APA PRESIDENTIAL ADDRESS
Increasing Psychology’s Role in Health
Research and Health Care
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Suzanne Bennett Johnson
Florida State University
The reductionistic, exclusionary, and dualistic tenets of the
biomedical model have profoundly affected U.S. health
care and health research as well as psychology practice,
psychological science, and graduate education in psychology. Although the biomedical model was a success story in
many ways, by the end of the 20th century its limitations
had become increasingly apparent. These limitations included the biomedical model’s failure to adequately address the changing nature of disease facing the U.S. health
care system, escalating health care costs, the role of behavior in health and illness, and patients’ mental health
concerns. Medicine’s recent paradigm shift from the biomedical to the biopsychosocial model is occurring in U.S.
health care, professional medical education, and health
research, with significant implications for psychology. This
paradigm shift provides psychology with both opportunities and challenges. Psychology must proactively and deliberately embrace the biopsychosocial model if it is to take
full advantage of the opportunities this paradigm shift
presents. The American Psychological Association can
play an important leadership role in this effort.
Keywords: biomedical, biopsychosocial, health research,
health care
F
or over 100 years, the biomedical model has dominated Western medicine. Its impact has been broad
and profound, increasing life expectancy and emphasizing biologic approaches to health care and health
research. However, with the changing nature of disease,
rising health care costs, increasing recognition of the importance of behavior to health, and the model’s failure to
adequately address mental health problems, the limitations
of the biomedical model have become more and more apparent. This has resulted in a paradigm shift from a biomedical to
a biopsychosocial conceptualization of health and disease.
This paradigm shift is occurring in health care, professional
medical education, and health research, with significant implications for psychology.
The Biomedical Model and Its Legacy
Stedman’s Medical Dictionary (2006) defines the biomedical model as “a conceptual model of illness that excludes
psychological and social factors and includes only biologic
factors in an attempt to understand a person’s medical
illness or disorder.” Since the wide acceptance of Louis
Pasteur’s (1822–1895) germ theory of disease, the biomedJuly–August 2013 ● American Psychologist
© 2013 American Psychological Association 0003-066X/13/$12.00
Vol. 68, No. 5, 311–321
DOI: 10.1037/a0033591
ical model has dominated Western medicine (Shore, McDowell, Johnson, & Donovan, 2011). Figure 1 illustrates
the clinical course of disease from a biomedical perspective. The body is exposed to some sort of external pathogen, a germ or a poison, for example. This leads to the
onset of disease. The preclinical phase— before the emergence of symptoms—may vary in duration from months to
days or even minutes depending on the pathogen. Once
symptoms occur, the patient may seek medical assistance.
Diagnosis involves identifying the most likely biologic
mechanism underlying the symptoms and initiating therapy. If the therapy is effective, the patient is “cured.” If the
therapy is ineffective, the patient may deteriorate or even
die. The model also provides a possible feedback loop in
cases of ineffective therapies; in such cases, new diagnostic
tests are run in an effort to correctly identify the underlying
pathogen and recommend a successful therapy.
The biomedical model is characterized by an exclusive focus on disease. It is both reductionistic and exclusionary. Disease is defined as a biologic defect, and whatever is not explained by an underlying biologic defect is
excluded from consideration. This approach, in turn, fosters mind– body dualism in which biologic (somatic) processes are considered separate from, and superordinate to,
the processes of the mind (emotions, cognitions, behavior;
Engel, 1977). The legacies of the biomedical model are
biologic assays and diagnostic tools, biologic interventions,
and biologic research.
Biomedical Model Successes
In many respects, the biomedical model has been extremely
successful. The germ theory of disease led to sanitation, the
development of antibiotics, a remarkable decline in infectious disease, and increasing life expectancy. In 1900, the
leading causes of death were tuberculosis, pneumonia and
influenza, and diarrheal diseases. Thanks to the biomedical
Editor’s note. Suzanne Bennett Johnson was president of the American
Psychological Association (APA) in 2012. This article is based on her
presidential address, delivered in Orlando, Florida, at APA’s 120th Annual Convention on August 3, 2012.
Author’s note. Correspondence concerning this article should be addressed to Suzanne Bennett Johnson, Department of Medical Humanities & Social Sciences, College of Medicine, 1115 West Call Street,
Florida State University, Tallahassee, FL 32306-4300. E-mail: suzanne
.johnson@med.fsu.edu
311
Macleod discovered insulin in dogs; in 1922, insulin was
tested in a 14-year-old boy dying of type 1 diabetes. Insulin
was truly a miracle drug; the boy recovered, and Banting
and Macleod won the Nobel Prize for their work in 1923.
Children with type 1 diabetes are still treated with daily
insulin injections today, and life expectancy for these children has steadily increased in the postinsulin era (Gale,
2012).
