During the 2016 American Public Health Association Annual Meeting and Expo, the APHA Mental Health Section partnered with national public health organizations to produce a roundtable that explored “behavioral health as a public health strategy.” This event drew directors of state and local health departments, and thought and practice leaders from national behavioral health organizations. The conversation was provocative and inspired the deeper discussion found in this interview.
To discuss how the framing of mental health and substance misuse issues affects the strategies for action at the population level, Elevate turned to Margaret Walkover, MPH, Chair of the American Public Health Association’s Mental Health Section. For 10 years, Ms. Walkover directed evidence-based and large-scale quality management and systems change initiatives within Alameda County California’s $440 million public behavioral health care system. Previously, she managed wellness and recovery practice change initiatives for the California Behavioral Health Directors Association, and staffed national projects for the Institute of Medicine and the Office of the Assistant Secretary for Planning and Evaluation in Washington, DC.
We hear terms like “mental health,” “behavioral health,” and “population mental health” in use among public health practitioners. Are there nuanced differences between these terms, especially in terms of framing public health priorities? If so, what are these differences?
My original training was in public health research and public policy. I learned about mental health by listening to people from all walks of life who entered our public health and social service systems when no other personal, family or community resources were available. This entry also led them into psychiatric hospitals, jails and shelters because there were no alternatives. And although we worked with them as individuals, if you looked at the data, they clustered into groups by often overlapping risk factors, including low income level, refugee status, ethnicity, homelessness, exposure to natural disaster and human-induced trauma (war, community violence), and zip code within our region of California. At this point, I also learned that people who do not have access to services will sometimes self-medicate with substances. Often, people who are abusing substances will experience symptoms that are drug-induced, which are often misinterpreted by professionals as mental health issues.
The term “behavioral health” was coined to support the financing and coordination of services that would address both mental health and substance use issues. This term reflected a desire to support the systems change required to ensure collaboration, and to address the financial incentives and disparate treatment cultures that supported the separation.
Between 1999 and 2010, the field made heroic efforts to bring evidence for population-based behavioral health strategies to the public. The National Institute of Mental Health, the U.S. Surgeon General, the Institute of Medicine, and President Bush’s New Freedom Commission on Disabilities and the Substance Abuse and Mental Health Services Administration (SAMHSA), the National Institute of Mental Health, the Surgeon General, the Institute of Medicine (more here and here), and President Bush’s New Freedom Commission on Disabilities produced well-respected “anchor” reports exploring the science and practice behind mental health and substance misuse across populations. These national reports engaged a well-respected range of stakeholders and sought to impact the stigma associated with both challenges. Leaders in the field reframed these challenges as population health issues with coherent and practical solutions.
I have implemented many of these recommendations, alongside some of our country’s first consumer/family members who advocated for recovery-oriented mental health services. These self-labeled “survivors” of community health systems taught me about the roles of hope, empowerment, collaboration, and choice in anchoring personal recovery, as illustrated by their motto: “Nothing about us without us.” In short, I learned everything I know about mental health from people who had the most experience with it.
And with their experience in mind, I came to prefer another term for this work.
What term is that, and why do you prefer it?
I prefer “population mental health.” To me, this term is very straightforward.
At this point, we have evidence supporting the reality that a person’s mental health is determined by her individual makeup, interacting with the culture she navigates, the neighborhood she lives in, the environment to which she is exposed, and the systemic challenges and injustices she may face at a population level. This kind of analysis is well understood in the world of public health. With this in mind, the fit between public health—with its emphasis on social justice—and population mental health is a good one.
Also, I think it is really, really important that practitioners be engaged with broader understandings of what contributes to mental health and resilience—for all people, regardless of whether they experience emotional stress at a mild, moderate, or severe level. At the 2016 APHA Annual Meeting in Denver, I heard the Surgeon General emphasize “mental and emotional well-being,” and he has integrated mental health into his strategy for whole health and prevention.
What can public health do better or differently to improve behavioral health at the population level?
What if it were common knowledge that everyone—no matter what walk of life you were born into—has deep crevices in their emotional geography? And that life circumstances (including natural disasters, epidemics, economic downturns, social inequities leading to generational poverty, and homelessness) are what make populations, and the individuals who are part of them, vulnerable to mental health challenges? Given that 20 percent of the population experiences at least one behavioral health issue, I see “stigma busting” around mental health and mental illness as a priority.
The public health community, including health departments and state Medicaid agencies, has a host of knowledge and skills that can be used to apply population health strategies to behavioral health. And, it’s curious that, at the same time, health department leaders whose communities have demanded more behavioral health services report that they don’t have the resources, or sometimes the background, to take next steps.
Meanwhile, behavioral health providers’ training and experience has left them unaware of public health’s most valuable tools, including health promotion and prevention campaigns, surveillance, and community based stakeholder initiatives (for instance, community gardens, public safety, and housing). The opportunity for collaboration, in the service of improving population behavioral health, is loud and clear.
Here is a first step for public health: initiate collaborations with state and local behavioral health organizations representing networks of mental health and substance use providers. Reach out to them. These folks chose their fields because they enjoy one-on-one relationships and want to be helpful; you will like working with them. Consider including your state Medicaid office (which pays for community mental health services) and your state health department (which might have jurisdiction over Federally Qualified Health Centers).
