The five truisms of mental health

As Arthur Evans Jr., Ph.D., Commissioner of Philadelphia’s Department of Behavioral Health and Intellectual disAbility Services (DBHIDS), spoke earlier this year in a conference room full of behavioral health treatment providers, one of the key topics in which he dedicated his presentation to was what he calls “The five truisms involved with a public health approach to mental health.”

1. Population Health. “Healing individuals is good; healing communities is better”

“I think it’s wonderful that we work with individuals and we work to heal individuals. But at the end of the day, I think it’s much better if we can heal communities,” he remarked to the group.  

Psychologists are trained to work with individuals in therapy and psychiatrists work with medications for an individual. “But the issue is, we have a whole population out there,” he said.

“Only 25% of the people in people in our communities have a diagnosable mental health condition. In fact, most of these people don’t even come into specialty care—only 1/10 if it’s a substance abuse issue, 40% if it’s a mental health issue,” Evans continued.

When looking at the other 75%, “it’s not like you get to this threshold where there are behavioral health problems or challenges and before that, there are none. It’s really a continuum,” he stressed.

Therefore, there are people out in the community who need help who are pre-clinical or haven’t been diagnosed.

2. Moving upstream. Evans admitted that he feels the field is much better prepared with specific strategies for preventing substance abuse than it is for mental health challenges. However, he acknowledged that it’s “way more efficient” to attempt to prevent or put in place early intervention strategies than it is to treat people.

Speaking about recent research, he said, “For people who have, say schizophrenia or another major mental illness, we as a field have become pretty good at predicting who is likely to develop schizophrenia. But what we know is that many people who have schizophrenia, for example, are coming into treatment way late into their condition. And we know that when people come in late, it’s much harder to treat them.”

He believes that if we can intervene early, we can actually change the trajectory for individuals who have even the most serious mental illnesses. “So rather than spending all of our energy at the back end, how do we start to shift resources towards the front end?” he asked.

3. Broader Range of Responses. “Social and economic factors are the most powerful health predictors.”

He explained to the crowd that “where and how people live, learn, work and play greatly affects people’s health.”

He estimated that healthcare probably accounts for about 10% of people’s health status. “Think of how much money we pour into healthcare but then when you look at what effects peoples’ health status, it’s all these other things,” he said.

Although it is known that that’s true for physical health, is that also true for behavioral health? Evans says yes. Then the question becomes, “What does that mean for us in terms of how we as behavioral health professionals begin to impact upon some of those other areas.”

For example, on the physical health side, there are policy-strategies that people employ to make the public healthier or safer, like adding fluoride to the water.

 He challenged behavioral health professionals to think about the following questions:

• What are the behavioral health analogs to hand-washing?
• What are the behavioral health analogs to clean water?
• What are the behavioral health analogs to policy-strategies that actually improve the health status from a behavioral health standpoint?

4. Wellness/Health Promotion. Evans shared an important lesson from his graduate school days which was “Health is more than the absence of pathology.”

The focus, at least from a treatment standpoint, needs to shift beyond just symptom management and over to how to help people stay healthy. “We know if people can stay healthy, that it is much more likely that they’re not going to have other kinds of problems,” he explained.
“For example, people with schizophrenia or another major mental illness who are employed, are going to do much better on a whole host of measures than people who are not. So to the extent that we can help people have the kind of life that any of us want, we’re going to have a much better chance at recovery.”

He also spoke about relationships/social support being the best predictor of a person’s psychological health. “Hundreds of studies have shown that when people have very strong social support, that generally they do a lot better in many areas of life, but in particular, in terms of their psychological help,” he said.

Knowing that, it’s important to educate the public and begin to move away from talking about illness and sickness, but begin to talk about strategies that people can employ to stay psychologically healthy.

5. The black box paradigm. Evans believes that the biggest challenge for the healthcare field, especially behavioral healthcare, is moving away from the “black box paradigm.” The black box has to do with the idea that people get sick, they go to treatment (the black box), they are “fixed”, and then they are discharged. Evans spelled out some of the various challenges with this paradigm:

• “It’s for individuals.”
• “It can take individuals a long time to get out of the black box.”
• “Some people go in and they never come out.”
• “When people leave, they’re not “fixed,” they usually have other symptoms.”
• “The box is a-contextual. In other words, we do the same thing for the person who lives in North Philadelphia as we do for the person who lives in Northwest Philadelphia, treatment doesn’t change all that much. And those are very different communities and very different contexts where people are returned.”  
• “Sometimes there’s barriers with people getting to the box.” One of the main barriers with people achieving their journey to the black box is stigma.
• And finally, probably the biggest challenge is that treatment – when speaking of this “black box” – is usually separate from the communities that the patients are from. It can be difficult then for the individuals in recovery to return back to their communities after being isolated at a treatment center. Also, it’s important for treatment communities to intersect with the general community and make the community aware of these individuals and work to reduce the stigma.  

I'd love to hear your thoughts on these truisms. Do you agree with all of these? Is there more you think should be added?