Dear NYAPRS Friends,
As I prepare to leave my position at NYAPRS, I’ve been reflecting on how ENews readers have inspired and motivated me over the past two years. Offering a farewell to you all is not an easy task. I’ve decided to offer a brief perspective on some of the trends we’ve experienced in NY and afield over the past few years, and consider some hopes and projections for the near future.
First, it’s inspiring that “traditional” mechanisms of policy setting and payment for mental health and substance abuse have embraced the social determinants of health in more than just a nominal way. Sweeping initiatives in NY to address housing, employment, and education are mirrored in other states, largely due to ACA reforms that brought new incentives for reinvestment in preventive and integrated activities. But in order to truly shift to a public health approach to treatment, far more than reinvestment capabilities are necessary. There are some noticeable gaps in our current conception of social determinants as health:
1. Alignment between the financial incentives for the people who have the money (federal/ state governance and managed care companies) and the people who spend the money (providers) must utilize mechanisms that may not be archived in our current payment paradigm. NY is attempting a dramatic shift in how value is fostered in our healthcare system through a Value-Based Payment approach that will allow providers to prove their ability to take on varying degrees of financial risk in order to use public healthcare dollars to the ultimate benefit of the individual depending on need and situation. This is the type of policy that takes years to implement widely, but it is inherently problematic to NY’s behavioral health system, which for decades has relied on lumped payments not tied to outcomes; money that has been used for individuals depending on need and situation. NY’s community based providers cannot be dragged through fee-for-service managed care just to prove themselves capable of using money flexibly to meet people’s needs. We could be establishing financial alignments that incentivize the homogenization of giant healthcare networks and remove innovative service designs from having a financial stake in how conceptions of “value” are created around social determinants. Progressing a dynamic and intuitive financial design to pay for social determinants requires that all viewpoints and paradigms are incorporated in how success is paid for millions of individuals across the state with varying needs. You’ll be hearing much more in the coming years about how this plan is progressing and the type of precedent it is setting for the future of healthcare in NY and across the country.
2. Our current concept of social determinants has as much to do with hegemonic conceptions of “success” than it does an understanding of what makes people well. Employment, education, and integrated housing are important goals for people to reach toward to feel “normal”, successful, and rehabilitated. But they are not everyone’s goals, and they are certainly not immediately accessible goals for millions of Americans with mental health and addiction treatment needs. If we’re going to create person-centered approaches to care, we cannot be over-reliant on employment and education as social determinants of healthcare. Aligning financial incentives for providers to be able to spend money on a range of needs at various points in a person’s recovery journey is essential, because as we know, success in recovery is not a straight-forward process toward full employment and meaningful community integration. Policy-makers have the option to do this by bringing systems that have been traditionally separate—like child welfare, education, criminal justice, housing, family planning, and veteran’s affairs—under a shared direction. The fear over losing control of the money attached to each piece of these systems has been too great to foster true integration and identification of the meaningful social requirements for well-being.
3. Culture isn’t (entirely) measurable, but it is significant. Culture is not race, but we will not succeed in fixing our mental health system until we address the systemic racism so pervasive to issues of poverty, stigma, access, and funding. Culture is not language, but we will not succeed until we address the linguistic barriers not only between people of different ethnicities, but genders, geographies, and generations. Culture is partly race and language, but also, culture is my relationship with my mother. It is the food I eat and where I choose to buy it. It is my birth order, my introverted personality, my gender and sexual identity and every experience that went into how those were and are being formed. Culture is that and so much more. Culture is intangible and messy, we must admit; but it is the ground beneath each decision an individual makes on their way to well-being. What do we do with it, as service providers, policy makers, family members, and as a community? Can we ignore it, and homogenize our system from the top to the bottom in an effort for simple outcomes and straight-forward reforms? Or can we embrace culturally informed practice not only into our services and missions but into the way we craft policy and evaluation of the social elements that foster and uphold well-being?
4. Trauma IS measurable, and it is significant. We know that trauma is real, that it can be measured and studied and treated, and we know it is pervasive. So why are we still treating it as if it is secondary to serious mental health needs and addictions? Why is it a part of the language of the recovery movement but vilified but others who claim it is escapist and ignorant of the “real” needs of people with serious diagnoses? These questions have been asked before, by researchers and journalists and the CDC. It is time that we re-base our understanding of serious mental health needs and addiction propensities as functions of various degrees of trauma stored in our body and minds as physical proponents of symptoms that lead to diagnoses.
