and Jeffrey T. Reiter2
(1)
Mountainview Consulting Group, Inc., Zillah, WA, USA
(2)
HealthPoint, Seattle, WA, USA
Electronic supplementary material:
The online version of this chapter (doi:10.1007/978-3-319-13954-8_7) contains supplementary material, which is available to authorized users.
Keywords
Medical modelStrength-based modelDefinition of healthTransdiagnostic interventionsStress-diathesis modelMotivational interviewingProblem-solving therapyProblem-focused copingAvoidance-focused copingAcceptance and commitment therapy“In theory there is no difference between theory and practice. In practice there is.”
Yogi Berra
Both of us recall all too well our clinical psychology graduate training. We remember using index cards to memorize the symptoms for each of the “mental disorders” in the DSM. Each disorder, we were taught, represented a discrete entity that could be differentiated from another if the right diagnostic tool and approach was applied. Even better, once the correct diagnosis was made, it could be matched to a tested manual-based protocol that could treat the problem. The goal, we were taught, was to treat our patients until the symptoms were largely gone. We spoke of each therapy session as a “dose” and used phrases like “in remission,” “symptom reduction,” and “differential diagnosis.” We were trained, in other words, in the medical model.
Commonly encountered in medical and other healthcare services, the theoretical stance in the medical model suggests that health is a state of freedom from disease. Applied to clinical practice and research, it teaches clinicians to match symptoms to disease and to then provide an intervention to eliminate, or at least reduce, symptoms. This model has been helpful with many biological illnesses, including pneumonia and cancer. However, it has some shortcomings when working with people whose suffering is linked to behavior problems, such as patients with chronic pain, diabetes, or what is called “depression.” To tackle these problems, we need a different model, one that considers the context of the behavioral problem and seeks to make changes to that context. When applied, such a model would also allow for flexibility in how patients change, recognizing that change comes from the patient and not from the provider. These needs become all too clear after spending time in the PC setting.
The Nature of Health and the Limits of the Medical Model
Working in PC helps one to learn a thing or two about the nature of health, merely through observation. It helps one to see the limits of the medical model. In contrast to specialty MH care, the patients in PC must be seen just as they are; they cannot be screened out of care because they are too complicated, too old, too young, or too unmotivated. Further, patients in PC are often followed over the course of years, allowing the clinician to observe the waxing and waning of symptoms as life happens. This unique vantage point helps one understand that health is a journey, not a destination, and it exposes the limits of the medical model. It also makes clear the need for a different intervention model than the one (still) taught in most psychology graduate schools.
From the perch of PC, for example, one notices many patients who do not fit neatly into any DSM diagnostic criteria yet who are clearly not functioning well. Traditional training would suggest the need for clarifying the diagnosis, with the expectation that would lead to a specific treatment plan that would clear everything up. The path to a cure would be paved with an empirically supported 12-visit protocol! Unfortunately, though, a clear diagnosis will never prove possible for many patients, and of the few who do clear this hurdle, very few are likely to complete an extensive therapy protocol. Most PC patients may simply not have the time, money, and/or energy for that. The good news is that despite all of this, many of these patients improve anyway. Functioning, one learns in PC, can be improved even without a clear diagnosis or an extensive therapy protocol. With holistic care and support that is provided at the right time, many patients find a way to improve without needing a therapist or doctor to provide a “fix.” Many of the most severely impaired patients improve even after just a few brief visits (Bryan et al., 2012).
From this perch, one also notices that many patients whose complaints do match up with a diagnosis have symptoms that fluctuate over the years. In contrast to the medical model perspective that a disease must be eradicated in order for the person to be healthy, many patients find ways to accept these symptoms and build a satisfying life despite them. Like the patient with diabetes who learns to live a satisfying life despite the ever-present diabetes, patients with MH symptoms often learn that these symptoms need not define how they live life. These patients are not often seen in specialty MH care because, by definition, patients presenting there have not yet learned how to do this. But they are commonly seen in PC. Thus, from the vantage point of the PC perch, one starts to question the notion that a person must be symptom free in order to have a good quality of life.
What the Therapy Literature Teaches Us
As it turns out, these observations merge quite well with a number of findings in the psychotherapy literature. Taken together, these data and experiences start to guide us away from the medical model and toward a strength-based model focused on understanding context and on improving functioning rather than symptoms. A concise summary of the most relevant literature is presented in a book on brief interventions by Strosahl, Robinson and Gustavsson (2012), which turns upside down many of the myths of traditional MH care and the medical model. For example, they note that the modal number of psychotherapy visits in specialty MH is one (Brown & Jones, 2005). That is, most patients seen in specialty MH are seen just one time. Of those who do continue to follow up, most will end care by the fifth visit, often dropping out without ever consulting the therapist (Brown & Jones, 2005; Olfson & Marcus, 2009). What most patients apparently want, as noted by Strosahl, Robinson and Gustavsson (2012), is emotional reassurance and problem-solving. These patients didn’t get the message that they are sick and in need of long-term therapy.