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Impact of the Biomedical Model on
U.S. Health Care
Suzanne
Bennett
Johnson
model, these diseases are no longer the primary causes of
death in the developed world (Centers for Disease Control,
n.d.). With the decline in mortality due to infectious disease, over the last 100 years we have seen a remarkable
increase in U.S. life expectancy from 49 years in 1901
(Glover, 1921) to 77 years in 2001 (Arias, 2004).
The biomedical model’s search for the underlying
biologic defect led to very successful biologic interventions
to treat a number of diseases. For example, before insulin
was discovered, children diagnosed with type 1 diabetes
died of their disease. In 1921, Frederick Banting and John
Figure 1
The Clinical Course of a Disease From the Biomedical
Perspective
Note. Reprinted from “Disease as a Process: Natural History and Clinical
Course” in AFMC Primer on Population Health (Part 1, chap. 1) by The Association of Faculties of Medicine of Canada Public Health Educators’ Network,
http://phprimer.afmc.ca/Part1-TheoryThinkingAboutHealth/Chapter1Concepts
OfHealthAndIllness/DiseaseorSyndrome (Accessed June 3, 2013). License:
Creative Commons BY-NC-SA.
312
It is not surprising that the biomedical model’s reductionistic, exclusionary focus on biologic defects underlying
disease would have a major impact on the U.S. health care
system. The model’s mind– body dualism led to a separation or “carving out” of mental health or behavior problems
from the larger health care system, which remained devoted to the diagnosis and treatment of physical disease. In
this system, physical complaints are given greater credence, and resources are devoted primarily to biologic
assays, biologic interventions, and biologic research. In
contrast, mental or behavioral problems are not considered
“real” or are undervalued, fewer resources are devoted to
treating and researching these problems, and treatments are
delivered outside of the larger health care system. In fact,
mental health expenditures account for only 6% of all U.S.
health care expenditures (Mark et al., 2007).
In contrast, the pharmaceutical industry—an industry
predicated on biologic interventions— has fared very well
in a health care system based on the biomedical model.
Nearly two thirds of all Americans take prescription drugs,
and over 90% of those 65 years of age and older do. The
cost of these drugs keeps escalating, from $65 billion in
1996 to $271 billion in 2010 (Agency for Healthcare Research and Quality, 1996, 2010). Even within the mental
health arena, expenditures for prescription drugs for mental
health and behavior problems now far exceed expenditures
for physicians or all other mental health providers combined (psychologists, counselors, social workers; Mark,
Levit, Vandivort-Warren, Buck, & Coffey, 2011). Taking
prescription medications to address health—and even mental health— concerns is consistent with the biomedical
model’s basic tenet that biologic interventions are most
likely to successfully address the biologic defect that underlies the patient’s concerns.
Training programs to prepare physicians and mental
health providers to work in the U.S. health care system
have mirrored the mind– body dualism of the biomedical
model. Mental health and physical health providers are
trained separately, with greater resources and prestige assigned to one type of professional training over the other.
This has resulted in an imbalance in the number of welltrained and well-paid providers, strongly favoring physical
health providers. Within this system, psychologists— experts on emotion, cognition, and behavior—are “mental
health” providers, and physicians (with the possible exception of psychiatrists) are the “physical health” providers.
July–August 2013 ● American Psychologist
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Impact of the Biomedical Model on
U.S. Health Research
Over the last 40 years, biomedical research has enjoyed a
meteoric rise in funding (see Figure 2). While funding for
other sciences, including psychology, has remained relatively flat, funding for biomedical research has increased
from approximately $3 billion in 1970 to over $25 billion
in 2000; no other science comes close to this level of
funding (Koizumi, 2008).
In this funding zeitgeist, we see the rise of cognitive, affective, behavioral, and social neuroscience. Table 1 provides a listing of some of the major journals in
this area with their inception dates and descriptions of
their areas of coverage; all are clearly focused on psychological processes, but by using the neuroscience label, the study of psychological phenomena presumably
becomes more acceptable within the biomedical framework. This was mimicked within federal funding agencies with the 1997 establishment of the Division of
Neuroscience and Basic Behavioral Science within the
National Institute of Mental Health, whose priority areas
include “how cognitive, affect, stress, and motivational processes interact and their role(s) in mental disorders through
functional studies spanning levels of analysis (genomic, molecular, cellular, circuits, behavior) during development and
throughout the lifespan” and “fundamental mechanisms (e.g.,
genetic, biological, behavioral, environmental) of complex
social behavior” (National Institute of Mental Health, 2013,
“Areas of High Priority,” para. 2, 3). Within the National
Science Foundation, the Cognitive Neuroscience Program
was established in 2002 to fund “interdisciplinary proposals
aimed at advancing a rigorous understanding of how the
human brain supports thought, perception, affect, action, so-
cial processes, and other aspects of cognition and behavior”
(National Science Foundation, n.d., “Synopsis”). Clearly the
biomedical model has not been friendly to psychological or
social science and has encouraged the metamorphosis of psychological phenomena into a neuroscience framework.
Limitations of the Biomedical Model
Despite the numerous successes of the biomedical model and
its profound impact on U.S. health research and health care,
by the end of the 20th century, the model’s limitations were
becoming increasingly apparent. The leading causes of death
were no longer infectious diseases, and the biomedical model
was less successful at addressing the chronic disease challenges facing the United States today. U.S. health care costs
continue to rise, unmitigated and perhaps even enhanced by
the biomedical model’s emphasis on biologic assays and
diagnostic tests and biologic interventions. The role of behavior in disease etiology, prevention, and management has become increasingly obvious. The failure to adequately address
mental health concerns by relying on a separate “carved out”
underfunded system has further undermined confidence in the
biomedical model’s ability to address the modern health care
concerns facing the United States.
Changing Nature of Disease and
Rising Health Care Costs
While infectious disease was the leading cause of death in
1900, today most Americans die of chronic disease: heart
disease, cancer, chronic lower respiratory diseases, and
stroke (Hoyert & Xu, 2012). Nearly one in two U.S. adults
has at least one chronic illness. Seven in 10 U.S. deaths are
the result of chronic disease, and chronic diseases account
Figure 2
Trends in Federal Research by Discipline, FY 1970 –2011
Note. Obligations in billions of constant fiscal year (FY) 2012 dollars. “Other” includes research not classified (includes basic research and applied research;
excludes development and R&D facilities). Life sciences are split into National Institutes of Health support and all other agencies’ support. (Source: National Science
Foundation, Federal Funds for R&D series. FY 2010 and 2011 are preliminary. Includes Recovery Act funding beginning in FY09. Constant-dollar conversions based
on Office of Management and Budget’s gross domestic product deflators.) From “Guide to R&D Funding Data – Historical Data, by Discipline,” by the American
Association for the Advancement of Science, 2012. Retrieved from http://www.aaas.org/spp/rd/guihist.shtml. Copyright 2012 by the American Association for
the Advancement of Science. Reprinted with permission.
July–August 2013 ● American Psychologist
313
Table 1
Journals Addressing Cognitive, Affective, Behavioral, and Social Neuroscience
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Journal
Inception date
Description
Journal of Cognitive
Neuroscience
1989
Cognitive, Affective, and
Behavioral Neuroscience
Social Neuroscience
2001
Social, Cognitive and
Affective Neuroscience
Cognitive Neuroscience
2009
“investigates brain–behavior interaction and . . . developments in neuroscience,
neuropsychology, cognitive psychology, neurobiology, linguistics, computer
science, and philosophy”
“the leading vehicle for strongly psychologically motivated studies of
brain–behavior relationships”
“examines how the brain mediates social cognition, interpersonal exchanges,
affective/cognitive group interactions, and related topics that deal with
social/personality psychology”
“addresses issues of mental and physical health as they relate to social and
affective processes as long as cognitive neuroscience methods are used”
“publishes papers on any topic in the field of cognitive neuroscience including:
perception, attention, memory, language, action, decision-making, emotions,
and social cognition”
2006
2010
for 75% of the U.S. health care costs (Centers for Disease
Control and Prevention, 2009).
Not only has the biomedical model failed to successfully address these new health care challenges, but the cost
of U.S. health care continues to escalate. In 1960, annual
per person health care expenditures were $147; in 2011,
they were $8,680 (Centers for Medicare & Medicaid Services, 2012). While the United States leads the world in
health care expenditures, U.S. life expectancy remains
lower than that in most other developed countries
(O’Rourke & Iammarino, 2002).
Increasing Recognition of the Role of
Behavior in Health
Although mortality statistics are commonly reported by disease, in their seminal 1993 article, McGinnis and Foege
pointed out that the factors underlying these diseases were
often behaviors: smoking, poor dietary habits, sedentary behavior, substance abuse, and so forth. They termed these
underlying factors “actual causes of death,” arguing that the
leading causes of death in the United States were not heart
disease, cancer, and stroke but tobacco, poor diet and inactivity, and alcohol abuse. This analysis was compelling because
it pointed out that certain behaviors such as smoking were
linked to many diseases (e.g., cancer, heart disease, chronic
pulmonary disease) and, as a consequence, were responsible
for far more deaths than a single disease entity. Updated for
2000, smoking remains the leading cause of death in the
United States, but obesity is now a close second (Mokdad,
Marks, Stroup, & Gerberding, 2004). The Centers for Disease
Control and Prevention estimates that health behaviors account for 50% of health outcomes in the United States, a far
larger proportion than genetics (20%), the environment
(20%), and access to health care (10%; Amara et al., 2003).
Beginning in the 1960s, the U.S. Office of the Surgeon
General has issued 37 reports on smoking and health,
repeatedly bringing attention to the critical role behavior
314
plays in the nation’s health. In addition to reports on
smoking, the Office has issued reports on television and
youth violence and numerous reports on nutrition, physical
activity, and obesity (all reports may be accessed at http://
www.surgeongeneral.gov/library/reports/index.html). In
1979, the Office initiated the Healthy People reports, which
identify the nation’s objectives for improving health. These
reports are revised every 10 years and highlight the critical
role of behavior in Americans’ health and well-being (see
(http://www.healthypeople.gov/2020/default.aspx).
