Integrated Behavioral Health and Primary Care: A Common Language

Fig. 2.1

A family tree of terms encountered in integrated behavioral health or collaborative care

Necessary components of integrated behavioral health. What actually has to be in place for a particular practice to be regarded as doing integrated behavioral health? This question posed the more difficult challenge, and is not fulfilled by the “family tree of terms.” It is all too easy for a practice or clinician to say, “Integrated behavioral health—yes we already do that. We have a social worker in the hospital and a psychiatrist across town on our referral list.” But for many, this would not count as a genuine instance of integrated behavioral health care. But on what basis? Who says? What is the package of functional components we all agree is necessary for a particular practice to be doing integrated behavioral health? This was important for many reasons—identifying genuine instances of integrated care in practice, enrolling practices in research, identifying differences between them—and of course knowing what you are buying and what functions you want to support if you are designing a system, payment model, or public policy.

Without common language for the subject matter and what counts as the genuine article, creating a national research agenda and other developmental tasks for the field would be difficult to accomplish. One of the conference tasks was to create a usable “lexicon” or system of concepts for this new (or newly rediscovered) field.

The 2009 conference experience led to a two-stage process to develop a lexicon or functional definition for behavioral health integrated in primary care. The first stage was to convene a subset of the planning committee to use a systematic lexicon development method to create a product for use only at that conference (Peek, 2011). The second stage was an AHRQ funded conference in 2012 to broaden and deepen that starter lexicon among members of the AHRQ National Academy Integration Council, a steering group for the Academy for Integration of Behavioral Health and Primary Care. Patient representatives were also included in this process.

Conceptual Confusion Is a Normal Stage of Development for Emerging Fields

The research conference committee decided it had to sharpen concepts and language if it was to successfully create a research agenda—the “deliverable” of the funded conference. And later, the AHRQ Integration Academy broadened and deepened the lexicon for its purposes—which included measures of integration (AHRQ, 2013), and workforce competencies—as well as to have a consistent way to portray the field via its website (http://integrationacademy.ahrq.gov).

All this was done without apology or sheepishness. All mature scientific or technical fields have lexicons (systems of terms and concepts) developed well enough to allow collaborative and geographically distributed scientific, engineering, or applications work to take place. Systematically related concepts have an esteemed place in the history of mature fields, such as electrical engineering, physics, and computer science, and have enabled them to become mature sciences or technologies with associated empirical triumphs. In many cases the definitional, conceptual or pre-empirical development of these fields was done so long ago that we take it for granted and now see only the concrete or empirical achievements. But it takes a generally understood system of concepts and distinctions to do good science. Here is one example of lexicon development from nineteenth century science:

At the time of the first International Electrical Congress in Paris in 1881, “complete confusion had reigned in this field; each country had its own units”. Multiple different units were in use across researchers and countries for electromotive force, electric current and resistance. At this first Congress, agreements were reached on the ohm and the volt—with ampere, coulomb and farad also defined, all done as one conceptual system. Governments saw that it had become necessary for commercial transactions to create an international system of definitions and to provide a forum of scientists, manufacturers, and learned societies to establish terminology for the whole field of scientific and technical concepts (du Couëdic, 1981).

Without this system of electrical concepts becoming community property with standing across all electrical researchers, the field could not have developed into the mature form of empirical science that we now witness. The effect was immediate:

The first Congress of 1881 has borne good fruit. It has not only brought about a rapprochement between electricians of all countries, but it has led to the adoption of an international system of measurement which will be in universal use. (The Electrical Congress of Paris, 1884)

Conceptual Clarification Is Especially Important for Anything “Behavioral”

Historically, subject matters that include the terms “behavior,” “mental health,” “psychosocial” or “collaborative” in their names have stereotypically been seen as soft, subjective, or not as conducive to scientific investigation, despite the existence of extensive literature and research. Different published papers often employ disparate conceptual and language systems, and this can lead to a sense (especially as seen by those outside the field) that the field is “not quite worked out” or seems to be re-created anew by each author. As important as “behavior” is to contemporary health care and the PCMH, an impression remains that it is a fuzzy concept compared to traditional medical areas. The behavioral dimensions of health and health care not only entail studying immensely complex phenomena, but also may be earlier in their development as fields compared to their biomedical cousins. Creating a lexicon for integrated behavioral health puts at least a few things “behavioral” or “collaborative” as they relate to primary care on a more systematic and consistent conceptual consensus-based foundation that is accessible to anyone, including the authors of the chapters of this book. More on the need for widely accepted conceptual systems for use in behavioral fields and psychology appears in Peek (2011), Bergner (2006), and Ossorio (2006).

A Consensus-Based Method for Creating a Lexicon for Integrated Behavioral Health

This section is adapted or paraphrased from Peek (2011) and Peek and National Integration Academy Council (2013).

