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Language Matters: How “Behavioral Health” Perpetuates Stigma and Misinformation

To the Editor: I first heard the term behavioral health last year when I moved to the United States to pursue my PhD in nursing. As a psychiatric-mental health nurse from Canada, this phrase was entirely foreign to me—both literally and figuratively. Not merely a colloquialism confined to the northeast, I was shocked to learn that it is widely used within professional contexts throughout the United States; adopted by health care organizations, academic institutions, and governmental agencies alike. Even largescale nonprofit mental health advocacy associations, such as the National Council for Behavioral Health, proudly boast this title. However commonplace, this phrase left me perplexed and perturbed for several reasons: the first being its utter ambiguity. While intended to be broad and inclusive of diverse health conditions and disorders, its lack of specificity causes considerable confusion. Behavioral health encompasses everything from mental health challenges, to substance use, and lifestyle behaviors deemed “high risk,” such as gambling or sexual promiscuity. Simply put, it is a catch-all for everyone’s deepest, darkest secrets. Perhaps more important, the term implies that the experience of any such challenge is a choice that can be skillfully and voluntarily managed through sheer will and determination. It is difficult to imagine that anyone would willingly subject themselves to emotional distress or illhealth, yet the word “behavioral” denotes personal preference, suggesting that individuals make an informed and deliberate decision not to engage in more positive habits or routines. The reality, however, is that many such psychological symptoms are beyond our immediate control and are a function of our social and physical environment. For those most disadvantaged and marginalized within our society, restrictive eating, smoking, or binge drinking may represent a highly adaptive coping strategy and meaningful form of distraction from daily hardships. Furthermore, such practices present an opportunity to exert control over one’s circumstances and are a welcome alternative to more drastic measures such as self-injury or suicide. Indeed, assigning individual responsibility for “questionable” or “reckless” actions may demonize people for simply surviving. By perpetuating blame and shame regarding negative or abnormal thoughts, feelings, and actions, the term behavioral health may also pose a significant barrier to professional help-seeking. To assert that these experiences can be willfully overcome is not only deeply invalidating but also discounts the prevalence and severity of such problems. With 20% of people affected by mental illness each year, neurological and psychiatric disorders represent a tremendous cost to society (National Alliance on Mental Illness, 2019; Substance Abuse and Mental Health Services Administration, 2016). This grim reality has become ever-more-apparent during the COVID-19 era, with rates of anxiety, depression, and suicidal ideation skyrocketing, according to a recent report by Mental Health America (2020). Now, more than ever, early screening, assessment, and intervention of mental health challenges is profoundly important; however, the stigmatizing nature of behavioral health may instill a sense of fear or self-deprecation that ultimately discourages disclosure. While concerning in their own right, each of the above-mentioned issues beg a larger, more troubling question: How do we prevent, treat, and mitigate the adverse effects of behavioral health conditions? Many would argue that a behavioral problem demands a behavioral solution, suggesting that clinical interventions, such as psychotherapy or pharmacological treatment, are the most appropriate forms of self-management. While effective at an individual level, such methodologies represent a Band-Aid solution, distracting from more upstream approaches that address the structural causes of mental health challenges. In this way, the term behavioral health unduly medicalizes psychosocial well-being, propagating the already dominant biomedical discourse within clinical disciplines. For in addition to genetic and biological characteristics, our mental health is influenced by socioecological factors—that is, relationships, community resources, broader social supports, and public policies that coalesce to inform our personal context. As such, marginalized groups are disproportionately affected by mental health challenges, given heightened exposure to stressors and limited access to appropriate psychiatric services. Indeed, individual identities and varying degrees of power and privilege within society influence our quality of life, opportunities for advancement, and receipt of health-promoting and life-sustaining resources. To say behavioral health is to imply that such harmful inequities are selfinflicted, when in reality, they are the direct consequence 999785 JAPXXX10.1177/1078390321999785Journal of the American Psychiatric Nurses Association letter2021