The problem with mental health care: Part I The Words We Use

Like so many aspects of the healthcare system in the United States, mental health care is fraught with a multitude of issues which have many different ways of being addressed if not understood. Many of ways need to changed, if not completely rebuilt from the ground up, and others need to be thrown out altogether. Most of these issues, when taken individually, represent daunting tasks which are not being addressed so far as I can tell in any meaningful way. However, if an appropriate solution could be found to any of these issues real progress could be made in resolving the overall issue of providing adequate solutions to mental healthcare needs.

Unfortunately, these tasks ignored by and large cannot be separated from each other and must ultimately be looked at as a whole, and that is the problem with mental health care. My goal with this piece is to add my voice to the multitude both in and outside my profession and maybe provide some answers which don’t seem too outlandish when really looked at honestly. I will do so, however, by limiting my discussion to two of the multitude of aspects one could address in resolving the problem with mental health care.

The first aspect I want to address is the modern tendency to label mental health care as behavioral health care. To be clear I don’t find the term Mental Health very satisfying either but to refer to the care I and others give as Behavioral Health is about as accurate as referring to cardiology (heart function) as circulatory health. Maybe that is accurate to the extent that cardiology does play a part in circulation but that ignores pulmonology (lung function) which also plays a critical role in circulation and as do the kidneys (nephrology) and multiple other organ systems.

The term Behavioral Health literally defines what a person does as all that matters, stripping away any other aspect of the person which could have an influence in how a person acts. Worse than that it requires the adherence to an assumption of right and wrong, appropriate and inappropriate behavior, which is horribly judgmental at best but at worst it requires behavior to be qualified in terms of rightness or wrongness and then used as justification for all manner of actions which are justified as a whole by labeling them as “treatment.”

Skipping over the philosophical debate which this line of thinking always leads me to, the discussion of who gets to decide a behavior is wrong and by what measure is the determination of wrong developed, I will address the issue just on a surface level discussion. That is the idea of behavioral wrongness depends entirely on the society making the determination as well as the time at which the determination is made.

As an example let me draw your attention to an interview Stephan King gave and I’m sure is on the internet somewhere but he mentioned it in a nonfiction book he wrote called On Writing. What he said was in order to be a good writer of fiction one must be a really good liar. He equated the making up of stories, the activities by which he feeds his family, as lying. I don’t think he is too far off the mark there, technically speaking, but that is not my point. So lying, if for the sake of entertainment (books and movies) is okay, even if one does it all the time as Mr. King does. But if you worked with someone or are related to someone who lies all the time I’m sure you would see that as a problem. Wouldn’t you?

So set and setting when one makes the judgment is important, even outside the context Mr. Leary used it. For those wondering chronic lying is a required symptom listed in the DSM (the book people like me are forced to use to get insurance companies to pay us for our time with a patient) for many conditions both in childhood and adulthood.

Let me give you another example. Hearing voices, or auditory hallucinations, falls under the category of psychotic symptoms in the afore mentioned book. There can be many sources or causes of such a symptom but most often auditory hallucinations is associated with formal thought disorders such as schizophrenia and is often accompanied by other symptoms such as delusions or what I like to call mistaken belief systems. To give you an example of how this works we all have an inner voice which could be referred to as a thinking voice. When you are thinking about something you may “hear” a monolog in your mind. Most of us pay little attention to the technicalities of this voice as we on some level know it to be our voice, even when it is not “sounding” like our voice.

Haven’t you ever noticed all the voices in your head aren’t yours?

No? A quick example then. Think of your favorite song. Really hear the song in your mind. Now think of who is singing that song in your mind. Is the answer you or the actual singer of the song?

Still don’t believe me? Another example than.

Ever have a dream where you are talking to someone? Both the dream you and the dream other person are in fact coming from your mind. (footnote: technically the dream and all the content is coming from your unconscious but I haven’t discussed that yet so let’s be overly simplistic here and say the dream comes from your mind). You are generated the image of you and you are generating the image of the other person. You are also generating the sound of the voices each person is using and if the person you are having the dream conversation with is an actual person you are using their actual voice in the dream. End result, two different voices one who is you and one who is the other person in your dream.

If you are following me so far perhaps you will follow me a little further and also accept that if you can generate someone else’s voice in your mind while you are sleeping you could also do the same when you are not sleeping. In fact you can but with the multiple layers of defenses which exist in consciousness (again a topic I will get to in the near future) you mostly do not become aware or interact with these “other voices” which exist in your mind.

A person with a formal thought disorder, schizophrenia for example (there are others), does not distinguish “my voice” from the “other voice” and accept them as both originating in their own mind. That is to say, both are me. Because the “hallucination” is occurring in conjunction with the delusional belief that the voice of the other is coming from outside of the self (I’ll get to that concept too) the conclusion is that the other must be someone who is not me. In many cases it is the voice of god or angels, some other outside entity known for speaking to human beings. In probably an equal number of cases the divine voice is demonic in nature and not angelic, but the other could also be one’s dead relatives or other spirits.

People who are “hearing voices” tend to make everyone around them uncomfortable so that particular behavior is judged to be problematic and by that justification all manner of “treatments” has been judged to be acceptable. In modern life we still lock these people away from the rest of society and often administer powerful tranquilizers now euphemistically known as “antipsychotics” to such levels as to leave the patient in a stupor. Very few psychologists or psychiatrists are as interested in talking to these patients as Jung was 100 years ago. That is to say figure out what may have occurred in the patient’s life to make such a behavior as hearing the voice of god necessary. I think we should still do so but that isn’t the thesis of this piece.

If you were to take the most psychotic, “crazy” patient in any facility today and dropped that person in an indigenous society living in some jungle somewhere, or on a mountain or on a plain in Africa or South America you would find that not only is that “crazy” person accepted as is, but he or she may also be revealed as a person who the spirits or gods chose to communicate with. The person in the tribe who speaks with and is spoken to by the gods is called the shaman.

I could give many more examples but I will limit myself to one more. A rambunctious energetic child in a playground is barely distinguishable from other children. Drop that child into a typical American classroom of 30 children and at best that child is labeled as disruptive and in need of discipline. At worse that child is seen as diseased (ADHD) and in need of chemical restraints (medication).

The time and the place at which a person’s behavior is judged is really, really important. By and large we as a western society don’t consider that. We lump things together we like away from those things which we do not like. Then we call one pile good and one pile bad. This would be a non-conversation except that when the piles we are talking about are people we tend to completely ignore that a set of circumstances may have lead to the behavior, let alone try to identify what that set of circumstances may be. We in the United States rush to medicate the behavior until it is something we find less discomforting to…..well…..the person passing judgment of course. The disruptive child is labeled as having an attention deficit by the teacher trying to control a room full of 25 or 30 other children. The person who is having a conversation with themselves believing they are talking to god is labeled as psychotic or crazy, even though the only difference between what he is doing (most people with psychotic disorders are male) and what you may have been doing in church or synagog last weekend is the place in which you were doing it.

The words we use are important and we should strive to be as accurate in our description as we can. Calling what I do practicing Behavioral Healthcare is not accurate in even the remotest sense, but if I want to work for a government agency or a healthcare system that is probably the title I will have to live with. I think that is mostly due to the medical model of healthcare which is dominant in society today but maybe that is a topic for another day.

We need to use our words more carefully when it comes to healthcare and we need to define the system we are using to not only come up with these words but also to use these words in any given setting. We need to strive to be more accurate and inclusive.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

Blog at

%d bloggers like this: