The disease management (DM) industry has existed for many years, epitomized by words of encouragement to eat better and exercise more coming from nurses and dieticians. A chronic disease like diabetes initially qualifies a patient for this encouragement. A nursing component may exist, but the essential goal is comparable to the wellness industry – getting people to change behaviors that impact health.
The goals for change may include everything from smoking cessation to medication adherence, given that the purview is behavior that drives health status. Actuaries are impressed with this area. A substantial percentage of health status derives from health behaviors, and costs are enormous. Behavior change is critical for managing the 50% of healthcare costs tied to chronic conditions.
The secret that health plans and their DM vendors know, but no one voices too loudly, is that the industry is largely ineffective. You will hear a growing chorus lamenting that it is very hard to change health behaviors. The solutions are either more of the same or fixing existing products around the edges. DM and wellness solutions need major renovation, starting with new ownership.
Changing behavior is rightly the domain of behavioral health professionals. History explains how these critical behaviors escaped their focus. The main answer can be found in the diagnostic and statistical manual. The DSM drives the work of the behavioral healthcare field, and health behaviors are not in the manual. The first corrective step would be for the field to nominate itself for an ownership change.
Pleased to meet you
Psychotherapy takes place in a private office. The relationship is confidential because it is expected people share some of the most intimate details of their lives in the hope of feeling better. The therapeutic alliance that forms is based on that expectation, along with agreement to work on specific tasks toward personal goals. This is the foundation for all established forms of psychotherapy.
This foundation is difficult to achieve in a phone call. DM and wellness coaches are pleasant and welcoming in their initial call with a client, but it is unlikely they establish a therapeutic alliance. This may account for some of the subsequent indifference from clients who receive a call back from the coach and don’t answer the phone.
While some people are clearly helped with telephonic coaching, few people are willing to participate in the first place. The preferred setting for such coaching is a private office, either a primary care office or a behavioral healthcare office. An earlier article describing the limitations of primary care integration outlines the need for a larger role for behavioral specialists in the primary care setting.
Many interventions taking place by phone are shifting to text and digital formats, and this clearly expands the population that can be reached and helped. It does not change the fact that health behaviors are difficult to change and will frequently require an alliance to do so. Alliance should be a prerequisite, much as it is for psychotherapy, when health coaching is the chosen intervention.
Is this coaching or therapy?
Not every person with unhealthy behaviors needs psychotherapy. Yet some could benefit from therapy, even if only in 20-minute segments. Coaching should look more like therapy in terms of the alliance and certain interventions. Therapy might seem to resemble coaching, but it starts with a licensed clinician and pursues conflicts that a coach must avoid due to lack of training.
If we believe health behaviors are critical to health status and total healthcare cost, then we should be willing to use our most powerful tools to have an impact. This means the behavioral healthcare field must train more clinicians in this domain. This is not a dramatic shift from basic clinical training, but it will entail learning some techniques specific to health behaviors that have proven effective.
Once all available resources are clarified, ranging from lower to higher cost, then the challenge is to deploy each at the level needed. Yet the common foundation should derive from psychotherapy. Digital tools introduce therapy techniques, much as coaches work in a therapy-based model. The historically dominant nursing model should be adjunctive.
The nursing model is a complement to the medical model, which is suboptimal if behavior change is the goal. The professional standard bearer is the licensed psychotherapist rather than the physician. It should be noted that anyone can call themselves a coach, but legal and regulatory guidelines view any service by a licensed person to be tied to that license regardless of what it is called.
Programs and people
Innovators in healthcare are often focused on designing programs that can help many people rather than just engaging in individual episodes of care. This has brought us many effective approaches to psychotherapy as well as effective ways to shape healthy behaviors. These effective models can be implemented once people are trained in the clinical protocols.
However, decades of psychotherapy research have proven that effective protocols are especially powerful in the hands of exceptionally therapeutic people. Consider psychopharmacology. Research has shown that some prescribers get better outcomes dispensing the same pills as others. Relationship based interventions are prone to producing a range of outcomes depending on the clinician.
The medical model acknowledges “bedside manner” in the course of diagnosis and treatment, but it disparages what happens in the context of a relationship as placebo. The common factors that drive psychotherapy outcomes are more non-specific interventions than placebo. The therapist who can form an alliance and listen empathically with different types of people has a genuine skill.
The proposal here is to put those clinicians in charge of behavior change who understand the power of relationships. People potentiate clinical techniques. There is a role for the knowledge of nurses, dieticians, and others in a behavior change treatment plan, but the first step in transforming the DM and wellness industries is to place it within consolidated behavioral health.
Diagnoses such as depression and anxiety are among the undetected reasons people struggle to change health behaviors. Behavioral health clinicians are needed to diagnose and treat these disorders when they complicate chronic illnesses and lifestyle changes. However, it is more common to find that people don’t manage illnesses and change lifestyles because bad habits are deeply ingrained.
Persistent unhealthy behaviors are often impervious to a well-meaning nursing model of providing clinical information, encouragement, and small, achievable goals. The transformation to a consolidated behavioral health model is needed because it recognizes that people are often too self-defeating, emotional, or guilt-ridden to change. Therapy may not be required, but a therapist may be.
None of this is intended to suggest the behavioral healthcare field has everything figured out. We just need a new starting point. Behavior change is difficult, whether the focus is depression, substance use, or health behaviors. The new health behavior team needs to know what works in psychotherapy, and then leverage those strengths to help millions of people stuck in familiar ruts.
Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.