Even more interesting, the literature suggests that these brief encounters actually work quite well for many patients. This will not be a big surprise to clinicians working in PC who witness this on a regular basis, but for those who have never worked outside of the specialty MH world, it can seem hard to believe. Yet, as a long list of studies summarized by Strosahl, Robinson, and Gustavsson (2012) demonstrates, rapid change is the rule, not the exception. A significant number of patients with posttraumatic stress disorder, irritable bowel syndrome, binge eating disorder, and others have all been shown to make rapid improvement in just the initial sessions of treatment. Around 15% of patients show significant improvement before even attending the first therapy visit! Because these rapid responders often fail to follow up once gains have been made, the specialty MH therapist may be left wondering how they are doing or may worry they are likely to relapse. Indeed, the medical model suggests that would be likely. Yet, more often than not, these rapid gains are actually maintained over the long term (Strosahl, Robinson & Gustavsson, 2012).
Note that while the studies summarized by Strosahl et al. were conducted in the specialty MH world, very similar findings have come from outcome studies of the PCBH model (Bryan, Morrow & Appolonio, 2009; Cigrang, Dobmeyer, Becknell, Roa-Navarrete & Yerian, 2006; Ray-Sannerud et al., 2012). None of this should come as a surprise to a BHC who has been paying attention from that PC perch. Rapid improvement is commonly observed, even in patients who initially appeared quite impaired and complicated. In addition, patients who drop out of specialty MH care eventually make their way to PC for one reason or another, and as a result a BHC often gets to observe improvement that the therapist never saw.
All of these observations and data lead us to an important conclusion: a different definition of health and a different model for health care is needed.
An Alternative Definition of Health
A definition of health consistent with the PCBH mission is “a state characterized by anatomical, physiological, and psychological integrity; ability to perform personally valued family, work, and community roles; ability to deal with physical, biological, psychological and social stress; a feeling of well-being; and freedom from the risk of disease and untimely death” (Last, 1988). Such a definition places the emphasis on a person’s context and ability to change. A definition for health must include a person’s ability to respond and adapt, and it must recognize the interconnectivity of human health with the health of other entities.
A Framework for the Primary Care Behavioral Health Model
Getting beyond the medical model is critical to one’s work in the PCBH model (and arguably to all work related to MH). To do this, the BHC needs to understand an important point about human suffering and human vitality: specifically, suffering is a part of life and excessive struggle with suffering often leads to more suffering. Construction of meaningful values and connections with them may create the impetus that people need to accept emotional discomforts and even physical pain. Note that this is in stark contrast to the medical model, which states that pain and discomfort are abnormal and need to be eliminated. When viewing suffering as part of pursuing a meaningful life, one’s interactions with patients will change toward being more able to model and encourage acceptance of suffering that comes with a patient’s value-consistent behavior. With this perspective, one can also let go of the notion that patients must be treated until symptom free.
Along similar lines, the clinician who realizes that the behaviorally influenced health problems patients present with are not discrete disease entities to be cured but rather occasional deviations from a healthy path is better able to do PCBH work. Instead of trying to take ownership of a patient’s “disease” and fix it, a clinician who views health in this way understands that the patient is in charge and the clinician’s role is merely to guide the patient back to a healthy path when a deviation happens. From a practical standpoint, this means focusing on understanding, at a contextual level, a patient’s health problems rather than diagnosing. It also means helping patients live a satisfying life even in the presence of symptoms, either by teaching skills or helping patients discover strengths and not being compelled to follow patients until their symptoms are gone. To the extent that a BHC is able to move beyond the medical model and apply this different framework, she will have a much easier time working within the PCBH model.
Therapies for the PCBH Model
Considering all of the above, we now review a variety of therapeutic approaches that fit easily into the framework described above and thus work well in the PCBH model. These approaches work well because they are transdiagnostic; i.e., they can be utilized with patients regardless of a presumed diagnosis. We first discuss the stress and coping model, as well as strategic change models, both of which stimulate patients to make rapid and meaningful change. Motivational interviewing and problem-solving techniques are two pragmatic approaches that support improvements in functioning. We also present more information on ACT and other contextual behavioral approaches. Skillful use of these approaches may empower the BHC and teammates to help patients with all manner of behavioral issues make important changes in behavior.
We also want to mention that there are other well-established behavioral and cognitive behavioral therapies (CBTs) that BHCs will likely use on a daily basis. Because they are so well known and because space is limited, we are omitting detailed information about them [though we do mention some briefly in this chapter and later chapters and provide case examples on the book website (www.behavioralconsultationandprimarycare.com)]. To learn more about CBT interventions in PC, we recommend Integrated Behavioral Health in Primary Care: Step-by-Step Guidance for Assessment and Intervention (Hunter, Goodie, Oordt & Dobmeyer, 2009). Appendices A and B (Chapters 16 and 17) provide a list of books that may be of interest to BHCs and other members of the team (including patients) as well.
