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Beyond Integrated: "Inseparable" a More Accurate Reflection of Our Services
Making your message distinct from others is sometimes challenging. Despite clarifications, some hear your message as being like every other. Word choice is often part of the problem. For example, integration is a popular healthcare goal, whether framed as medical-behavioral integration or behavioral and primary care integration.
The most prominent model for integration is the collaborative care model. It essentially connects primary care physicians (PCPs) with a psychiatric consultant and a care manager to optimize the prescribing of psychotropics. This is a positive, yet limited step. However, the word “integration” gets in the way whenever clinical collaboration is described from other vantage points.
One new framework is epitomized by an alternative word: inseparable. It is not only distinct from integration, but its value can be traced from neuroscience to clinical practice to healthcare funding.
Integration models make a basic mistake. They seek to connect the silos in our fragmented care system. Yet it is insufficient to patch over divisions that were ill-conceived initially. Reform should begin with the premise that medical and behavioral care are equal and inseparable. Integrated care tries to unite systems long treated as unequal. Evidence of their equality is growing and requires a new start.
How are medical and behavioral services equal? Their equality lies in how they impact our health status. If one accepts this clinical equality, it follows that our healthcare system should value and fund them equally. The idea of equality initially seems strange because biomedical advances have led us to rightly cherish the medical model. This can be rectified by understanding the inseparability of the two.
Physicians see this vividly in how patients respond to treatment. Medical illnesses are impacted by psychological and social experiences. Consider the common example of how loneliness or social support impacts coping with illness. Psychosocial factors can either improve or worsen the state of illness. Accordingly, doctors should consider behavior in all diagnoses (BiAD).
Some are using the term “inseparable” to reinforce the idea that serious mental illnesses are diseases like any other, despite being separated and stigmatized socially. This new use of the term highlights the unacceptability of discrimination in healthcare, but it is ancillary to the foundational concept of mind-body inseparability.
Neuroscience embraces inseparability. Old dichotomies have been abandoned since mind and body are well understood as interdependent. The plasticity of the brain is now clear. Research shows how life experience fosters brain development and molds the brain’s circuitry. While brain circuitry may be shaped by experience, our life experiences require brain functioning to exist. Separating them is a theoretical mistake with serious practical implications.
This clarifies how primary care has been misguided since its inception. PCPs should be routinely collaborating with behavioral experts to provide comprehensive care. Medical care is profoundly lacking without equal, inseparable behavioral care. This takes us beyond caring for diagnosable behavioral health disorders and is why the collaborative care model is so limited. We need a new model.
The universal behavior model is an alternative framework recognizing inseparability, and it acknowledges some practical complexities. For example, people may have dysfunctional attitudes and behaviors interfering with health, and yet how might therapists impact this during routine office visits? More is involved than simply giving therapists lists of useful interventions.
Clinicians preferably use tools that have been well validated, and in this regard, psychotherapy is a bit complicated. The evidence shows it to be “remarkably efficacious,” but research also shows improvement to rely more on the therapist than any specific procedures. Improvement in both physical and mental health often relies on changed thoughts, feelings, and behaviors. Therapy discussions may be more unique for their focus (personal issues) and emotional tone (non-judgmental empathy) than the techniques used. This valuable process could work equally well in medical settings.
Unfortunately, inseparable care is a new idea, whereas integrated care (especially, collaborative care) is known and trusted after many implementations and empirical studies. Yet, many are ready for a more comprehensive approach to care. Inseparability is intimately tied to our field’s psychosocial roots. Those origins are relevant today as we engage in becoming full participants in general healthcare.
Let us start with language and patience. We should find and replace the word integration with the concept of inseparability. However, since our field has only recently matured as a biopsychosocial enterprise, we must adopt a long-term view. Meeting medical care on equal terms is a bold new idea.
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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