In 1982, the Institute of Medicine published Health
and Behavior: Frontiers of Biobehavioral Research, a
landmark volume that emphasized the importance of behavior to health. This was followed by a number of other
important reports: Promoting Health: Intervention Strategies From Social and Behavioral Research (2000); From
Neurons to Neighborhoods: The Science of Early Childhood Development (2000); and Health and Behavior: The
Interplay of Biological, Behavioral, and Societal Influences
(2001). (All of these reports can be retrieved at http://
www.iom.edu/Reports.aspx). Just like the reports from the
Office of the Surgeon General, these Institute of Medicine
publications gave important scientific credence to the role
of behavior in health.
Although these reports emphasized the role of behavior in disease prevention and health promotion, behavior is
also critical to the management of disease, particularly
chronic disease. Patients suffering from chronic disease are
often expected to carry out multiple daily disease management tasks at home. These tasks might include medication
taking, dietary or exercise modifications, or physiological
assessments (e.g., blood pressure monitoring or blood glucose testing). Patients often fail to adhere to these treatment
regimens, and poor adherence is often linked to poorer
health outcomes and higher health care costs (Johnson,
2012; Willey et al., 2000). The importance of behavior to
successful disease management extends beyond patient beJuly–August 2013 ● American Psychologist
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havior; provider behavior can be just as problematic. In
2000, the Institute of Medicine published a seminal report
documenting that medical errors are so widespread and
serious that they are the eighth leading cause of death in the
United States (Kohn, Corrigan, & Donaldson, 2000). Some
have estimated that half of the medical recommendations
made to patients are actually inappropriate (Myers &
Midence, 1998). Clearly, both patient and provider behavior are critical to chronic disease management. The biomedical model’s failure to include behavior in its conceptual framework underlies its failure to successfully address
the chronic disease challenges facing our nation.
In response, new structures within the National Institutes
of Health (NIH) began to emerge. In 1995, the Office of
Behavioral and Social Science Research was established.
Even the Human Genome Project—an inherently biomedical
enterprise—recognized the importance of a broader perspective with the 1990 establishment of the National Human
Genome Research Institute’s Ethical, Legal, and Social Implications Research Program.
Failure to Adequately Address
Mental Health Concerns
Mental health concerns are common—26% of U.S. adults
have a mental disorder, and 6% have a serious mental
disorder—and are the leading cause of disability in the
United States (National Institute of Mental Health, 2008).
Most patients bring their mental health concerns to their
primary care provider. However, given the mind– body
dualism of the biomedical model, primary care physicians
are ill-equipped to address these concerns. Many patients’
mental health problems go unrecognized or untreated or are
inappropriately treated (Kathol, Bulter, McAlpine, & Kane,
2010; Young, Klap, Sherbourne, & Wells, 2001). To complicate matters further, mental health disorders are frequently co-morbid with physical disorders. As many as
40% of medical patients are co-morbid for a mental health
disorder and as many as 75% of seriously mentally ill
patients are comorbid for a physical disorder (Kessler,
Ormel, Demler, & Stang, 2003). Patients who are comorbid
for both physical and mental disorders can be extremely
costly; total health care expenditures for such patients may
be twice those for patients who suffer from a medical or
mental illness alone (Druss, Rosenheck, & Sledge, 2000).
The biomedical model’s failure to adequately address mental health concerns is one of its major limitations. Many
believe that the mind– body dualism of the U.S. health care
system is one component of its escalating health care costs.
When patients’ mental health concerns go unaddressed or
are inappropriately treated, health care costs rise in a neverending effort to identify the biologic defect underlying the
patient’s complaints.
Medicine’s Paradigm Shift From the
Biomedical to the Biopsychosocial
Model
In 1977, George Engel, an American internist at the University of Rochester, introduced the biopsychosocial model
July–August 2013 ● American Psychologist
in an article in Science. He argued that the biomedical
model—the dominant model of Western medicine—was
inadequate because it is reductionistic, exclusionary, dualistic and “leaves no room within this framework for the
social, psychological, and behavioral dimensions of illness” (Engel, 1977, p. 135). Although Engel’s biopsychosocial model gained considerable credence within academic circles and among health psychologists, until very
recently, it had little or no impact on the U.S. health care
system, which remained strongly aligned with the biomedical model.
