Watch Your Words

Meet Marianne, a hypothetical new patient. She is interested in getting telepsychiatry for what she described as “kind of an eating disorder.” At 20, she has been in 6 different programs and seen 8 psychologists and 10 psychiatrists. Her insurance has no one in the behavioral health network who can see her for 7 weeks. Right now she’s on medical leave from school and supposed to be getting “help.” Her father is pretty frustrated with her. He wonders if telepsychiatry could help her. Nothing much else has yet.


I listen to people fumble language about my specialty. Its not their fault. There’s a lot to know and, yes, it’s a conceptual hornet’s nest. We have confused them and often don’t correct misconceptions. They often don’t know names of diagnoses that keep changing and are difficult to grasp, contradictory, or overlapping. People struggle to describe the treatment patients are getting. The words confuse them, even if they are able to say whom someone saw for what and maybe why it was helpful. No one says the word “psychotherapy” anymore, I notice. People barely use the word psychiatrist. The lexicon got rewritten and psychiatry was written out. Legitimate criticisms of psychiatry aside, this change is not for the better.

It’s now called behavioral health, which for me goes in that dictionary with provider, psychopharmacologist and counselor. I wish it were simpler, to clean up the concepts and just eschew words that are automatic downgrades. The other psychiatrists are by now rolling their eyes at me. We lost those battles decades ago. I truly have no interest in nitpicking debates about language that serve to further alienate us from each other. But some of this language has had terrible consequences. There is no brand of absolutism or reductionism from any camp or ideology that is going to help our patients. The medical or disease model itself can be an uncomfortable fit in some ways, but more reductionism doesn’t help force it. The patients don’t always look like their purportedly corresponding guidelines. Some of us think guidelines are inane, oversimplifying or possibly overcomplicating. We have to help the patients anyway. There are so many obstacles from without and now from within. It is distressing and exhausting to watch us devalue each other and get so heated about problems in psychiatry that we are confusing patients by making the whole profession look dishonest, lazy, unethical or backward. I would love to see this stop. Conflating psychiatry with quackery, drug-pushing or other sorts of exploitation is terribly sad if it stops those who need help from seeming it. I know that it does.

Doctors and patients need to definitively and loudly reject the whole premise of behavioral health, wherever possible. Behavioral health has been used to cut psychiatry off at the knees. It is at once a dismissal, a distortion and a disguise for the work that psychiatrists can do. What does it mean? In practice it often means 15 minute “med checks.” It postulates that psychiatrists are supposed to be helping people change their behavior in 15 minute appointments. It implies a lot of things that make no sense. Cognitive behavioral therapy, just like medication, is simply a modality that helps some people sometimes but its overselling it distorts what it has to offer if it makes it the answer to everything. Behavior is a small subset of what a psychiatrist studies. Psychologists study behavior, too. Neither discipline makes the construct of behavioral health any sort of metric or endpoint. Normal is up often up for healthy debate. Normal might be subjective, informed by the patient’s perception, as much as a diagnosis. There is so much room to rip this fragile specialty to shreds and demoralize everyone.

Behavioral health, though, is nothing but failed rebranding. A telemedicine company, for example, has a Behavioral Health President. What training does one need to be a Behavioral Health President? Most likely there’s one hard and fast requirement- he can’t be a psychiatrist. No wonder people are so confused. Language serves to jam the most confusing medical specialty’s square peg into yet another ill-fitting round hole where someone can profit. Constantly being reinvented to suit the needs of third parties, psychiatry submits to one indignity after another. Let’s stop acquiescing to the linguistic assaults and assaulting each other because this creates obstacles to patients getting help. They are confused, ever more mistrustful, hazy on who can help with what.

We, doctors, patients, advocates, and other clinicians may not all agree to the same language. We may debate with interest about mind versus brain, thoughts and emotions, receptors and adverse experiences. But if language grossly devalues and oversimplifies our work with patients we can at least agree to reject that. Behavioral health not only is not synonymous with psychiatry, it is antithetical to it. No doctor I have ever known thinks behavior change is at the core of psychiatric care. Behavioral health as a construct is so patently absurd it’s analogous to calling gastroenterology Bowel Movement Health. Behavior, like bowel movements, can be observed and measured, which is, indeed, convenient. But, out of context, behavior may actually tell us very little about a person.

Isolating pathologic behavior from biology, family, society, diagnostics and the framework of a relationship with a clinician is misleading. It is the most primitive of wishful thinking that behavioral change is achievable in any specialty independent of consideration of other elements of a human life and mind. Patients know this and we need to validate them.

Let’s go back to my hypothetical patient Marianne. Marianne actually has diabetes and an eating disorder. She does what used to be called insulin purging. She refuses to use an insulin pump because it causes her to appropriately store her glucose as fat. She would prefer to be in and out of intensive care units with diabetic ketoacidosis than to be storing fat. She also cuts herself and misuses sedatives. She has a history of abuse. Right now her diabetes is so out of control one of the cuts is infected to the bone. She is going to a surgeon since it’s going to need a complex operation. He is worried about her, and also worried she is going to look like six different complications on his quality measures. She dreads dealing with his perceived impatience but she knows she can’t annoy him or he might fire her. He feels badly for her but doesn’t quite know what to say. He wonders why she continues not to get psychiatric care. There is no psychiatrist calling him to explain. No psychiatrist has evaluated her in a year. She has seen various interns and trainees at programs. There’s no one who can provide a summary.

