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Taking Issue   |    
A Convenient Truth
Saul Feldman, D.P.A.
Psychiatric Services 2009; doi: 10.1176/appi.ps.60.12.1573
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The belief that integration with medical care would greatly enhance the quality of behavioral health services has become the conventional wisdom among behavioral health professionals. It is true that most people talk first to their physicians about behavioral health problems, that such problems exacerbate medical ones and vice versa, that people with behavioral disorders have medical needs that are often overlooked, and that there is too often a disconnect between behavioral health care and medical care.

But has this become a convenient truth, a distraction from the long-standing integration problems within behavioral health itself? Is too little attention being paid to these problems? Are they not at least as damaging to good patient care as those caused by the lack of behavioral-medical integration?

It seems to me that a displacement process may be occurring—an unconscious transfer of energy to issues and ideas that are less threatening and more acceptable to behavioral health professionals. It is more convenient to focus on medical-behavioral integration than on the serious problems related to integration and quality of care within behavioral health itself, problems that reflect deep-seated differences and disagreements about practice, policy, and prerogatives.

I have spent many years as an executive in community mental health at the National Institute of Mental Health and in managed behavioral health at United Behavioral Health, and examples are not difficult to find. Ideological disagreements, competition for resources, separate organizational structures, and disparate training programs divide mental health services from substance abuse services. Behavioral health professionals are trained in separate professional silos, with slight if any interdisciplinary training and scant knowledge of important research published in professional journals other than their own. Progress in integrating service and science, and evidence-based practice with practice-based evidence, has been painfully slow, despite widespread acknowledgment of its importance. Integration of behavioral health care with the other human services, such as schools, housing, employment, and social services, so vital to prevention through early intervention, remains more a belief than a reality. Consumers and family members acknowledged to be a potentially important part of the behavioral health workforce have yet to be sufficiently integrated as such.

These and other integration problems within behavioral health will not be easily or quickly resolved, even with greater conviction about the need to do so. It has been said that behavioral health professionals could well get into a circle if asked to form a firing squad. But at least the solutions rest within behavioral health rather than with others. And finding solutions would have a dramatic effect on the quality of behavioral health services in the future.

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