When selecting an intervention during a patient visit, remember that PC is ultimately a place for pragmatists. This is true whether one is a BHC or a PCP and whether using medications or behavioral interventions. Whether one chooses to use a motivational intervention, a traditional behavioral intervention or a contextual behavioral approach depends on multiple factors, such as the results of the life context and functional analysis assessments, provider knowledge, fit with the patient’s perspective, time available, and what the patient has tried before (among other factors). The goal of the following sections is to highlight approaches that fit well in a BHC’s armamentarium.
Stress-Diathesis Model
The stress-diathesis model provides the foundation for all BHC interventions. It views human existence within a dynamic environment that involves responding to both internal and external stress using stress-buffering or coping responses. Audy (1971) suggested that preservation of health requires the maintenance of equilibrium, in the context of ongoing insults from both internal and external sources. Problems with functioning arise in the interplay of three major social and psychological realms: (1) recently occurring stresses that can vary in magnitude from daily hassles to major life events (and also include environmental factors such as poor air quality), (2) personal dispositions that influence the individual’s reactivity to the stresses (including genetic vulnerabilities, resources, and liabilities resulting from remote learning histories), and (3) the individual’s repertoire of coping skills (e.g., stress management, problem-solving, mindfulness, etc.). Behavior problems occur when a person encounters stressful events that overwhelm current skills for coping and result in heightened vulnerability (Skodol, Dohrenwend, Link & Shrout, 1990). Viewed from the perspective of a medical model, a person in a heightened state of vulnerability may appear to have a disorder requiring treatment with medications. From a stress and coping framework, a BHC may see the behavior of the same person as indicative of a shift in stress-coping equilibrium and work to create a behavior change plan to correct the imbalance.
A central assumption of this model is that most psychologically healthy or normal people have symptoms of dysfunction, just as physically healthy people at times have aches and pains. The difference between a person who receives a label from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (American Psychiatric Association, 2014) and a person who does not may center on the person’s coping skills. We learn the skills we have over a lifetime of interacting with our environment through numerous processes, including language training, modeling, and operant and classical conditioning. Some skills are adaptive and health protective, as in the case of someone who learns to go for a walk when stressed. Other skills are maladaptive, as in the case of someone who learns to drink alcohol to excess when stressed. Whatever the coping strategy a patient implements, a clinician working in this model assumes only that the person learned the behavior and that the behavior serves the person in some way (e.g., excessive use of alcohol may shut down painful emotions but at the cost of causing interpersonal and physical health problems). The clinician avoids prejudging the inherent value of the behavior and works with the patient to better understand the function of the behavior, relative to its promotion or detraction from health and well-being. Insufficient or maladaptive skills for coping are not an indication of pathology or disease but rather an indication of a need to learn new skills.
Teaching PCPs
Many behavioral health providers have some training in brief and strategic therapies and/or cognitive behavioral therapy, both of which originate from a stress-diathesis perspective. In fact, coping and stress reduction skill development are almost always at the core of most empirically supported cognitive behavioral treatments (Strosahl, 2005). In contrast, most PCPs have training in the medical model that suggests use of the DSM as a method for identifying specific mental diseases and, if needed, prescribing medications. Thus, BHCs may help PCPs develop new skills for identifying, conceptualizing, and treating behavioral problems by teaching them about alternative approaches to conceptualization and intervention development.
Informal case discussions and more formal case presentations during staff meetings provide a good format for teaching brief stress management techniques. Most PCPs already talk about stress with patients but may welcome more specific information about brief stress reduction techniques. Many will also welcome information about standard CBT interventions for common problems, particularly if accompanied by a brief 1-page handout that can be shared with patients. Many PCPs and RNs want to better understand relaxation training, problem-solving, scheduling of pleasurable activities, and personal assertion skills; BHCs can teach these in 5- and 10-minute presentations at staff meetings or during lengthier lunch hour presentations for those who are interested. Of course, not all providers will be interested. However, our experience suggests that many PCPs will try these techniques with patients. Some will be immediately successful and some will come back for more coaching from the BHC.
Several years ago, in response to the overwhelming need for more behavioral health care, the Australian government gave PCPs support for learning a group of “focused psychological strategies.” After training, the PCPs began to offer these interventions to patients (Jackson-Bowers & McCabe, 2002). The 2002 Medicare Benefits Schedule (MBS) for Australia included codes for PCPs to use for the services (Commonwealth Department of Health and Ageing, 2002). Focused psychological strategies included psychoeducation, motivational interviewing, behavioral therapy, cognitive interventions, relaxation strategies (including progressive muscle relaxation and controlled breathing), skills training (including problem-solving, anger management, social skills training, communication training, and parent management training), and interpersonal therapy. Trained PCPs are credentialed to provide these interventions to patients in 30-minute visits in up to six sessions in any 12-month period (Hickie & Groom, 2002). We mention this initiative because it provides an excellent list of skills BHCs can use in teaching interested PCPs. In the United States, PCPs will not usually be able to see patients for 30-minute visits, but the more of these approaches they know the more agile they will be in their 15-minute visits.
Most of the standard cognitive behavioral techniques mentioned above will be familiar to readers. However, two that might not be, motivational interviewing and problem-solving therapy, deserve some elaboration. Both are approaches that can be widely applied in the PCBH model and are important to teach to PCPs as well.
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