Her diabetic bulimia behavior is, obviously, not healthy. But there is no addressing this behavior without first looking at all its aspects. Likely there are many for her in addition to her having a variant of an eating disorder, itself layered in meaning. Perhaps the meaning is also having to do with not wanting to be a sick person at all. Perhaps it reminds her of being different, to wear a pump. Perhaps she feels unattractive. Alternatively, perhaps she gets attention in hospitals that is rewarding. It could go on and on like this. What she may need, from what I hear so far, is for someone to listen, empathize, understand and possibly help her see what she may not. She may eventually choose to change her behavior but I think what I can sense from her is there is a feeling that she wants first of all to be understood, respected, not shamed, and that she will keep escalating until she does. I could be wrong, of course. There are likely many other angles and approaches. Why things haven’t worked out so far for her could be that she never stopped using substances or trusted a psychotherapist. Everybody thought the medication she barely took (which she worried would make her fat) would fix her. I can see that this fear and this wish, the magical thinking about medication, have got to be addressed front and center. You can see: she isn’t going to benefit from telemedicine. Or behavioral health. Or collaborative care. Whatever that is. She needs a psychiatrist who sees her as a whole human being.

Marianne is self- destructive. When we focus exclusively on changing behavior, or even make the flawed assumption that people generally behave rationally, or align with incentive or punishment, we will fail to understand or ever explain what humans think, feel or do. Failing that, there will be no hope of change. Even presuming that one understands them, taking a leap, this does nothing much for change. Changing behaviors requires complex and often multipronged long-term interventions. There is no formula. There is never just one kind of answer in psychiatry. I know that’s not aesthetically pleasing but it is true. The worst ramifications of the behavioral health mythology that I see are with respect to suicide and addictions. People seem to be profoundly underestimating the complex and refractory nature of these problems, which has led to massive underacknowledgement and undertreatment of psychiatric illnesses, mislabeling and pervasive magical thinking about prevention.

There is no changing any behavior in medicine without studying it and identifying many predisposing, precipitating and perpetuating factors. Typically these are systems and families and individuals in a complex interplay. The individual patient has much to teach us but the generalizability of his story varies. The macro- solutions being proposed are not going to be enough. Does anyone really think we can address addiction by just more easily reversing overdoses? Do people think we can address physician burnout and suicide by telling doctors they need to become more resilient? Do people think there’s a pill for self-hatred? A therapy for hallucinations? These things may help, perhaps, but the fantasy of a cure is dangerous. We have become complicit with the powerful agenda of oversimplification.

These problems people have have many layers, rich, deep, interesting and tragic. Psychiatry is about biology, culture, families, trauma, psychology, relationships, the mystery of a person. It is also often now about the failure of systems and clinicians to see, understand and act. It is not just one person and one behavior. I think that the seductiveness of selling this concept of behavioral health is that it has created a mirage in which people believe one person/one behavior can be managed at a macro level. Clearly it cannot. This oversimplification has helped further convince people, many of whom were already steeped in stigma and antipsychiatry, that psychiatry does not help patients. This discrediting and devaluing was necessary because psychiatry is too expensive and inconvenient. It doesn’t generate revenue for third parties. So it is much easier to just say that people just need to change their behavior than to try to understand.

The antipsychiatry movement is loud. The critics have some valid points. The overmedication of patients and the problems of reproducibility and ethics in research have served the interests well of those who seek to completely discredit psychiatry. There are many who are now firmly convinced that psychiatry does more harm than good. People think we treat the wrong patients with the wrong interventions and this may sometimes be true. This discrediting is tragic and destructive. The behavioral health paradigm has carefully nurtured the malignant split in psychiatry leading to biological reductionism, which doesn’t help patients, while at the same time devaluing psychosocial treatments by making it all about the individual choosing to change his behavior. Behavioral health cuts patients and treatments into pieces and obscures anyone integrating the big picture. There are a lot of forces lining up to rip us apart as a profession.

Creating healing in psychiatry just does not exist in a vacuum. Our work is often intimate, private, ambiguous and the answers often inconveniently lie in grey areas. They are politically charged and the stigma can poison dialogue. It is not easy to defend what we do until it works and, like everything else in medicine, sometimes it doesn’t. The problem is that there is no one size fits all answer for any given person. The interventions range in scale from molecular to global.

One could choke on memes and words in healthcare all day long, like engagement or disruption. These are are largely euphemisms and rebranding for less is more. There is limited value as I see it in debating pure philosophy in the patchwork that is psychiatry, except when a movement uses words as a thinly veiled agenda redefining care. The subtext of the myth of behavioral health is all about control, not understanding or healing. If we are to help patients, addicted, suicidal or otherwise in need of our expertise, we cannot allow our work to be cast as a way to merely manipulate peoples’ behavior even if it is seemingly for their benefit. The patients, like Marianne, can’t just change their behavior even if they want to and there is no magic pill, psychotherapy or app to make them wear the pump, or quit drugs or stop cutting. There is help but it cannot start with the charade that it’s just about behavior change. Let’s be careful with our words, with each other and with the patients. We can at least start with that.