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Expand the Behavioral Health Field Beyond Its Medicalized Boundaries
The behavioral health field has a time-limited opportunity for expansion. We must decide how we will integrate with medical providers, especially primary care physicians (PCPs). Narrow types of integration exist today, limited by our field’s prevailing medical orientation, but we could expand significantly beyond these boundaries.
What shapes our medically based boundaries? They are formed by our field’s defining diagnoses, much like other healthcare specialties. Broader expansion means embracing a psychosocial approach that takes us beyond diagnostic categories. It means accepting a more prominent role in improving health and preventing illness in populations.
Consolidation in the healthcare industry will steadily impact our field and end its long independence. Therapists will transition to being salaried employees, much like 75% of US doctors today. New approaches to primary care are being tried now, but a standard way of integrating behavioral and medical care eventually will be accepted.
Expansion is a business decision, partly informed by the clinical orientation of our work. Orientation is a high-level abstraction that involves the models or paradigms framing our clinical solutions. We can stay within the bounds set by the medical model or expand with psychosocial solutions. Psychotherapy epitomizes these solutions, relying on a unique therapeutic relationship and diverse techniques.
Most practicing clinicians care little if their services are framed conceptually either as medical or psychosocial. Yet this distinction is becoming more consequential. Should our field be constrained to providing therapy as a medical service for specific diagnostic disorders, or might we adapt our psychosocial services to impact population health in new ways?
The Medicalization of Our Field
Clinical models matter, as seen in how medicalization circumscribes our work. Consider 3 examples. We largely limit our services to Diagnostic and Statistical Manual of Mental Disorders (DSM) conditions. We leave non-DSM issues to other specialties—e.g., we do not claim health behaviors as our field’s domain (despite contributing valuable health psychology research). Our current work with PCPs is consultative, secondary to their medical focus.
These points need amplification. For example, one might counter that therapists treat many clients without using diagnostically based clinical techniques. However, they must bill insurance with such a diagnosis, and a future medically dominated field might insist on a guideline-driven, standardized approach to therapy. It is conceivable that only specific therapy techniques would be authorized.
Our field includes health researchers and clinical consultants to PCPs focused on health behaviors. However, this is a small fraction of our workforce, and physicians do not see our field as leading on these issues. Accordingly, many doctors promote their specialty in “Lifestyle Medicine”. They might include a therapist on their team, but these medical specialists would be in charge. They represent “a rapidly emerging clinical discipline that focuses on intensive therapeutic lifestyle changes to treat chronic disease, often producing dramatic health benefits.”
Therapists increasingly are active in primary care, but staffing levels are low. One behavioral model for this work, the Collaborative Care Model, focuses mainly on medications, and another, Primary Care Behavioral Health (PCBH), is deeply medicalized. PCBH clinicians prioritize diagnostically based techniques and value post-licensure training to bolster knowledge of medical and behavioral diagnoses.
These examples highlight a single point. The medical model is the dominant model in healthcare, and in the future, our field could be compelled to accept its direction—this could impact how therapy is practiced and how we function in the primary care setting. Yet, an alternative is possible.
Expansion Via the Psychosocial Model
Traditional therapy is not needed for everyone with behavioral needs. Many can benefit from brief work with an empathic therapist to focus on health behaviors, life stressors, early signs of depression, and so on. Primary care relies on trusting relationships for intermittent, longitudinal work—a good fit for us.
Patients need specialists skilled in behavior change, but healthcare has many volunteers for such work. For example, lifestyle medicine MDs and unlicensed “behavioral counselors” are growing. Yet not all services are equivalent or interchangeable.
A medicalized approach promotes fidelity to therapeutic techniques and, when possible, manualizes them for use by licensed or unlicensed staff. By contrast, a psychosocial view stresses the therapist, the person providing care, as driving more clinical change than therapeutic techniques. It values psychosocial work as a unique healing paradigm comparable to the medical model.
This psychosocial view is a driving force behind Primary Behavioral Care, a proposed reorganization of the primary care setting to incorporate a new level of behavioral care. Some PCPs may be surprised by its boldness but will like its scalable solutions. This level of care has many features, but it essentially ramps up licensed therapists (along with tech support systems) and pursues underutilized funding sources well-suited for this setting.
Our field is quintessentially bio-psychosocial, but we can grow today based on its psychosocial dimension. The real challenge is not understanding the fine points of these theoretical issues. Instead, we need leaders to seize this opportunity for business expansion. A simple idea should drive them—therapists are highly effective change agents who need a formal base for their services in primary care.
Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health.
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
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