One of the biggest things we can do at all three levels is to pay attention to the words we use. Language matters and is one of the biggest influences on stigma, discrimination and even access to care. Simply being more mindful of how we, as individuals, discuss mental illness is a good place to start. And at the policy level, what words and language do we use in our legislation? Our regulations? Our propositions? Our grants and funding requirements? Do we unintentionally let stigmatizing language into those? Changing this starts with a reconceptualization of what it means to have a mental illness, even a serious one. It’s common to say people “suffer,” but is that necessarily so? Dr. Marsha Linehan, the founder of dialectical behavior therapy (DBT), talks about suffering, influenced by mindfulness traditions, as a non-acceptance of our situation. The presence of symptoms and illness can cause discomfort, pain, etc., but is that always translated as suffering? I like to use the analogy of people in the ICU or even dying of cancer. Two folks with similar symptoms can respond very differently — one suffering and one not. Why do we almost always assume people with mental illness suffer? Can that contribute to stigma and discrimination? Does it reduce the hope that we can live fulfilling lives with behavioral health conditions? I would suggest changing language to something like “people with mental illness” or “people with behavioral health conditions.”
As part of my series about “Mental Health Champions” helping to normalize the focus on mental wellness, I had the pleasure to interview Dr. Josh Morgan. As SAS’ National Director of Behavioral Health and Whole Person Care, Dr. Josh Morgan helps public health agencies use data and analytics to support a person-centered approach to improving health outcomes. A licensed psychologist, Morgan was previously the San Bernardino County Department of Behavioral Health’s Chief of Behavioral Health Informatics. His clinical work includes adolescent self-injury, partial hospitalization, intensive outpatient programs, psychiatric inpatient units and university counseling centers. Morgan earned his Bachelor of Arts in religious studies from the University of California, Berkeley, and a PsyD (Doctor of Psychology) in clinical psychology with an emphasis in family psychology from Azusa Pacific University. He is also trained in dialectical behavior therapy.
Thank you so much for joining us! Can you tell us the “backstory” about what brought you to this specific career path?
I originally planned to go to film school (my wife is a voice actor, so I’m still somewhat close), but wanted to make a clearer direct impact on people’s daily lives. My goal was to help change people’s lives, primarily by helping them find hope.
After exploring several career paths, I found psychology was a very good fit, as it is focused on improving people’s lives and helping them find meaning. Or so I thought. Once I graduated, I kept facing roadblocks to wellness-oriented and even strengths-based care. It wasn’t a covered benefit. That’s not policy. Symptom reduction was to be the focus.
Leading a grant-funded program and being asked to report on outcomes internally and externally gave me the experiential insight into the power of data and analytics to advocate for good care, new benefits and health systems that are truly person-centered and strengths-based. If we can provide evidence that these are beneficial, both in human and fiscal outcomes, we can influence public policy, funding and even culture. This is also why I came to work for SAS. There was clear alignment in vision to use data for good, improving our overall communities.
According to Mental Health America’s report, over 44 million Americans have a mental health condition. Yet there’s still a stigma about mental illness. Can you share a few reasons you think this is so?
A big part of it has to do with the language we use that unintentionally perpetuates stigma. In conversations about integrated health, for instance, we talk about “mental/behavioral health” and then “physical health.” That implies mental/behavioral is not physical, when we know the opposite is true. And we value the physical more than the psychological, so it’s easier to dismiss the psychological.
As our health care culture, appropriately, shifts its focus to outcomes to determine if we’re making a difference in people’s lives, I believe we’re also unintentionally contributing to stigma. Think about the outcomes that are measured and emphasized by those holding the purse strings. Special government initiatives often focus on decreasing emergency department utilization, hospitalizations, criminal justice recidivism and homelessness. Insurance companies share similar priorities, but also consider expensive diseases those with behavioral health conditions may have.