Although Engel did not provide a conceptual diagram
of his biopsychosocial model, many were subsequently
developed. Figure 3 provides one example (Evans & Stoddart, 1990). Note that the biomedical model is a small
component of this larger framework. Some pathogen or
poison (a subset of the Physical Environment) or some
genetic defect (as subset of the Genetic Environment) impacts the patient’s biology (a subset of the Individual
Response), resulting in Disease. Biologic diagnostic tools
and biologic therapeutics are then used (a subset of Health
Care) in an effort to treat the Disease. The framework of
the biopsychosocial model considers a broader array of
social, environmental, and genetic factors that might affect
the individual. The Individual Response is expanded to
include behavior in addition to biology. Health Care might
include a variety of assessment strategies, therapeutics, and
delivery systems in addition to those that are purely biomedical. In this biopsychosocial framework, disease is no
longer the primary outcome of interest. Rather, the model
articulates the importance of Health, Function, and WellBeing in addition to Disease per se. While the biomedical
model’s exclusionary, reductionistic focus on disease leads
to mind– body dualism and an emphasis on biologic assays
and biologic treatments, the biopsychosocial model rejects
Figure 3
Evans and Stoddart’s (1990) Biopsychosocial Model
Note. Reprinted from “Producing Health, Consuming Health Care,” by R. G.
Evans & G. L. Stoddart, 1990, Social Science & Medicine, 31, p. 1359.
Copyright 1990 by Elsevier Ltd.
315
the separation of mind and body and incorporates environmental, social, and behavioral factors in its effort to understand health, illness, and well-being. In this model, treatments may be behavioral, environmental, or biologic.
Medicine’s paradigm shift away from the biomedical
model toward the biopsychosocial model is under way; this
paradigm shift is likely to have a profound impact on U.S.
health care, medical education, and health research.
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Implications of the Biopsychosocial
Model for U.S. Health Care
There is considerable interest in a new approach to health
care based on the biopsychosocial model: patient-centered
integrated care. When health care is patient-centered and
integrated, mind– body dualism is abandoned and the patient is viewed as a whole person. All of the patient’s needs
are addressed by an interprofessional health care team that
includes both health and mental health expertise in a nonstigmatizing environment that considers the patient’s preferences and culture. To the extent that these tenets of
patient-centered care can be realized in actual practice, we
would expect increased quality of care (all of the patient’s
concerns are addressed, not just physical concerns), greater
access to care (patients have immediate access to highquality mental health care as well as medical care), reduced
stigma (mental health concerns are not ignored or “carved
out” to some third party), lower costs (when all of the
patient’s concerns are addressed, unnecessary diagnostic
tests in search of some underlying biologic defect may be
avoided and appropriate treatments are more likely to be
administered), and greater patient satisfaction (the patient
feels listened to and cared for and receives any needed
treatments in a timely fashion).
The Patient Protection and Affordable Care Act
(available at http://www.healthcare.gov/law/full/index.html)
is consistent with the tenets of patient-centered care and the
framework of the biopsychosocial model. Essential health
benefits are not limited to medical concerns but must include mental health, preventive and wellness services, and
chronic disease management—aspects of health care that
have been previously “carved out” or completely ignored.
The Affordable Care Act stipulates that the services listed
in the U.S. Preventive Services Task Force’s A (high certainty that the net benefit is substantial) and B (high certainty
that the net benefit is moderate or moderate certainty that the
net benefit is moderate to substantial) recommendations must
be provided. Currently, of 45 A and B recommendations, 11
are behavioral (see Table 2). A number of other behavioral
recommendations are under review (e.g., counseling to prevent tobacco use in children and adolescents, counseling to
prevent child abuse and neglect, screening for suicide risk,
screening for intimate partner violence and elder abuse; see
http://www.uspreventiveservicestaskforce.org/uspstf/topicsprog
.htm). Consequently, we can expect additional behavioral
screening and counseling recommendations to become part
of the essential health benefits as the scientific evidence
warrants their inclusion.
316
In addition to focusing on patient behavior and wellbeing, the Affordable Care Act repeatedly highlights the importance of provider behavior. In addition to requiring evidence-based screening and interventions as part of the
essential benefits like those described in Table 2, the Act
emphasizes patient safety and the reduction of medical errors.
The electronic medical record, including decision support
systems, is often viewed as a mechanism to enhance patient
safety and reduce medical errors.
Unlike the disease focus of the biomedical model, the
Affordable Care Act also highlights patient functioning and
quality of life as important health outcomes, establishing
the Patient-Centered Outcomes Research Institute, which
focuses on “outcomes that people notice and care about
such as survival, function, symptoms, and health related
quality of life” (see http://www.pcori.org/research-wesupport/pcor/).
Implications of the Biopsychosocial
Model for Health Provider Education
Recent policies of the American Association of Medical
Colleges (AAMC; 2011) highlight the expanding influence
of the biopsychosocial model on medical education. Based
on the AAMC’s 2011 report, Behavioral and Social Science Foundations for Future Physicians, the structure of
the Medical College Admission Test (MCAT) will change
in 2015 and will include a section on psychological, social,
and biological foundations of behavior, accounting for one
quarter of the exam questions (see https://www.aamc.org/
download/273766/data/finalmr5recommendations.pdf). Currently, medical school accreditation requires instruction
in behavioral science as well as adequate training in
patient–provider communication skills, the impact of
patient culture and beliefs, the medical impact of common societal problems, and the impact of provider bias
and beliefs (Liaison Committee for Medical Education,
2012). The larger health care community’s acceptance of
patient-centered integrated care delivered by health care
teams is highlighted in the Core Competencies for Interprofessional Collaborative Practice (Interprofessional Education Collaborative Expert Panel, 2011), a
collaborative effort of the AAMC, the American Association of Colleges of Nursing, the American Association of Colleges of Pharmacy, the American Association
of Colleges of Osteopathic Medicine, the American Dental Education Association, and the Association of
Schools of Public Health.
