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Perspectives

Against the Medicalization of Behavioral Healthcare

February 11, 2020

Our field has an identity problem. We are tied to the juggernaut called the medical model. It has generated solutions that have transformed human history, not just the lives of individuals. Any field would want to be part of that story. Yet membership requires looking at problems in a specific way. You may embrace the prestige of the medical model, but you get the clinical focus that comes with it.

The highly successful medical model promises cures for many diagnostic entities. A dilemma is created when this model exceeds its scope and fails to meet its promise. There are many wonderful, life-saving psychiatric medications. That is not up for debate. The pervasiveness of the medical model for solving all our ills is the issue we must confront.

People with cancer and heart disease expect a cure and they often get one through surgery, medication or both. Behavioral health conditions have few cures today, partly since we are focusing on curing aspects of the human condition. Can we cure depression? We can try to limit claims for a cure to specific, potentially biological types. Yet medical model proponents counter with bold dreams.

Many critiques of the medical model have been written, but that is not the purpose here. The goal is to point out where the medical model is not needed and where an alternative exists to help people. This alternative, the consolidated behavioral health (CBH) model, has been described in previous articles, and the remaining debate is how the medical model might diminish the potential of CBH.

Many people fighting stigma believe the medical model has been a friend in this fight. For example, the medicalization of depression helps explain what has been previously opaque. It was a major advancement to view alcoholism as a disease rather than a moral failure. Many are rightly worried about leaving the protection of the medical model.

These gains will not be surrendered under the CBH model. We will remain in a powerful clinical model rather than returning to confusion and moral judgement. A parallel path for normalizing behavioral health issues will be described here. It should be stressed that we can embrace the CBH model and still value psychiatric medications. They exist in parallel.

There will be many more biological solutions developed for biologically based disorders. This does not mean that the entire behavioral healthcare field should be medicalized. The CBH clinical model calls for embracing non-clinical problems, like lifestyle behavior change, that do not call for medication. We also embrace the remarkably efficacious treatments under the general heading of psychotherapy.

One might ask why we need an alternative to the successful medical model which confers legitimacy to disorders included in the diagnostic manual. Reimbursement is an enticing reason to get under the medical umbrella. Yet our powerful services need promotion under their own auspices. The medical model has a dark side, as a bright beacon illuminating inflated hopes for cures that may never exist.

The substance use disorder arena offers a very clear example. Medication-assisted treatment (MAT) is essential for those seeking to end opiate addiction. Psychosocial treatments are essential for recovery. There is no conflict here, only synergy. The biopsychosocial model should be a guiding light. However, it is obscured by the medical model decades after being articulated. Its light is dim in comparison.

Let’s celebrate MAT as adjunctive to treatment, rather than a cure. Let’s situate SUD treatment under the CBH behavior change model and take hopes for a medical cure off the table for now. If one arrives, we can adjust then. Let’s normalize addiction as a behavioral problem that people have battled for millennia. Calling SUD a brain disorder is like pointing to the brain as the site of the mind.

Can treatment providers be adequately reimbursed for behavior change services? There is no question that calling problems illnesses will ease the process of payment. Can we then classify behavioral health problems as a distinct category for healthcare reimbursement? Something like this will need debate. Lifestyle health behaviors may tip the cost-benefit analysis in our favor forever. How?

The CBH clinical model contemplates leveraging knowledge gained in the treatment of mental health and SUD problems for changing lifestyle health behaviors. Realization of that promise could reduce healthcare costs that today are included in the 50% of costs attributable to chronic health conditions. Achieving that goal would make behavior change as valuable from a cost perspective as many cures.

The title of this article might suggest an ideological agenda to some. This is partly because questioning the medical model seems heretical. However, this article, like the CBH model, is driven by empirical research. Ideological biases seem more prominent with those who argue we will ultimately have medical solutions to all behavioral health problems. They allow belief to eclipse research.

This is not a time for supporters of any clinical model to be self-satisfied. The field could use new and better psychotropic medications. Behavior change is real but highly dependent on the change agents, as seen in the literature on therapist effects. The promise of the CBH model for generating better solutions by integrating knowledge from its three domains seems fair. But it is just a promise.

The goal is to have clinical models fairly valued and funded in their own rights. The medical model is having no trouble. The economics of behavior change do not scale as well, especially when one-to-one interpersonal interventions seem necessary. This will be an impediment at times, but success stories exist. Psychotherapy in some cases may be more cost-effective over time than pharmacotherapy.

Opposition to a behavioral model is fed by a constant search for underlying biological causes. Psychology starts with thoughts, feelings and behaviors that we all experience. Some innovators seek causes behind those experiences. Freud epitomizes the many pioneers who developed complex explanatory systems with minimal value. Human experience is still a good and productive guide.

The behavior change model is rooted in experience, but not in a view of people as rational actors. We are emotional, self-defeating, and complicated. Psychotherapy, as the paradigmatic behavior change intervention, often finds strong motivations outside the everyday consciousness of people. We can harness decades of knowledge to help people make lasting changes that vastly improve lives.

Clinical models have value for generating new solutions and organizing established findings. The medical model has proven itself and need not overreach. Medicalizing behavior is a step too far. CBH is also a powerful model with millions of people deriving benefit every day. Let’s celebrate our field as combining medical and behavioral models. Evidence will be our best roadmap over time.

Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.

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