To make progress on discussions about prevention, promotion, or surveillance, it will be important to ask your partners about what works. Come to the discussion with a common incentive to understand behavioral health issues through a population-health angle. One incentive is the understanding that 90 percent of Medicaid clients have experienced complex trauma—more than one traumatic event that often recurs over time—and are at risk for developing mental health challenges and substance misuse and abuse. These populations are seen across all of public services, including primary care, public health, behavioral health, social services, jails, and schools. Culturally competent, strengths-based interventions that provide opportunities to rebuild a sense of community are critical.
We will also need a way to interrupt the stigma that public health leaders often face when advocating for mental health and substance misuse issues across subfields and sectors. Behavioral health partners may know how to answer questions about symptoms and recovery in ways that will help everyone understand how people experience substance misuse and mental health symptoms—and, most importantly, which strategies and interventions nurture the conditions that encourage a person to take on the journey of recovery.
The U.S. Department of Health and Human Services (HHS) notes that “mental health and substance abuse social workers and school counselors are projected to have the largest shortages of more than 10,000 full-time equivalents nationwide in 2025.” What are the potential implications of this for the public health workforce and systems? What can local health departments—and public health practitioners generally—do to prepare for this?
Much of a provider’s impact on a client is based on the strength of the relationship, combined with the client’s sense of hope. We also know that people feel hope when, having worked through hardship, they can share their story with another person or people coming from a similar background. One way to prepare for a decrease in staff, while implementing a population health strategy that addresses economic disparities, is to fund high school academies that offer a culturally competent career pipeline into local colleges and then back into their communities. For example, in California, second-generation Vietnamese and Cambodian immigrants who have gone back to school and returned to their community to give back offer recent refugees mental health and primary care services.
Speaking of prevention and schools, the idea of improving the culture of school environments is another behavioral health strategy based on the principle of trauma-informed care. We know that the skills of self-regulation (the ability to self-identify distress and create feelings of comfort and safety) can be taught by peers. So why not teach these skills to students and their teachers?
Another workforce strategy builds on the resources offered by the Public Health Learning Network (PHLN). We know that the number of public health and other professionals who understand behavioral health is very small. Why not initiate a prevention strategy by identifying a behavioral health curriculum to be disseminated through the PHLN? This curriculum would include basic knowledge, skills and experience in creating helping environments that feel comfortable and safe; vicarious trauma training for providers, and the basics of motivational interviewing and skills that promote self-regulation that could be shared with patients. We also know that bodies heal from physical ailments when nervous systems—in the brain, the heart and the stomach—are calm.
With changing social and political times, do you see any changes ahead for population-level behavioral health needs, particularly when it comes to ongoing refugee crises, emboldened xenophobia and racism, or the effects of poverty, anxiety, and funding cuts?
Unfortunately, yes. The emergence of a government that appears to threaten the safety of some citizens over others creates an environment in which the safety of all may feel at risk. The feeling of power differentials is traumatic and disrupts our sense of trust, which can overwhelm a person’s ability to cope. Complex trauma, in which the same or different intense events repeat over time, is correlated with behavioral health symptoms on the population level. This level of trauma impacts many aspects of people’s lives, including the ability to stay in school, maintain employment, keep relationships, and manage mental and physical health. This trauma often spans generations.
Symptoms of trauma often look like mental and physical illness, substance use, and other challenges. Researchers understand that people often exhibit severe symptoms as a reaction to past experience with trauma, or as a way to indirectly signal to others that they need help. Using this lens, “symptoms” are understood as attempts to survive. In other words, what appears as a set of symptoms may also represent a person’s current, best, and only solution to cope.
How would you respond to the themes and questions raised by the editorial in February’s Elevate?
I agree that “this is a crucial time for the public health field and its partners and allies to affirm and speak up strategically about evidence and priorities.” And that we need “to focus on prevention, social determinants, strengths, and other factors that shape population health.” Also, I agree with the idea that while “language is imperfect” we have a responsibility for “using it effectively, understanding its weight, and examining its influence on our priorities.”
My experience in behavioral health has taught me the importance of leveraging the language, metaphors, and experience of the audience in service of understanding something new. With this in mind, we need to advance the science of engaging people in their self-efficacy, in addition to advancing our ability to grow social movements in defense of health equity across populations. Given this, I do not think that a focus on behavior in our language will distract us from root causes—we need both. We need to increase our understanding of the skills, knowledge, and experiences that support mental health for individuals as much as we need to leverage our knowledge of social determinants in pursuit of social justice.
It’s important to go beyond the words. When I worked in county government, I was sent to a leadership training that taught new bureaucrats how to bring culture change into a rigid bureaucratic system. First, we were asked to recognize the talent of others and align, align, align. The task was to bring together people who share values and vision; celebrate and engage people with diverse skills, and engage people at different levels. We were taught to attract people who were interested in leadership roles, stay close to those who were ambivalent, and not engage people who were not interested in change.
We learned that when the opposition seeks to use its authority to divide and conquer, the best strategy is to align with people who share similar values and priorities. Eventually, the politics of unity outlast the politics of division.
Margaret Walkover, MPH, Chair of the American Public Health Association’s Mental Health Section and Lecturer at University of Hawaii – Manoa, Office of Public Health Studies & School of Nursing
Mikhaila Richards, MS, Communications Strategist at the National Coordinating Center for Public Health Training and NNPHI