A CONVERSATION WITH STEVEN LOCKE
BOL: You are best known for your contributions to our
understanding of psychoneuroimmunology (PNI). I wonder to what
extent the
research
observations and hypotheses of PNI informs your approach to the
clinical
practice of behavioral medicine.
Locke: The field of PNI research has contributed enormously to behavioral medicine by elucidating mediating mechanisms that could explain the relationship between behavioral factors -- such as stressful life change -- and the onset or course of human illness. PNI research takes many forms. Some of the research is basic neuroscience research which has increased our understanding of the interaction between the nervous and immune systems.
In contrast, other research is applied, clinical research, including clinical trials of behavioral interventions for the purpose of altering immunity and enhancing the resistance to disease. The basic neuroscience research has advanced to the point where there are now sessions on PNI at the prestigious Society of Neuroscience meetings, several textbooks in the field, three scientific journals dedicated to PNI, and two societies for PNI research. As recently as 15 years ago, a famous professor of medicine at Harvard stated "I can't think of two systems in the body less likely to be related than the CNS and the immune system." Today, such a statement from an informed physician-scientist would reveal a shocking degree of ignorance.
Unfortunately, the clinical research has been less convincing, due largely to the cost of clinical trials that require the assessment of both medical outcomes as well as the measurement of immunological factors. Despite these barriers, there have been some impressive studies in recent years that have demonstrated that stress is associated with greater susceptibility to immune-resisted diseases and that behavioral interventions such as cognitive behavior therapy (CBT) (Fawzy, Fawzy, et al.) and support groups (David Spiegel, et al.) can improve resistance to the spread of human cancer. There are even some encouraging new data to suggest that CBT may slow the progress of HIV infection to AIDS (Michael Antoni, et al.)
Taken collectively, these findings help me to design and implement new clinical programs in behavioral medicine at Harvard Pilgrim Health Care, the largest HMO in New England. In particular, the accumulating data which confirms the existence of a psychosomatic neuroendocrine-immune network which underlies the biopsychosocial model makes it easier for me to approach physicians in primary care and medical specialties with proposals to create collaborative behavioral programs. And there is even room for antidepressant and anxiolytic psychopharmacotherapy in this model as well! Perhaps "Biobehavioral Medicine" would be a better term. (As near as I can tell, the only problem with the term "psychosomatic" medicine -- which literally means "mindbody"-- is a marketing issue.)
BOL: If I read you correctly PNI science lends credence to behavioral medicine practice in a general way, but doesn't provide help immediately in shaping what you do to help the individual patient. I will also guess that what you do with a patient is guided most by your accumulated clinical experience. But instead of guessing I'll ask: how do you go about the task of assessing the patient's needs and choosing an appropriate behavior medicine intervention?
Locke: Nowadays, the answer to this question depends in part on the nature of the health care system in which the care is provided. Even in my private practice, the way I approach a patient's care depends not only on the diagnosis but on how the patient's care will be financed. I know this sounds like a poor basis for treatment planning but these realities are inescapable. Some people are in managed care plans that restrict what treatments are covered or which providers may be seen. If you are a patient in an HMO -- and the percentage of patients in HMO's continue to rise -- you are limited to the programs of care offered by that plan.
At Harvard Pilgrim Health Care -- the largest HMO in New England -- we have been offering behavioral medicine interventions for over 15 years. This began with the development of the Ways to Wellness program by Dr. Matthew Budd and his colleagues Roberta Colasanti, Margot Fanger, and Holly Burnes at Harvard Community Health Plan. More recently, this program has been improved and renamed the Personal Health Improvement Program, or PHIP. It is a six week group program which meets weekly for two hours at one of our health centers. (Unlike other programs in Massachusetts, this program is available in sites throughout eastern Massachusetts.)
The program was designed to meet the challenge of treating patients with stress-related illness and chronic disease. At present, over 5000 patients have benefitted from the program and an average of 1500 referrals are received annually. Outcome studies documenting the benefit to patients and the reduction in utilization of medical services have been published. The purpose of the program is to teach patients how to pay attention to their moods and behaviors. As they reflect on the prevalence of specific, recurrent moods, patients begin to see the effect on their bodies and their health. Patients are guided in this process by an experienced facilitator so that they learn new ways of coping with the chalenges of daily living and management of their symptoms. Patients often benefit by experiencing increased self-awareness, greater self-care, and decreased somatization. This is frequently accompanied by improved social support, decreased isolation, a greater sense of self-mastery and empowerment, and more active coping behaviors. We have begun to tailor the program for patients with specific complaints, like asthma, eczema, fibromyalgia, back pain, and so forth.
As I see it, the goal is to work closely with our doctors in primary care to identify patients who are under stress or manifesting symptoms of depression or anxiety and to screen them using either paper-and-pencil self-assessment tools or, eventually, to use computer-based behavioral assessment -- something which I think will help us to identify patients who would benefit from joining a PHIP group. Then we will see not only reductions in symptoms, but also increased patient satisfaction and greater cost-savings too.
BOL: What you have said so far is very interesting. Let's include others by continuing our conversation on the Behavior OnLine Forum.
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