ADVERTISEMENT
Fulfilling the Biopsychosocial Model Requires Psychiatric Leadership
The biopsychosocial model was conceived by a psychiatrist. It reflects the breadth of thinking one might expect when a physician focuses on the mind. It predictably starts with biology, extends to the psychological depths of experience, and encompasses the social determinants of physical and mental health. Psychiatrists in the mold of its creator, George Engel, still exist, even if biology now dominates the profession in many ways.
The past decade has launched a new era for behavioral healthcare as our institutions are incorporated into larger healthcare entities. Yet we need better medical-behavioral integration models. Psychiatry is growing its biomedical tools for a subset of patients, but these advances alone will not transform healthcare. This lofty goal of transformation may depend on making a biopsychosocial orientation central for all healthcare.
Psychiatrists are ideal for leadership positions in healthcare’s multi-specialty environment. They are the quintessential medical-behavioral clinicians, straddling 2 service settings which are ripe for implementing a model with a biopsychosocial orientation. Specialty behavioral healthcare is an obvious domain, but the primary care setting is a larger arena with a wider range of patients to impact.
A biopsychosocial orientation has been both accepted and marginalized in psychiatry. It remains incidental for those primarily focused on biomedical breakthroughs, a view that can often appear to demean the psychosocial domain. Some dismiss psychotherapy as ineffective in spite of its robust empirical support, and there is a mistaken tendency to only view structured therapies like CBT as having empirical validation.
Many psychiatrists value psychotherapy and easily accept the idea that biomedical and psychosocial interventions are the twin pillars of our field. Yet they also know that neither medication nor formal therapy nor both can resolve every psychosocial issue that drives the health status of patients in the primary care setting. This is where Engel’s vision of the biopsychosocial matters most.
Engel understood the power of the mundane. While psychopathology has a profound impact on health and illness, so too do common thoughts, concerns, feelings, and behaviors too often dismissed as trivial by many clinicians. This is one area where psychiatry’s collaborative care model falls short. It primarily focuses on diagnosing and treating disorders like depression and anxiety, while neglecting the maladaptive attitudes and behaviors that can be as impactful.
The biopsychosocial model does not aim to improve the psychiatric skills of medical providers. It helps all physicians maintain a holistic focus. Consider care after a heart attack. We praise programs that screen for depression, a common and debilitating co-occurrence, but every maladaptive response needs similar attention. We know that successful biological results are often enhanced by addressing underlying psychosocial factors.
These interventions are, perhaps, best delivered by talented therapists able to maximize brief interactions, best led by psychiatrists with broad clinical knowledge, and best managed by executives familiar and comfortable with complex systems. Each individual function is vital, as is the traditional work of PCPs, and yet the presence of a dedicated psychiatrist may be the critical piece, and one too often glaringly absent in the primary care setting.
However uncommon, this practice configuration is not unimaginable. Psychiatrists mostly practice independently and are rarely called to consult with PCPs today. Again, the collaborative care model promotes active consultation but with a specific diagnostic focus. Few PCPs or psychiatrists are lobbying for a broad partnership currently, and yet we envision that they would surely embrace a highly successful new clinical model.
It may be time to question the impact of placing therapists in primary care settings without a psychiatrist fully or even tangentially engaged there. The question is not whether therapists can work well independently. Instead, might the entire team, including the PCP, function optimally with a medically trained leader, skilled in psychosocial care as an integral part? Is psychiatric leadership the missing ingredient for teams to fully realize the biopsychosocial paradigm?
This may be a problem solved in stages. As a realistic consideration, the challenge of working on such a team may be most appealing to psychiatrists early in their careers. Training programs regularly tout the promise of collaborative care. The well documented shortage of psychiatrists may also limit this approach. Certainly, these unique teams will mature over time. The presence of a full-time psychiatrist may become less essential once there is widespread understanding, support, and experience with this model.
Improving primary care early and often is a top priority in our healthcare system today, and most reform proposals include greater focus on aspects behavioral and social care. Some are quite modest and only include health coaches or envision traditional therapy with subsets of patients or conditions. Defining primary care as fundamentally a biopsychosocial enterprise is new territory. Our field must carry that idea forward.
We should implement this timeless model with the best team possible, using clinicians with the training and creativity to apply their skills to diverse, often unfamiliar challenges. Few ideas for healthcare reform have such wide applicability nor match its potential for improving population health. The clinicians leading this charge should be masters of all 3 of its dimensions of care.
The biopsychosocial orientation is a gem never fully tested in the right healthcare setting. Today’s primary care is that setting. Psychiatrists personify the concept. However, none of this can happen without strong executives forging a new business reality. Executives are needed to make the timeless timely.
Ed Jones, PhD, is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health. Chris Dennis, MD, is the chief behavioral health officer for Landmark Health and co-founder of Minded.
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.
References
