Visualizing the whole of health
Why our reductionistic approach to mental health misses the mark
A few years back, my team at Colorado had been asked to help write framework for a large foundation. Our goal? How to more comprehensively tackle the issue of integrating mental health and primary care. On the surface, it seemed like a pretty simple task. We would lift up the obvious things like delivery innovation, payment reform, policy change, and training and education. And while those issues were indeed in need of attention, it was clear from our process that only doing those things weren’t going to move the needle very far for mental health. Without careful attention, our framework could have overly simplified the issue leaving us in a place where we had a beautiful product, but a product that didn’t do much to advance our goals.
It's been almost seven years since the report was released, and I still think about it often. While the framework and recommendations were sound, what stuck with me was how we challenged the field to think bigger. We included ideas like “organizing the field” and “building a movement,” and emphasized the need to look beyond the walls of a clinic to consider more critical factors like housing, education, employment, and the environment. Said differently, our framework attempted to embrace the inherent complexity of improving mental health and brought in elements not typically thought of in these exercises.
Throughout my career, I've developed many frameworks that aim to simplify complexity and organize different aspects of a problem into actionable categories for decision makers. In mental health, there are quite a few frameworks out there to choose from - some better than others - but they all are trying to point to the need to advance mental health. In reviewing many of these frameworks, it got me thinking more about what happens when this work starts to work against our goal.
I’ve found that there’s a natural tendency in our attempt to develop and use these frameworks that we start to reduce our action items into manageable chunks, which can cause us to lose the intended impact. Additionally, we can lose sight of the connection between different facets of mental health, reducing it down to the actions that one leader in one sector needs to take; we reduce it down until it starts to lose its power and moves us away from critical concepts like integration and comprehensiveness.
Recently, a colleague created an innovative tool called The Well-Being Sphere, which provides a comprehensive overview of the current state of mental health and well-being in the US. This visual presentation looks at 92 multifaceted issues that impact mental health and aims to capture and visualize fragmented pieces of mental health care to allow viewers to comprehend the issues and explore solutions with a more whole person, whole community, and comprehensive perspective.
The Well-Being Sphere is not a survey or assessment tool, which often oversimplifies data; instead, it’s a Unified Reflectment Instrument, which is a tool designed to help individuals or groups reflect on complex topics in a structured way by presenting information as trends to promote a more holistic understanding of the subject at hand, encourage creative and critical thinking, and identify areas where more information is needed. When you look at all the items that go into our mental health and well-being, it allows us the chance to go deeper on the issue. Tools like this push us to better prioritize and collect data that might be missing, encourages us to see connections that may not be obvious, and I for one, find it to be a novel online conversation map that uses contextual reasoning to clarify the content.
The Well-Being Sphere is another reminder that we need must better visualize the complexity surrounding mental health in our assessments and solutions. If you find yourself in a position to be helping create a framework for mental health transformation in your community, there are a few key things you should pay attention to.
Focus on the person, their family, and their community: If we begin a framework without thinking about who we are ultimately trying to help, we have missed the point. The end user must be central to the design, including being a part of the thinking about the plan. Designing a framework for action without the inclusion of the people most impacted by the plan is irresponsible and can lead to another document that doesn’t really meet the needs of the community. Pro tip: don’t put the person or their family in a bubble at the center of your framework as it makes them looked trapped and works against your intent to have them prioritized!
Prioritize actions that can have the most impact: There’s a tendency in frameworks to look at the easiest things we can do. We put those first when in reality they may be the equivalent of using a spray bottle on a forest fire. Rather than start with those wins we know we can achieve with a little help, force yourself to go bigger and let your sequencing and strategy reflect that. For example, when I worked on the Healing the Nation framework, we intentionally placed vital community conditions first in our framework as the foundation for achieving our goals for mental health and well-being. While our focus was ultimately on mental health, including other issues like access and coverage, we knew that any framework that did not see community conditions as foundational would never be thorough enough for transformative change.
Measurable goals: One of the most powerful questions you can ask yourself when looking at a framework is “how do you know?” Think about it. If someone uses your framework, how will they know they have achieved the goals of the framework if they don’t measure. Offering up your intended impact and how you will measure what you do will only add value to those trying to use your framework. Without this, it almost becomes an academic exercise or one grounded entirely in theory and not action. For broader adoption, acceptability, and relevance, list the outcomes you expect on your framework alongside how you would measure it.
Multisector partnership and possibilities: A key driver of achieving major mental health reform is the need to broaden the parties responsible for mental health. We can’t create a framework that relies entirely on the mental health system to do all the things that need to be done; no, that system is already stretched too thin. Sure, the mental health system can be a component of your redesign, but it can’t be the only partner responsible for doing things. Frameworks that bring more people into the change process, share measures and accountability are far more likely to achieve impact and the intended goals. We need public-private partnerships, and our frameworks should allow for everyone to see a place for themselves on it.
Let’s stop being so simple with our thoughts about mental health redesign and embrace the actual complexity of meaningful reform. Frameworks are important for mental health redesign because they provide a structured approach for understanding and addressing the complex interplay of factors that contribute to mental health and well-being. As we know, mental health is not just about the absence of mental illness; it is a state of complete physical, mental, and social well-being and includes factors that are far outside the clinical setting. Our frameworks must help organize the many different aspects of mental health, such as individual, community, and societal factors, into categories that leaders can take action on through their programs, policies, and investments.
Ben, have you considered pursuing the open role for Commissioner of Colorado’s Behavioral Health Administration? It’s a Cabinet-level position and we need someone leading the BHA who has this kind of ecosystem-mapping, integrative perspective.
We as a society, community, and country must address the growing need for easily accessible resources to address the behavioral aspects of health. Resources for prevention, early intervention, diagnosis and treatment at the lowest and most cost effective level will save money, pain, and possibly lives.....