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How Would You Characterize Our Clinical Era?

January 14, 2020

I became a psychology major in college with the conviction I was studying a great field, and I was even more convinced upon the award of my doctorate in clinical psychology. The abiding debate in those years was which model of psychotherapy was best, and the implicit promise in this was a growing awareness that we were figuring out how to help people resolve some of the misery in their lives.

Those earlier debates between Freudians and behaviorists seem quaint now, both in form and substance. The form seemed akin to a religious debate, while the substance has largely been lost beneath years of empirical evidence. The field has witnessed decades of research proving the overall effectiveness of psychotherapy, if not the superiority of one model over the other.

We now find ourselves in the behavioral healthcare field, and the energy has greatly subsided over schools of psychotherapy. We see addiction being as important a focus of treatment as mental health, and many clinicians are expanding to include health-promoting behaviors like nutritional eating and physical movement as a critical pillar of behavioral health.

It is often difficult to discern the defining issues or accomplishments of one’s own time. I would suggest with that disclaimer that we live in a time with tremendous knowledge about how to help people, and now we face the challenge of disseminating and realizing the broad impact of that expertise. Today it is possible to improve the health of populations, not just that of individuals in psychotherapy.

Psychotherapy research

Psychiatrists may share similar feelings of pride in their profession, and the goal here is not to disabuse them of that view. The intent is to ask what steps our field should take when its tools for psychological change are proven and adaptable. Such a claim rarely goes unchallenged, and so a quick review of the “talking cure” may be the best place to start. The value of medication is someone else’s issue.

Statistics are best understood when placed in context. Telling someone that psychotherapy has a large effect size of 0.8 generates little enthusiasm. Placing psychotherapy alongside other medical interventions by statistical results can produce more interest. The truth about psychotherapy is that it stands up very well against other healthcare treatments as being empirically supported.

Leading outcomes researcher Bruce Wampold references the statistical measure, called Number Needed to Treat (NNT), as a way of showing the impact of psychotherapy relative to other healthcare interventions. The NNT for psychotherapy is far superior to results for statins and flu shots, for example, and yet these standard medical treatments receive full reimbursement and little stigma.

It is important to note that NNT identifies psychotherapy as highly effective, not any specific approach to therapy. This is critical since no one approach stands out as more effective in the research. Does this mean we should ignore models of psychotherapy? Not at all. Yet we should probably pay more attention to results by therapist, since those results vary, particularly at each end of the distribution.

Beyond psychotherapy: Coaches and digital modules

If our goal is to reach people in need who cannot access psychotherapy, then we should develop lower cost, widely available resources grounded in psychotherapy models. Toward this end we should distill:

  1. How top-achieving therapists achieve their outcomes (e.g., empathic listening)
  2. The clinical tools used in successful therapy models (e.g., cognitive restructuring)

The next logical steps would be to train peer counselors in the best clinical practices, and to develop digital modules that present therapeutic tools in an interactive way that simulates therapy.

These activities are occurring to some extent. Peer counselors are a feature of some treatment programs for seriously mentally ill clients, but this model could be expanded to address broader populations. Digital tools are becoming more common as part of the adjunct services offered by healthcare payers, but they are in the early stage of dissemination and adoption by consumers.

We are poised today to leverage decades of innovation in models of psychotherapy along with research into their effectiveness. Our clinical leaders and their techniques are less mysterious than in the last century, and many now recognize that unmet needs can be addressed with the judicious use of non-professional counselors and the unlimited availability of evidence-based digital tools.

Population health

Psychotherapy was not developed initially to treat addictions, nor were health-promoting behaviors in mind for any of the innovators. Yet the applicability of psychotherapy models to these problems was readily apparent. Practical applications for treating substance use now exist, and an expansion of therapy models to health behaviors has started, with further work just a matter of time.

It will soon be an irrelevant historical fact that experts in psychotherapy were not focused on the complete range of behavioral health issues from the start. Wellness programs staffed with nurses and registered dieticians were sensible approaches. Yet they were ill-equipped to manage the complexity of thoughts, feelings and behaviors. They never even understood the intricacies of a therapeutic alliance.

We are not meeting diverse needs today for mental health. Depression is a pervasive and disabling scourge, while sub-clinical levels of common conditions impair functioning as well. Only about 10% of people with substance use problems are getting the help they need, and health-promoting behaviors are impervious to current interventions. Obesity is a national crisis, while vaping grows with alarm.

When you combine these domains of behavioral health and consider the impact on population health from providing effective interventions on a wide scale, it seems reasonable to consider discussing the dawning of an era. What could be wrong here? In short, a financial shortfall. We are proceeding under the radar and without the funding commensurate with current or forecast needs.

Call to action

There are many reasons for this, but the solutions start with leaders in our field. We have poorly communicated the remarkable effectiveness of psychotherapy. We have been slow to accept responsibility for all three of the domains of behavioral health – our mental health, our use of substances, and our health-promoting behaviors.

These problems are neither surprising nor insurmountable. Progress on this scale never moves in an organized manner. Behavioral health experts are working on aspects of what has been discussed here, and it is time for them to coalesce. The next era of psychology is approaching, and we are providing some of the most powerful clinical interventions to improve the health of populations in a generation.

Let’s not squander our potential. We will do so if we remain stuck in our careers and our areas of specialization. We can improve the health of populations, but it is best done with more marketing promotion and capital campaigns than is our norm. We need industry leaders to galvanize the many psychology majors in our midst to lobby for wider distribution of our proven clinical tools.

Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.

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