Implications of the Biopsychosocial
Model for Health Research
As the Affordable Care Act illustrates, the biopsychosocial
model changes the concern of evidence-based medicine
from a narrow focus on disease to a wide array of potential
patient outcomes—patient satisfaction, functioning, and
quality of life, to name a few. Instead of a narrow focus on
biologic assays and biologic interventions, a wider variety
of treatment options—including psychological or behavioral treatments— can be tested as part of the scientific
July–August 2013 ● American Psychologist
Table 2
U.S. Preventive Services Task Force (USPSTF) A and B Behavioral and Counseling Recommendations Relevant to
the Implementation of the Affordable Care Act
Topic
Alcohol misuse counseling
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BRCA screening and
counseling
Breastfeeding counseling
Depression screening:
adolescents
Depression screening: adults
Healthy diet counseling
Obesity screening and
counseling: adults
Obesity screening and
counseling: children
Sexually transmitted
infections counseling
Tobacco use counseling and
interventions: nonpregnant
adults
Tobacco use counseling:
pregnant women
USPSTF recommends:
Grade
Effective date
Screening and behavioral counseling interventions to
reduce alcohol misuse by adults, including pregnant
women, in primary care settings
Women whose family history is associated with an
increased risk for deleterious mutations in BRCA1 or
BRCA2 genes be referred for genetic counseling and
evaluation for BRCA testing
Interventions during pregnancy and after birth to promote
and support breastfeeding
Screening for adolescents (12–18 years of age) for major
depressive disorder when systems are in place to
ensure accurate diagnosis, psychotherapy (cognitivebehavioral or interpersonal) and follow-up
Screening for adults for depression disorder when staffassisted depression care supports are in place to ensure
accurate diagnosis, effective treatment, and follow-up
Intensive behavioral dietary counseling for adult patients
with hyperlipidemia and other known risk factors of
cardiovascular disease and diet-related chronic disease
Clinicians screen all adult patients for obesity and offer
intensive counseling and behavioral interventions to
promote sustained weight loss for obese adults
Clinicians screen children aged 6 years and older for
obesity and offer them or refer them to comprehensive,
intensive behavioral interventions to promote
improvement in weight status
High-intensity behavioral counseling to prevent sexually
transmitted infections (STIs) for all sexually active
adolescents and for adults with increased risk for STIs
Clinicians ask all adults about tobacco use and provide
tobacco cessation interventions for those who use
tobacco products
Clinicians ask all pregnant women about tobacco use
and provide augmented, pregnancy-tailored counseling
to those who smoke
B
2004
B
2005
B
2008
B
2009
B
2009
B
2003
B
2003
B
2010
B
2008
A
2009
A
2009
Note. Adapted from “USPSTF A and B Recommendations” by the U.S. Preventive Services Task Force, 2013. Retrieved from http://www.uspreventiveservicestaskforce
.org/uspstf/uspsabrecs.htm.
enterprise. New areas of inquiry, such as translation research and implementation science, are attracting some of
the best scientific minds. But perhaps most important, the
biopsychosocial model encourages interdisciplinary research or team science in which scientists with differing
areas of expertise come together to address the complexities of understanding and promoting health as well preventing and treating disease. Epigenetics, pharmacogenomics,
and personalized medicine are just a few of these new
interdisciplinary areas of inquiry. Interdisciplinary science
was the focus of the National Academy of Sciences’ 2004
groundbreaking report Facilitating Interdisciplinary ReJuly–August 2013 ● American Psychologist
search (National Research Council, 2004). It is also a
component of the NIH Roadmap for Medical Research’s
“Research Teams of the Future,” consisting of investigators
from many disciplines combining their skills and knowledge to accelerate discovery. The NIH has set aside funds
“to change academic research culture such that interdisciplinary approaches and team science spanning various
biomedical and behavioral specialties are encouraged and
rewarded” (http://commonfund.nih.gov/interdisciplinary/).
Using data obtained from the NIH’s Research Portfolio
Online Reporting Tools (RePORT; see http://projectreporter
.nih.gov/reporter.cfm), I found that funded grants that used
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the search terms “multidisciplinary” or “interdisciplinary”
in their titles or abstracts increased sevenfold from 1990 to
2010; total funding for these projects increased fourfold
from 2000 to 2010.1 This analysis likely underestimates the
extent of interdisciplinary funding at NIH, since many
interdisciplinary science teams do not choose to use these
search terms in their titles and abstracts.