For instance, a lot of the integrated health work is motivated by cost containment for expensive patients. This is not inherently bad, of course, but only focusing on cost containment fundamentally shifts our focus to the burdensome elements of care rather than a more holistic approach to both helping people and saving costs. California passed SB82, the Mental Wellness Act of 2013, to help address significant public costs for people with mental health conditions who often impact multiple systems, especially hospitals and the criminal justice system. Despite the name “Mental Wellness,” all of the outcomes are negative, talking about reducing hospitalizations, emergency department utilization, and criminal justice encounters. What message does it send when we only equate mental wellness with the absence of things that supposedly burden society?
These are important questions and outcomes. But, if this is all we report on, then when we talk about those with behavioral health conditions, the conversation focuses on how these citizens are filling up our emergency departments, hospitals, jails and streets (which is largely untrue, on average), and sucking up our tax dollars. How does that inspire a desire to want to help people?
It also reinforces the false idea that those with behavioral health conditions are “other people” rather than us. The people we’re talking about are our parents, siblings, cousins, children, friends, neighbors — and us. What else do we want policymakers and funders to know about our loved ones and ourselves? What are other positive and negative impacts of behavioral health? How else does treatment improve people’s lives beyond these narrow metrics? If we broaden out our measurement and reporting, might we have a more complete, accurate understanding of people? Could we build more compassion and empathy with a more whole-person perspective?
Can you tell our readers about how you are helping to de-stigmatize the focus on mental wellness?
My current efforts are around advocating for more whole-person approaches to data, analytics and evaluation, which are fundamentally person-centered and strengths-based. Rather than just reporting on symptoms and pathology, we should include other contextual factors.
This can include the buzz phrase “social determinants,” but even that can still be illness-focused and stigmatizing. What could make a provider write-off a patient as resistant or non-compliant to treatment, but are honest barriers to care? If we knew that, might they have more compassion and empathy? Might we, as a society, consider other policies and funding to address these system challenges?
More broadly, we also need to truly focus on strengths. Not only will this help reduce stigma, but many people want to have wellness, not just the absence of illness. Unfortunately, a lot of existing treatment ends when medical necessity (defined by the presence of impairing symptoms) is not present. With the inclusion of behavioral health as an essential health benefit, there are more opportunities for prevention and wellness work, which is rare.
A major reason for this is that we treat what we measure. I like using an analogy to education and complaints about “teaching to the test.” If your funding and rewards are tied to the tests, then you will focus all your efforts on achieving the results measured. Tests are not bad things in and of themselves, but they’re also not complete. And the things not included quickly become unimportant.
Social support is critical in behavioral health (and, realistically, in all health). It’s something most behavioral health providers will work on. Collateral contacts can even be billed at times. But how often do we really ask if we have helped consumers build relationships with family and loved ones (or even to establish meaningful relationships, in general)? How would that change our work and even how we view people?
Even for those with chronic serious mental illness, some of these folks may be permanently on disability. Does that mean they don’t have any role in our society? How would it impact everyone to intentionally weave those with behavioral health conditions into the fabric of society?
But these are not metrics we usually evaluate. So, it doesn’t show up on treatment plans and we have trouble justifying volunteerism, social connectedness, and other strengths that not only improve symptoms and reduce costs, but also improve wellness and combat stigma and discrimination.
Was there a story behind why you decided to launch this initiative?
It is really the culmination of several experiences building on one another, and I hope that continues. I was strongly trained in person-centered, strengths-based approaches, so I credit my doctoral program (Azusa Pacific University) for establishing these values and eye for this work.
When I first started being responsible for reporting outcomes on multiple programs, I really saw the significance of asking the right/wrong questions. Multiple intensive outpatient programs used the same symptom-focused questionnaire. My program, which was focused on adolescent self-injury with a very clear, concrete symptom reduction goals, performed very well. But another, more general program performed much worse. We heard story after story of the positive impact on the lives of the adolescents and their families, so why didn’t the data show that? It measured the wrong things. There was a major focus in the other program of improving communication and family relationships. However, it wasn’t measured, so they didn’t get credit for it.
As I worked in county government, I saw the same process repeated, both locally and in state/national conversations. Our providers would often perform fine on the standard metrics, but there was a lot missing. They made other differences in consumers’ lives but didn’t get credit for it.
