Strategic Initiatives: Biopsychosocial Advocacy
by Eric M. Plakun, MD, Director of Biopsychosocial Advocacy
As one of several key Austen Riggs Center initiatives identified through a comprehensive strategic planning process, Biopsychosocial Advocacy is intended to influence the field in three ways:
- Clinical advocacy for the importance of psychotherapy and other psychosocial treatments as central parts of psychiatric practice and training within a biopsychosocial model.
- Social policy advocacy for full implementation of the parity law, including careful review of the ethics of psychiatrist utilization reviews for insurance companies based on standards that are out of compliance with the parity law.
- Funding advocacy for a shift in NIMH research funding from its current “either/or” focus emphasizing brain and biology research linked to biomarkers to a “both/and” strategy that restores meaningful access to funding for research into clinical treatment methods, especially psychotherapy research.
By way of context, the word “biopsychosocial” is a mouthful, but it is an important concept for psychiatry and other mental health disciplines. The term was introduced in the 1970s by Dr. George Engel to name the superordinate perspective in the field that mental disorders were caused by—and best treated by—a model integrating an individual’s biology, psychology, and social context. Since the 1990s, the field shifted dramatically toward a superordinate idea that mental disorders are more biomedical than biopsychosocial. Treatment and research shifted toward biology—with medications emerging as the mainstay of treatment in psychiatry.
Studying the brain and breaking the code of the human genome in 2003 were expected to reveal the biological and genetic underpinnings of and guide new treatment approaches for such mental disorders as depression, schizophrenia, and bipolar disorder. Although we have learned much—and in no way do we intend to disparage the importance of brain science and psychiatric genomics—the reality is that virtually nothing has emerged from several decades pursuing the biomedical model that improves patient outcomes. The same brain regions are involved in multiple mental disorders, no “biomarkers” of mental disorders have been found, we tend to use the same 75 medications for all disorders, while the genetic contributions to mental disorders turn out to be quite complex—with the focus now less on genes alone than on “gene-by-environment” interactions. We have learned, too, about the limits of medications, and about the salient contribution of environmental factors, like early adverse experiences, to later psychiatric and medical problems.
There is also substantial evidence that several forms of psychotherapy are effective in treating patients with single, complex comorbid, and treatment resistant disorders—and that psychotherapy may be the preferred treatment for those with histories of early adverse life experiences. There is a shift away from competition between schools of therapy toward recognition of a need to define shared elements of psychotherapy associated with change—regardless of school of therapy. It is also timely to re-emphasize the importance of psychotherapy as a more prominent part of the training and practice of psychiatrists. With this goal in mind, we established an American Psychiatric Association Psychotherapy Caucus that has grown in just a couple of years from 10 to close to 300 members.
Although the Mental Health Parity and Addiction Equity Act was passed in 2008, implementation of the parity law has been slow and incomplete. Biopsychosocial Advocacy calls for full implementation of the law, which means support for psychosocial treatments like psychotherapy and residential treatment, and the need for careful review of the ethics of managed care psychiatrists who implement utilization standards that are known to be out of compliance with the parity law.
What we are learning suggests that the superordinate idea of the biomedical model may be too narrow, and that it is time to go “back to the future” to the biopsychosocial model that is actually more consistent with emerging science. After all, “gene-by-environment” is just another way of saying “biopsychosocial.”
Our goals are ambitious, but very much worth trying to achieve. Linked below are examples of columns I have authored for the Journal of Psychiatric Practice that define and elaborate on these issues more fully.
- An Introduction From the New Psychotherapy Columnist (November, 2016)
- Psychotherapy, Parity, and Ethical Utilization Management (January, 2017)