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Implications of the Biopsychosocial
Model for Psychology
The biopsychosocial model is consistent with psychology’s multivariate conceptual heritage and its scientific
and methodological expertise. Many psychologists have
been early adopters of the model and proponents of its
development and application. These include health psychologists, pediatric psychologists, rehabilitation psychologists, neuropsychologists, geropsychologists, and
primary care psychologists, to name a few. These psychologists already work in public health as well as
primary and specialty health care settings. Psychologists
have been leading scientists in the development of interdisciplinary fields such as neuroscience, behavioral
genetics, psychoneuroimmunology, medical decisionmaking, and bioethics. Three of the first four directors of
the Office of Behavioral and Social Sciences Research at
the NIH have been psychologists: Norman Anderson,
David Abrams, and Robert Kaplan.
However, the impact of the biomedical model on
psychology practice, psychological science, and graduate education in psychology has been profound. The
reductionistic, exclusionary, dualistic tenets of the biomedical model meant that psychological practice or science was excluded or “carved out” from the larger health
care and health research enterprise. In response, most
psychologists became solo practitioners and solo scientists focusing their efforts primarily on mental health,
working in their own offices or laboratories with little
collaboration with other medical practitioners or scientists from other disciplines. Graduate psychology programs responded by preparing students to succeed in this
environment. As a consequence, many psychologists
feel ill prepared to adapt to the interprofessional practice
or interdisciplinary science framework that the biopsychosocial model demands.
Many professional psychologists have no experience working on health care teams in larger group practices or health care settings. They have been trained
solely in mental health and have no expertise in addressing a wide array of behavioral issues common in health
care (e.g., medical regimen adherence, pain management, coping with disability, life style behavior change).
They are unfamiliar with the larger health care culture,
including evidence-based practice, treatment guidelines,
and electronic health records. They have no experience
with how to collaborate with other health care providers
and organizations to develop new payment models to
assure mental health coverage as part of patient-centered
integrated care.
318
Although health research is now conducted primarily
by interdisciplinary science teams, many of our psychological scientists have never been trained to operate in such
environments. Other scientists on these teams are often
unfamiliar with the contributions psychological science can
make or are openly hostile to such contributions. With no
experience on such teams, psychological scientists often
fail to defend their role successfully, if they attempt to join
a science team to begin with. Our academic hiring and
tenure practices further discourage interdisciplinary science
and encourage solo science by valuing first-author and
single-author publications and funding above all else and
discouraging cross-discipline hiring.2
Medicine’s paradigm shift from the biomedical to
the biopsychosocial model presents remarkable opportunities for psychology in both health care and health
research. However, if psychology is to take advantage of
these opportunities, it must abandon the mind– body
dualism of the biomedical model and fully embrace the
biopsychosocial model in practice, research, and graduate education. This means that practicing psychologists
must be trained to function as health providers, not just
mental health providers, delivering services as members
of interprofessional health care teams. Similarly, psychological scientists must be trained to function successfully on interdisciplinary science teams and to embrace
the wide array of interdisciplinary sciences— epigenetics, psychoneuroimmunology, personalized medicine,
clinical trials, dissemination research, to name a few—
that will characterize the health science of the future. In
my view, psychology must be proactive and deliberate in
its acceptance of medicine’s paradigm shift to the biopsychosocial model. No one will plead with psychology
or wait for psychology to act. If psychology does not
embrace this paradigm shift, others will fill the gap,
providing the needed mental health services on interprofessional heath care teams and the behavioral science on
the interdisciplinary science teams of the future. While
others may step in if psychology does not, I do not
believe psychology’s remarkable professional and scientific heritage can be easily matched. As a consequence,
psychology’s failure to act will be a loss not only for
psychology but also for quality patient care and health
research.
The American Psychological
Association’s Response
As the largest association of U.S. psychologists and the
largest publisher of psychological science in the world, it is
critical that the American Psychological Association
(APA) provide leadership in this time of unprecedented
opportunity and challenge for psychology. A number of
APA policies are very consistent with evidence-based medicine, the Affordable Care Act, and medicine’s ongoing
1
No funding data were available before 2000.
This issue is not limited to psychology but is a problem across
academia.
2
July–August 2013 ● American Psychologist
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
paradigm shift to the biopsychosocial model, providing an
important framework for APA’s leadership in this area (all
of the following APA policies are available in the Council
Policy Manual at http://www.apa.org/about/policy/index
.aspx): Recognition of Psychologists as Health Service
Providers (1996); Changing U.S. Health Care System
(1999); Criteria for Evaluating Treatment Guidelines
(2000); Health Service Psychologists as Primary Care Providers (2003); Evidence-Based Practice in Psychology
(2005); Health Care for the Whole Person: Vision and
Principles (2005); and APA Principles for Health Care
Reform (2007).
Two components of APA’s strategic plan— expanding psychology’s role in health and increasing the recognition of psychology as a science—are consistent with
APA leadership in assuring psychologists as active participants in the interprofessional practice and interdisciplinary
science teams of the future (see http://www.apa.org/about/
apa/strategic-plan/default.aspx for more on APA’s strategic
plan).
