When I chaired the Greater Providence YMCA board, I learned some of the Y’s history. Of particular note was Dr. Luther Gulick, who in 1891 proposed a red triangle as the YMCA symbol. In his words, the equal sides of the triangle stood for “man’s essential unity – body, mind and spirit – each being a necessary and eternal part of man, being neither one alone but all three.”
True then, and equally true today, it highlights what is missing from most traditional workplace wellness programs – the mental, emotional and spiritual components. Hardly surprising given the remarkable and highly puzzling resistance mental illness treatments encounter.
The term “mental illness” usually refers to recognized mental illnesses in accordance with the Diagnostic and Statistical Manual published by the American Psychiatric Association, such things as depression, anxiety, psychoses and bipolar disorder. While substance abuse and addictions are not so neatly categorized and are sometimes referred to as “behavioral disorders,” an indeed odd phrasing, we will refer to all such afflictions as “mental health” or mental illness.
Through the Middle Ages, the mentally ill were believed to be possessed or in need of religion. This almost always led to nasty religious interventions, barbaric medical treatments, alternative starvings and beatings, or confinement. None seemed to be very effective. But in the 1840s, Dorothea Dix lobbied for better living conditions for the mentally ill. It took Dix 40 years, but she successfully persuaded the federal government to fund the building of 32 state psychiatric hospitals.
Institutionalization persisted as the treatment of choice until the 1960s, when Congress passed the Community Mental Health Centers Act of 1963 that deinstitutionalized all but those individuals “who posed an imminent danger to themselves or someone else.”
By 2000, the number of state psychiatric hospital beds per thousand people was less than 10 percent of what it was in 1955. While “deinstitutionalization” continues to be hotly debated today, it represents an ongoing attempt to assimilate the mentally ill into society, just as we do for our physically ill.
The quest for mental health “parity” followed. Mental health parity proponents fought to remove differences between physical and mental health treatment, benefits and coverage. While some states, such as Rhode Island, enacted partial parity legislation, little overall progress was made until 2008, when Congress enacted the landmark Mental Health Parity and Addiction Equity Act, which eliminated both financial and nonfinancial (e.g., maximum days; coverage limits) ways that insurers could limit access to addiction and mental health care. [Note: I’m proud to have been the only health insurance representative to testify in favor of the legislation, and of course our congressman, then-U.S. Rep. Patrick Kennedy, played a key role.]
The inanity of some of these artificial limitations was obvious. Most insurance plans limited the number of mental health office visits (for counseling) to, say, 30 a year. For those truly in need of substantial counseling, when did their coverage run out? Just before the holidays, when they most needed it.
People don’t overuse counseling. Just the opposite. And yet, this limit was inserted for God knows what reason. Office visits never break the bank. Such limits are outlawed today, unless there are similar limits for nonmental health care coverage.
Since enactment, mental health parity has continued to encounter resistance and difficulties. There is remarkable societal and professional resistance to recognizing and handling mental health issues the same as physical health issues.
The stigma of mental illness has not entirely left us. Addiction continues to have overtones of moral reprehensibility and implied lack of willpower or moral integrity. This is tragic, because it not only encourages subpar treatment – it also greatly frightens off those who might otherwise seek care or ask for help, particularly in the workplace. And it places mental health advocates in the conflicting position of wanting/needing greater confidentiality protections for mental health care than for physical health care.
Today we know that most people receiving care for mental health conditions also have related (sometimes called “co-morbid” – a really odd descriptive) physical health conditions; and vice versa. We know that many forms of mental illness require physical health treatments, in addition to counseling, and we know many forms of physical illnesses have tremendous mental/emotional components.
For example, where does one begin and the other leave off in the case of an obese, pre-diabetic, depressed, bullied, 14-year-old girl with severe acne and abusive parents? Just seeing her pediatrician once or twice a year is suboptimal to say the least. Coordinated care amongst a psychologist, psychiatrist, dermatologist, social worker, PCP, school representative and a specialist or two is optimal. Changing the culture of her environment? In a perfect world, yes, because without that, she may never recover full health, despite good care. While we can’t always change the world, the parallels to workplace well-being seem obvious.
Health care delivery today is starting to see the benefits of co-located, integrated physical and mental health care, particularly in primary care, patient-centered, medical-home models. Some insurers (most notably our Blue Cross & Blue Shield of Rhode Island) are using innovative and very helpful funding techniques to advance this obviously needed change to how we deliver care.
When one considers the most common prescription drugs taken today, one can immediately see how one or more mental/behavioral components contribute to the underlying physical condition:
n Statins (cholesterol).
n Blood-pressure meds.
n Anti-depressants (Prozac, Lexapro, etc.).
n Sleep meds (Lunesta, Ambien, etc.).
n Digestive disorders (Prilosec, Nexium, etc.).
The above categories of drugs should not (with the exception of anti-depressants in some cases) be life sentences. These drugs should be prescribed with the goal of stabilizing physical conditions for a period of time needed to make one or more lifestyle changes to eliminate or lessen the habits and behavior causing the underlying problem. For statins, blood-pressure and digestive-disorder meds, it usually is proper diet, exercise, AND the medications until a weaning can take place.
With sleep meds and anti-depressants, it can be more difficult, but counseling and other activities should be undertaken with an eventual goal to reduce or eliminate the medication over time.
That is not happening in America today. Our delivery system treats the symptom rather than the underlying cause. We produce a Band-Aid with meds and think we are healthier when our cholesterol and blood pressure readings are lowered to appropriate ranges due to the medications.
We are not healthier; we are medicated or sedated.
Accordingly, we can see the powerful influence of the mental, emotional and spiritual over our abilities to cope with the challenges of becoming healthier. They are all interrelated and interdependent.
Part 2 of this series will focus on what this means in the workplace. n
James E. Purcell is the former CEO of Blue Cross & Blue Shield of Rhode Island. He is also an attorney and operates a national consulting practice on workplace wellness.
