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Perspectives

Paradigm Shift: Reimagining Primary Care in Partnership with BH Leaders

January 18, 2021

PCPs are often told they do not prescribe as well as psychiatrists nor modify patient behavior as well as psychotherapists. On the other hand, behavioral healthcare professionals typically lack the abiding commitment of PCPs to both body and mind. Psychiatrists focus largely on biology, therapists on behavior, while PCPs explore all options as they tackle every conceivable healthcare problem.

Primary care physicians chose their specialty based on a desire to engage and communicate with patients. The importance of behavior change was taught from day one. So too was the need to gain patient trust. The full armamentarium of biological solutions for every bodily system was also taught, including the nuances of prescribing psychotropic medications.

PCPs take criticism from specialists in stride. They are not surprised by comments that they do not prescribe as expertly as cardiologists or psychiatrists. They are aware that psychotherapists have skills they lack. That is the point of primary care. Patients present every complaint for diagnosis and relief. Referrals for specialty consultation are given for problems that are obscure, complex or unresponsive.

The phrase “biological psychiatry” reveals a core insecurity. It expresses the urgency of psychiatry’s tie to the biomedical world. PCPs have no such worries. They roam the mind-body continuum and welcome help from all quarters. They know the big missing piece in their toolkit is making behavior change happen. Some are now seeing that this piece could launch fundamental changes in primary care.

What principles guide PCPs today? Results matter far more than any theoretical bias. PCPs are generally not dogmatic, and hyper-specialization is antithetical to their work. They know enough about every specialty to provide good general care. They know that they provide some treatments as effectively as specialists, but not all. Their advantage over specialists is intervening early with problems.

PCPs are not equally familiar or comfortable with every treatment along the mind-body continuum. They respect behavior change solutions but often lack the training, skill, or even motivation to learn more. Pharmacological solutions multiply every year, as do the patients explicitly requesting them. Many decry how this medication focus impacts the communication side of primary care.

Primary care needs to be reconstituted with a new treatment team of clinicians equipped with tools across the mind-body continuum. Therapists need to bring their skills building therapeutic alliances. Their interventions must fit into brief and virtual contacts. They will need to learn how to enhance emotional health in a clinical setting where patients are coping with a wide range of physical ailments.

Why is this an important development for the behavioral healthcare field? It is an opportunity to reconstitute the field with a modern understanding of brain and behavior. We can reorganize our work as part of primary care, oriented by the biopsychosocial model.  Sadly, only a fraction of those needing our services get them today. As primary care services, our work becomes easily accessible.

Can clinicians do this alone? Do PCPs and behavioral health professionals just need a solid clinical model? Will the details work themselves out after that? Hardly. This is a healthcare delivery issue and a problem for those skilled in operations. The administrators within behavioral healthcare are critical partners. The literature on integration largely addresses it as a clinical problem to be solved.

Describing change can be difficult. Integration is a worn-out slogan. Primary care and behavioral health can be combined in many ways. Yet we need a descriptor. Paradigm is another overused term, but it seems to fit the basic changes to theory and practice described here. This paradigm shift would not only transform two professions, but it would also change how care is experienced in our country.

Much is new in this paradigm. Virtual services are gaining support for improving access, and in this new primary care configuration digital care is potentiated. We need executives to iron out a new workflow with therapists working in exam rooms. They will surrender their comfortable chairs, navigate the fast-paced world of brief interventions, and impact many more lives than they ever could previously.

Executives have unique skills, including both formal and informal knowledge. No integration model can succeed without the design and support of executives from each world. Change is hardly a foregone conclusion. We need executives rallying their forces to define and defend a new paradigm. The complexity of our healthcare system is well-known. Successful reformers find a way to cope with it.

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

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