For the first time, APA is undertaking the major task
of developing evidence-based treatment guidelines. The
first guideline will focus on depression, and the second
guideline will focus on obesity. These two topics highlight
the broad role psychologists can play in the larger health
care arena. In the 1970s, medicine was faced with overwhelming data showing that very little medical practice
was based on scientific research. In response, evidencebased medicine and the development of scientifically
grounded treatment guidelines became widely accepted
(Eddy, 2005). It is important that APA join the evidencebased movement if it is to be a true player in health care.
Psychologists have important expertise to offer and can
play a critical role in assuring that psychological interventions are part of evidence-based treatment guidelines. Consistent with the biopsychosocial model, patients should
have access to effective psychological interventions and
not be limited to drugs or other biologic treatments. (To
learn more about APA’s treatment guideline efforts, go to
http://www.apa.org/about/offices/directorates/guidelines/
clinical-treatment.aspx).
APA has also been very active in graduate education relevant to training psychologists to practice in
integrated care. APA lobbied successfully for the Graduate Psychology Education Program that established
psychology as a health profession within the federal
Bureau of Health Professions grant programs in 2001.
This program currently provides competitive funding to
accredited doctoral, internship, and postdoctoral programs for psychology students providing services to
underserved populations in interdisciplinary integrated
health care settings. (To learn more, go to http://bhpr.hrsa.gov/grants/mentalbehavioral/gpe.html). APA is
also a member of the Health Service Psychology Education Collaborative, an interorganizational group that
has articulated the necessary competencies for psychologists to practice as health service providers (Health
Service Psychology Education Collaborative, in press).
In a similar partnership, APA joined with nine other
July–August 2013 ● American Psychologist
organizations to produce a document identifying the
competencies for psychological practice in primary care
(McDaniel et al., 2013). These reports provide important
resources for practicing psychologists wanting to expand
their skills to function in the larger health care arena and
for the Commission on Accreditation and the graduate
programs that are responsible for training the next generation of professional psychologists to function effectively in health care. Finally, although not a party to the
development of the Core Competencies for Interprofessional Collaborative Practice (Interprofessional Education Collaborative Expert Panel, 2011), APA’s Council
of Representatives took the important step of endorsing
this document in 2013.
Most recently, APA joined with the American Psychological Association Practice Organization to establish a
new Center for Psychology and Health. The goal of the
center, directed by APA CEO Norman Anderson, is to
expand the use of psychological knowledge within evolving health care settings as well as prepare psychologists to
practice in these settings. A unit of the center, the Office of
Health Care Financing, will focus on payment models that
are fair and sustainable for both health systems and practitioners. The office will coordinate APA’s participation in
the American Medical Association’s (AMA’s) Current Procedural Terminology (CPT) Editorial Panel—where CPT
codes describing psychologists’ work are developed—and
the AMA’s Relative Value Scale Update Committee,
where those procedure codes are valued. (To learn more
about the Center go to http://www.apa.org/health/index
.aspx). It is critically important that other health practitioners understand the value of having psychological expertise
on their health care teams. However, these teams cannot be
sustained unless new payment models are developed. The
Center will play critical roles both internally— educating
psychologists—and externally— educating and collaborating with other health care providers and their organizations
to assure patient access to high-quality psychological expertise.
APA is also committed to conducting a work force
analysis as one of its strategic initiatives. A work force
analysis is sorely needed in order to respond to the nation’s
work force needs of the future and to assure an adequate
response by the discipline. However, psychology’s work
force analysis will look very different if professional psychology is viewed as a central player in patient-centered
integrated health care than if it remains a “carved out”
mental health profession.
Finally, APA is committed to a path toward interdisciplinary science broadly conceived, including interdisciplinary health research. Interdisciplinary education, professionalism, and science were the foci of the 2011 Education
Leadership Conference (for more information, go to http://
www.apa.org/ed/governance/elc/2011/index.aspx). APA
has also produced a task force report relevant to this issue
(APA 2009 Presidential Task Force on the Future of Psychology as a Stem Discipline, 2010) and is currently represented on the Council of Scientific Society Presidents’
Committee on Interdisciplinary Science. The purpose of
319
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
this committee is to do more than identify barriers to
interdisciplinary science—such as hiring practices, promotion and tenure requirements, and funding formulas— but
to identify solutions. There are a host of creative models
that have successfully been used to increase both interdisciplinary science and teaching within the academy. By
articulating models and solutions, APA can join with other
scientific organizations to promote interdisciplinary science that includes psychology.
APA’s leadership is important if psychology is to take
advantage of medicine’s paradigm shift from the biomedical to the biopsychosocial model. However, APA cannot
do this alone. Individual psychologists and other psychological associations, at the state and national levels, must be
proactive and deliberate, joining with APA, each other, and
other health care providers and their organizations to make
patient-centered integrated care a reality.
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