Requirements for a Lexicon Development Method

For a lexicon to become more than one person’s invention for one limited study or application, it would have to serve the practical purposes of a broad range of people over a broad range of applications. This could not be created and published as an opinion by one person or small group in isolation, which is a common to proposing definitions and gives rise to the sense of cacophony that policymakers and researchers had noticed. Instead, a method for creating a lexicon with standing in the field should:

Be consensual but analytic (a disciplined transparent process—not a political campaign)
Involve actual implementers and users (“native speakers” of the field—those actually doing the work—not only observers, consultants and commentators)
Focus on what functionalities look like in practice (not just on principles, values, goals, or visible “anatomical features”)
Portray both similarities and differences (specify both theme and legitimate variations)
Refine and employ existing familiar concepts that are serviceable to the extent possible
Be amenable to gathering around it an expanding circle of “owners” and contributors (not just an elite group with a declaration)

Fortunately methods for defining complex subject matters that meet these requirements exist in the published literature—“paradigm case formulation” and “parametric analysis”—as described by Ossorio (2006). The product, a lexicon for posing integrated behavioral health care research and practice development questions, is described in later sections.

About Definitions, Paradigm Case Formulation, and Parametric Analysis

Before describing the lexicon itself, we’ll step back and contrast paradigm case formulation and parametric analysis with the usual approach to creating definitions. The usual approach is to create one or two sentences, such as “integrated behavioral health care is X, Y, and Z,” often done pragmatically for the purposes of just one study or project. If done to structure the concepts for an entire field, a standard definition would attempt to identify genuine instances on the basis of uniformities in common across all instances. But integrated behavioral health care is characterized not only by uniformities (a common core), but also by many legitimate differences between instances of integrated behavioral health. The definitional challenge is to develop a consistent shared language for both commonalities and differences without devolving into either “a cookie cutter” or “anything counts.” A simple one-sentence definition such as “integrated behavioral health care is X, Y, and Z” would likely be oversimplified, full of qualifications and exceptions, or considered wrong or incomplete by many.

Paradigm case formulation . For complex subject matters such as integrated behavioral health care, a paradigm case formulation is an improved device for creating a definition because it maps both similarities and differences at any level of detail desired. For example, the concept of “family” is a complex subject matter and would be very difficult to define in a single sentence that would satisfy everyone. The paradigm case formulation approach to “family” starts with one archetypal statement (the paradigm case) that no one could possibly disagree with—and then goes on to systematically describe what could be changed (transformations of the paradigm case) and still be “family” (see Fig. 2.2).

Fig. 2.2

Example—paradigm case formulation of “family” (Quoted from Ossorio, 2006; pp. 26–27)

Note that constructing a paradigm case formulation calls for careful decisions and the exercise of judgment in regard to which cases to include or exclude. Disagreement may arise among different persons. For example, T6-T9 seem much more likely to elicit objections (“I wouldn’t call that a family!”) than T1-T5.

In this example, the paradigm case and its transformations becomes the “definition” of family. One can distill a one-sentence summary definition of the usual sort found in great diversity and abundance in dictionaries, in professional publications, and on the web. But the limitations of one-sentence definitions are why the paradigm case formulation method was employed for the integrated behavioral health lexicon.

Parametric analysis . A complementary device, parametric analysis, goes on to create a specific vocabulary for how one instance of integrated behavioral health in action might be the same or different from another instance across town. In the “family” example, two of the parameters would be “number of children” and “number of parents.” Parametric analysis (understanding the dimensions of something) sounds exotic, but is commonplace in other fields. One extremely simple illustration is shown in Fig. 2.3—parameters of number 2 × 4’s.

Fig. 2.3

Example—parameters of 2 × 4’s

A scientific example of parametric analysis is in the specification and comparison of different colors employing the three parameters of color: brightness, hue, and saturation. Any color can be specified through supplying a “setting” (formally called a “value”) on each of these parameters as expressed in the Munsell color chart (Ossorio, 2006; pp. 35–36). Parametric analysis is used routinely to fine tune product design and market competitiveness for industrial products and software because it allows the designer to measure the influence of all parameters (or design features) on the outcomes desired and the trade-offs between them (Thieffry, 2008).

Parametric analysis sets the stage for comparative effectiveness research in integrated behavioral health care, where one set of arrangements is tested against a different set of arrangements. The “arrangements” are expressed through the parameters.

Overview of the Consensus Process to Reach Paradigm Case and Parameters

The lexicon process began with a core group of CCRN program committee members in 2009 that consisted of Benjamin F. Miller, Gene Kallenberg, and Rodger Kessler and this author. A larger circle of contributors included research conference participants and those attending a Collaborative Family Healthcare Association presentation soon after. With this wisdom incorporated, the lexicon became the organizing system for integrated behavioral health care research questions submitted to AHRQ (Miller, Kessler, Peek, & Kallenberg, 2011). The lexicon shown here is a condensation of the updated version (Peek and the National Integration Academy Council, 2013).

About the discussion process for creating a consensus definition. (Adapted from Peek, 2011 ). An functional definition to serve practical purposes for a broad range of people interested in integration of behavioral health and primary care could not be created by one person or perspective alone. Doing so would increase the sense of ambiguity or multiplying compatible but different definitions (usually without much functional specificity) that implementers and patients had noticed, sometimes as cacophony.

As described earlier, a “paradigm case formulation” is a vehicle for creating a definition that maps both similarities and differences. A “parametric analysis” builds on the paradigm case to create a specific vocabulary for how one instance of integrated behavioral health practice might differ from another instance across town.

The paradigm case and parameters amount to a set of interrelated concepts (like an extended definition) that can be used in comparing practices, setting standards, or asking research questions using a common vocabulary.

The consensus process is facilitated in two stages. (1) A core group draft was done in this case by four people, followed by (2) a “second ring” review/contributor group in this case of 20 people.

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