differences are closely linked with social, economic, and environmental disadvantage. It shows how disparities or inequities impact groups “who have systematically experienced greater obstacles to health.”

Social injustice of this sort ultimately requires social change, and yet we can also make changes at the client level. Clinicians can learn to eliminate hidden bias in decision-making. A recent medical study showed this by having physicians discuss treatment options in a small group, using the technique “networked collective intelligence.” It demonstrates how to remove subtle bias at the clinical level.

Derald Sue and colleagues have published 8 editions of their definitive handbook on multicultural counseling and therapy. Social justice can take root in our work as we become aware of how social factors have shaped each client’s experience, as well as our own views. Similarly, executives can hire from underrepresented groups and implement steps to end stigma.

While everyone has a role to play in addressing access to care, executives might best take the lead on this priority. It is largely an executive function to grow our institutions, and it entails more than standard sales and marketing. Executives would be well served to confront the social forces suppressing access, highlight the social determinants of health, and widely promote our many treatment solutions.

Access to care is a fundamental deficiency in our field. Some may perceive a greater need for clinical advances, but highly effective services are already underutilized. As we consolidate our knowledge across clinical areas, we can help people change self-damaging behaviors without shame. Yet we can not only help clients, we can contribute to dismantling pernicious social stigma and marginalization.

Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.

The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.