Second, the entire community of people who work in and receive services from the mental health and substance abuse field is experiencing an ongoing identity crisis that is only further highlighted by recent movements by public officials to address the severity of need for an adequate system to address both. Our fragmented language not only perpetuates misunderstanding and stigma, but distracts from a growing body of evidence that has the potential to advance practice and combat discrimination.
1. What is a brain disease? The somehow progressive notion that psychiatric diagnoses are “brain diseases” is often touted by people who want to equate these diagnoses with other common disorders like Type II Diabetes. This is supposedly in an effort to destigmatize what is often perceived as some failure of morality, will, or upbringing. But how is a psychiatric experience any more of a brain disease than Diabetes? This definition is also often touted by the same people who have progressed the notion that the brain and body are inextricably linked, and thus we should be treating the whole individual when we treat mental health and addiction. So then, why would we minimize a psychiatric experience to the brain? Why offer psychiatric medications as a panacea to an experience when those medications can have devastating impacts on the entire physical body, and which have not been sufficiently studied as to their impact on total body well-being, let alone the feedback loop they have on mental health? This is particularly confusing given the host of new research that concludes or finds correlative evidence to posit that:
– epigenetic stress can cause cell damage throughout the body that can cause and exacerbate extreme experiences and the tendencies to abuse substances;
– dietary intake may be not only linked to cellular damage and stress that can cause extreme experiences and the tendency to abuse substances, but also to actual permutations in the way our organs (including the brain) communicate with one another, perceive external stimuli, and form cohesive and rational patterns of thought and behavior. There are so many hundreds of resources on the internet about this emerging science, it is impossible to select a sample to indicate here. But I believe that the link between diet and mental health is the next frontier in research and treatment for mental health, and that a breakthrough is soon coming that could fundamentally alter the way we acknowledge food as the basis of our well-being.
We cannot claim to be truly treating mental health as a whole or addiction unless we are willing to accept that our understanding of the connection between our bodies and behavioral health is quite limited. Incorporating traumatic and dietary stress into our understanding of the actual chemical underpinnings of well-being is an essential piece of the future of research, practice, and policy in behavioral health.
2. What is behavioral health? I use this term all the time; many of us do. It has become the catch-all term for mental health and substance abuse experiences. But it is inherently damaging to our progress as a field. Using the same comparison as above, how is a diagnosis of schizophrenia any more related to prior or current behavior than Type II Diabetes? In fact, I could make an easy argument that the latter is driven more by behavior than any mental health diagnosis. The term is also at odds with our supposed departure from mental health and substance abuse as failings of personality or morality. I see the future language of our field truly embracing the differences between the types of actual experiences, driven by a multitude of causes, that people with diagnoses and addiction deal with. Embracing the diversity of causes and experiences that are truly present for individuals will lead to a richer, more cohesive course for our community.
Finally, I believe the most important way we can acknowledge the ultimately human experience of discovering our mental health is to bridge to communities that have been through their own revolutions together. The recovery community often likens our movement to the LGBTQ or civil rights movements, but we haven’t truly found intersectionality with groups that we can find strength, motivation, and communion in, nor have we formed a collective identity that rejects imposed boundaries.
1. We need to create a common language of mental health. And no, I don’t mean that the recovery community needs to (finally) agree on which words are and are not appropriate to use. We just need to agree on the ones that ARE NOT, under any circumstance, appropriate to use. There exists a normative parlance that includes derogatory and stigmatizing words and imagery about mental health and addiction. We can all do something about this, and it starts by standing up to people in the way members of the black and LGBTQ communities stood up to discriminatory language and changed what was normal and acceptable. Let’s start with our loved ones, and then our colleagues, and then work through collective resistance against media representations of a language unfit to represent human identity and experience.
2. The dismantling of the US system of mass incarceration is imperative not just for people locked up who have mental health and addiction treatment needs. Our justice system criminalizes poverty and institutionalizes racism and pan-discrimination. We do not achieve an adequate mental health system until mass incarceration is turned away from as a paradigm of “justice”. It is not as dramatic a shift as we may imagine; there are dozens of countries that have transformed their systems toward progressive justice from a historically punitive and regressive approach. We need to ally ourselves with community members already working towards these goals and add our skills and concerns to their ongoing journey. These connections are being made in a way now that is unprecedented. Find the people in your community who are working on issues of criminal justice reform—including implementing restorative and community-based justice methods—and work with them.
There are so many more issues on our collective horizon; I will continue to be motivated by you all for taking them on. NYAPRS friends, it has been a pleasure to come into communion with you each morning. Thank you for offering me trust, compassion, inspiration, and family along the way.
Best wishes for the journey ahead,
Briana