The Universal Behavior Model: A Comprehensive Approach to Integrated Care

The views expressed in Perspective pieces are solely those of the author and do not necessarily reflect the views of Psych Congress Network, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspective entries are not medical advice.

Paul McCartney wrote timeless songs.  His 1966 reflection on loneliness, Eleanor Rigby, resonates with healthcare professionals today since research has identified loneliness as a common and powerful driver of physical and mental health.  McCartney’s question remains, where do they all belong?  Some may need care for an underlying depression, but the critical question is not one of diagnosis.

Loneliness highlights how the human condition often involves pain. A caring response is needed, but medicalization does not take us in the right direction.  We know that loneliness is not trivial.  It makes people unproductive at work, isolative at home, and less likely to engage in a healthy lifestyle. Lonely people may sabotage relationships, develop metabolic syndrome, and forget to take medications.
Lonely people present themselves for routine primary care every day.  PCPs generally inquire little about it, yet this is exactly where lonely people belong—where we can see them. This is the first step in helping people who are lonely or struggling in other ordinary ways. Yet the primary care setting needs some adjustments to better respond to their needs.

PCPs can start by remembering the mnemonic, Behavior in All Diagnoses (BiAD), with every patient.  This clinical reminder was created by my primary care colleague, Norm Ryan, MD, and he also named the related conceptual framework, the Universal Behavior Model.  This stands in contrast to the more familiar, Collaborative Care Model. Universality is the key idea in this new model.

Our behavior (combined with thinking and feeling) is a critical factor in promoting illness or health.  The universality of behavior as a driver of health status is easily understood.

Yet it is easily ignored in our multispecialty, organ-focused healthcare system.  What is missing?  We need psychotherapists based in primary care, often focused on mundane issues rather than the complexities of diagnosis or treatment.

Whereas the Collaborative Care Model addresses a subset of primary care patients with psychiatric diagnoses often needing medication adjustments, the Universal Behavior Model addresses every patient and every condition due to the ubiquity of behavior. PCPs can learn to engage more in this process, but therapists are needed for a new type of triage—one devoted to everyday concerns.

“All the lonely people” belong in primary care for conversations about improving their overall health. Therapists do not meet all needs, but that process can begin here. The therapist can decide on the appropriate type of engagement for each individual.  Some may need to engage community resources, others might benefit from digital therapeutics, while a course of formal therapy may be essential for others.

We miss this psychosocial aspect of care today.  Let us not blame PCPs for being unequipped to help.  The medical focus can function as blinders.  Consider the Collaborative Care Model.  It is a psychiatric model originating in diagnosis.  It selects those with depression and other advanced diagnostic conditions for attention.  Yet others, like some “lonely people,” may have deteriorating health too.

We do not need immediate answers for everyone.  PCPs are often satisfied planting seeds for patients, waiting to see when they might be ready for lifestyle changes.  The problem is that PCPs do not uncover most of the unmet psychosocial needs of their patients, and they can be quickly outside their comfort range when they do.  The Universal Behavior Model opens up another dimension to care.

Therapists specialize in this care dimension and know the enormity of it.  NAMI suggests “nearly half of the 60 million adults and children living with mental health conditions in the United States go without any treatment.”  Add the millions with pre-clinical conditions and maladaptive behaviors.  Remember human conditions like loneliness.  While a major pathway to health is behavior, it needs to be paved through primary care.  

Critics of our healthcare system fault it as more a sick care than health care system.  If we are to shift to a greater focus on health and wellbeing, then we are largely shifting to changing behavior.  This shift must account for social context as well, given that many existing health inequities are socially determined.  Doctors are beginning to see medical care as part of a connecting chain with psychosocial solutions upstream.

The Collaborative Care Model has numerous studies showing its value for certain primary care patients.  The Universal Behavior Model is not focused on specific diagnostic groups and lacks empirical studies.  It is a clinical model promoting the centrality of behavior to health status, but it is more fundamentally a professional and structural model. It asks all clinicians to think and act differently.

PCPs must affirm the essential role of behavior and integrate therapists into their practice setting.  Therapists must embrace a new way to improve care access and use their therapeutic skills as needed. Practice managers can debate this reorganization. There are probably many good ways to integrate therapists into primary care. We need a sense of urgency about this neglected dimension of 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.