The good news is that psychotherapy is much more effective than other common medical treatments. The bad news is that, on average, studies show more people fail to benefit than make gains. This distressing news should be a call to action, but we must start with clarity. The best way to understand comparisons of clinical effectiveness is with a statistic called “number needed to treat” or NNT.
NNT is a way of expressing clinical improvement commonly cited in the literature on evidence-based medicine. It is a number that reflects how many people need to receive an intervention to have one better outcome than an alternative (such as a placebo or no treatment). Psychotherapy has an NNT of 3, and this means 2 people get results equivalent to no treatment while 1 has a positive outcome.
As one expert notes, “it is disturbing to know that only one in three psychotherapy clients benefit.” This is true, and yet perspective is needed. Widely used medical solutions like flu shots (NNT = 12) and statins for high cholesterol (NNT = 60) are much less effective. The more important question is how to boost the broad social impact for therapy, our most common psychosocial intervention.
Some may respond to this knowledge by exploring how to improve our therapies, while others might focus on improving the skills of therapists. My reaction is that we should leverage a good thing. Let us start from the reality of having a remarkably effective treatment today. We should then devise ways to increase the population receiving that service. That is, grow the pie and keep it sliced into 3 pieces.
People entering therapy must scale several hurdles. They must first realize their distress warrants professional help. They need to find that help and pay for it. Practical or logistical challenges vary for everyone. Completing one visit is most common. Many people getting a referral never make a visit.
In previous articles I have argued that psychotherapists should be providing services within the primary care setting. The ubiquity of behavioral issues in that setting establishes the need. Our ability to improve the health status of many through behavior change confirms the value. The effect of moving to primary care is that services are offered in a stigma-free environment. Primary care is routine care.
Another effect of moving to primary care is more people can receive our services. There are nearly 500 million primary care visits every year in this country. People see PCPs for annual exams, check-ups for chronic care, and all manner of routine and urgent conditions. If a normal part of general care included behavioral health, more people would get our care. They would do so without thinking much about it.
How can we increase the impact of therapy in real world settings? We might want to either grow or improve the pool of providers. One approach would be to measure therapy results, stratify clinicians by outcomes, and then get more patients to the top performers while retraining our worst performers. However simple this may be in principle, our institutions are not yet structured to accomplish this.
A similar model is being tried today with non-professional coaches. Research on psychotherapy outcomes has long validated that academic degrees and training do not determine the best results. Whatever factors might drive performance, it is possible to identify people who get above-average results coaching others. Healthcare products are being built around these natural healers today.
Consider another approach that presents people with some of the key elements of therapy. We cannot predict how everyone will respond to various therapeutic interventions. Why not offer them some highlights? This approach is behind the rise of digital health solutions. Interactive programs modelled after therapy discussions help some. Videos of peers and professionals with self-care tips help others.
The full power of these ideas is achieved by combining them. Imagine this scenario: Behavioral healthcare professionals in primary care assess and treat. They also refer certain patients to non-professional coaches (validated as being effective) for virtual visits. They refer others to digital sites for practicing cognitive behavioral therapy skills. They coordinate all behavioral healthcare services.
This mixture expands the pool of people getting help. We can leverage our knowledge about therapy and disseminate its benefits more widely by changing its delivery. People will get services that are brief, virtual, and non-stigmatized. We start by focusing on questions of where, who, and how care is delivered. We can use the science, change the delivery, and boost the social impact of our work.
Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.