This effort for more whole-person analytics not only benefits consumers directly, but it can also shape our systems. Providers can and should get credit for holistic person-centered, strengths-based work. Policies and funding need to align with those approaches. But we also need the data to provide evidence for these approaches. That’s the advocacy piece.
In your experience, what should a) individuals b) society, and c) the government do to better support people suffering from mental illness?
One of the biggest things we can do at all three levels is to pay attention to the words we use. Language matters and is one of the biggest influences on stigma, discrimination and even access to care. Simply being more mindful of how we, as individuals, discuss mental illness is a good place to start. And at the policy level, what words and language do we use in our legislation? Our regulations? Our propositions? Our grants and funding requirements? Do we unintentionally let stigmatizing language into those?
Changing this starts with a reconceptualization of what it means to have a mental illness, even a serious one. It’s common to say people “suffer,” but is that necessarily so? Dr. Marsha Linehan, the founder of dialectical behavior therapy (DBT), talks about suffering, influenced by mindfulness traditions, as a non-acceptance of our situation. The presence of symptoms and illness can cause discomfort, pain, etc., but is that always translated as suffering?
I like to use the analogy of people in the ICU or even dying of cancer. Two folks with similar symptoms can respond very differently — one suffering and one not.
Why do we almost always assume people with mental illness suffer? Can that contribute to stigma and discrimination? Does it reduce the hope that we can live fulfilling lives with behavioral health conditions? I would suggest changing language to something like “people with mental illness” or “people with behavioral health conditions.”
As a society, we need to accept and integrate folks with overt mental illness into daily life and give them an integral role. I say “overt mental illness” because people with mental illness are ubiquitous in society already. Fifty percent of people will meet criteria for a mental illness diagnosis at some point in their lives. This is important to remember when we are tempted to consider those with behavioral conditions as “the other.”
There is evidence that people with schizophrenia can have better outcomes in the developing world than in developed countries, even with our treatments and advanced medications. How can we help cultivate roles in society for everyone so that more of us have meaning, purpose, social connection, etc.?
There are many actions at individual and societal levels that can support this. I spend much of my time discussing this in a government context, though. Let’s go back to legislation and outcomes. How often do mandated outcomes from our government agencies include these more holistic, strengths-based goals? Could someone with serious mental illness still contribute to a community garden, for instance? It may sound simple, but what difference could that make in their lives as well as the community? What would change if we started including these positive goals as part of our legislation, regulations, funding, and overall outcomes? When our reporting only focuses on decreasing negative outcomes (which are important), we may unintentionally contribute to stigma and discrimination because all we talk about is the bad stuff going on with folks with behavioral health conditions.
Let’s start integrating more of the good. I have a blog post with more on this topic:
What are your 6 strategies you use to promote your own wellbeing and mental wellness? Can you please give a story or example for each?
What are your favorite books, podcasts, or resources that inspire you to be a mental health champion?
Viktor Frankl was my favorite theorist throughout graduate school, and I still credit him with my emphasis on meaning-making and a more holistic view. Man’s Search for Meaning is a short, very accessible book for a general audience. His other books are targeted at providers and go into more depth about the importance of meaning in life and behavioral health interventions.
Despite loving existential approaches, I was later intensively trained in Dialectical Behavior Therapy (DBT). I see major alignment between these approaches. Marsha Linehan’s (DBT founder) work and writings are excellent in providing evidence and concrete actions to move the field forward and combat stigma and discrimination. Her work was really motivated because of the stigma and discrimination within health care against those who are chronically suicidal. A big part of DBT is helping providers see the people in need differently and build compassion and empathy. Her work has helped ground the more philosophical existential ideas exemplified by Frankl into my work in analytics to find data and evidence to tell a story.
Finally, something a little less academic that I love reading regularly is virtually anything from the Greater Good Science Center. It’s based at my undergrad alma mater, UC Berkeley, so that helps, but it is inspirational for overall population wellness, compassion, empathy, strengths and growth, rooted in good science. They provide accessible updates on research, inspiration and concrete suggestions for improving individual and corporate life.
Thank you so much for these insights! This was so inspiring!