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Viewing Behavior Change Through the Lens of Primary Care

October 05, 2020

I have worked for years on integrating behavioral and primary care. This has brought me into contact with many primary care physicians. They have educated me on the priorities and issues unique to their clinical setting. It is always good to see the world from another’s perspective, especially when your goal is to move into their domain with big plans for change.

Any professional might react negatively to unsolicited outside advice. Moving behavioral healthcare professionals into the primary care setting will demand a compelling clinical justification. Why would PCPs welcome such a move when they have bigger business challenges to address and already manage behavioral health issues? Afterall, they heavily prescribe psychotropics for a range of problems.

Today’s decision makers about how to deliver care are more likely to be corporate leaders than care providers. Nonetheless, PCPs must be engaged in any change process. Successful collaboration will depend on their trust. We should proceed with a clear understanding of their worldview. Effective messaging always starts by knowing your audience.

I have worked closely in the past year with a PCP colleague on establishing a pilot to test our ideas on collaboration. He has taught me that doctors take a practical clinical approach. Research results are important to start a serious conversation, but the focus quickly becomes patient care. A letter he recently submitted to a medical journal contains a precise statement about what is needed. He argued:

Behavior change must become a tool in primary care used proportionate to its great impact on chronic disease.

His language is striking. “Behavior change” is used as if it is a medical treatment. “Proportionate” is remarkably exact. I imagine a chemist finding the right dosage of behavior change for every case of chronic disease. He wants another “tool” to use as he solves each clinical puzzle. Yet I have a different mental image of this behavior change scenario. It is more focused on the process of care.

I see a complex interpersonal situation in which two people explore uncomfortable issues. The patient is searching for personal reasons to change. The relationship is unique as a safe place. Thoughts and feelings stand out more than behaviors, but the goals relate to behavior and lifestyle. This process is foreign to the PCP. Most avoid such difficult discussions. They need therapists to assume this role.

Let us assume that therapists facilitate behavior change. What messaging will mobilize PCPs to welcome us into their practices? They want to provide better care for more patients. They are not interested in the process of care described here, except to know there is a “secret sauce” providing the results. A good salesperson has a nice tip to offer. Start by understanding your customer’s pain.

What is the context in which PCPs operate? Many are retiring early or leaving private practice for large healthcare systems. Most are enraged at the administrative burden of electronic health records. Apart from practical frustrations, most are aware that unhealthy behaviors fuel an epidemic of chronic medical conditions. They want better tools to make themselves more valuable to patients and payers.

Many physicians are also aware that distress drives doctor visits for problems with no medical origin. Is this too an opportunity to prescribe behavior change? Behavior change may seem an odd name for treatment focused on many aspects of life. Yet medicines for one purpose are often prescribed for another. The bigger question is if behavior change attacks root causes or gives temporary relief.

The lens of primary care is dispassionate and results oriented. It also lacks a biological bias. Exposure to biological psychiatry might give one the impression that physicians expect any solution to ultimately be biological in nature. Yet PCPs did not announce an era of biological internal medicine. They had no period of talking cures to erase. PCPs long ago accepted that lifestyle changes can transform people.

PCPs also understand that countless patients are unhealthy, stressed, and seemingly unable to change. Are we on firm ground volunteering psychotherapists to enter this setting to use their traditional skills in new ways? Physicians want simple answers. Will our tools work like others they use? Our honest answer is maybe. PCPs are used to partial solutions. Cures are not expected for everything.

There are two ways to approach psychotherapy and research on its results. A diagnosis-driven model asks what disorder or condition is being treated, and then evaluates targeted treatments. For example, how is psychotherapy for reducing obesity? This model presumes we need a tailored clinical approach for each disorder. Findings accumulate slowly given that many potential targets exist for research.

The second empirical path rests on the general value of therapy. People seeking help to improve their lives represent a fair test for therapy. Psychotherapy is quite effective across countless studies (i.e., a large effect size of 0.8). We can tell PCPs that psychotherapists will have the desired impact for many patients, but not all. The reality is that we should refine our work in this setting to maximize results.

Refinement might follow the model described by Atul Gawande in his New Yorker article about the pandemic. He notes that the impact from hand washing, masking and social distancing on a standalone basis is low, but the combined use of each is highly effective at containment. Therapy for unhealthy behaviors may be similar. Therapists may need a combination of approaches for each patient.

Dr. Gawande notes that combining social solutions for the pandemic makes sense to him as a physician. It parallels work with combination therapies or so-called “drug cocktails.” We have been able to stop metastatic cancers and the progression of HIV using combined therapies. The lesson is clear. Physicians view new treatments through the filter of what they have seen work in practice.

This leads to the issue of trust. PCPs want a grounding in empirical results. They want to understand how talking helps, and they will quickly grasp that therapy is not a simple injection of motivation to change. It addresses the unique thoughts, feelings, and behaviors for each person. Motivation is personal. Root causes are specific rather than general. Such clarity will help build trust in therapists.

Psychotherapists do not start with strong credibility. Distorted media images are layered onto the murkiness of working in a confidential bubble. There are professional and personal dimensions to building trust. We need our executives and clinical leaders to begin a dialogue with PCPs. Show them we understand their world. Make our services more appealing. Use those valuable relationship skills.

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

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