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Let’s Not Overengineer: Searching for the Essence in Clinical Therapies and Products

November 18, 2019

The world is complicated, but sometimes we make it so for no good reason. We have several examples in the behavioral healthcare field, and psychotherapy is a good place to start. Few people today follow all the intricacies of the models of psychotherapy they were taught. Freud is too easy a target, and so let’s focus on brief therapy models.

Many books were once written on brief psychotherapy. I struggled to incorporate all the available wisdom. There were clever questions to ask, states of mind to embrace, and procedures to follow. In the crush of competing models for brief therapy, I never got very good at any of them. I will confess now that I never had the guts to ask anyone the miracle question.

What is left today? The enduring insight of brief therapy was in the name of the therapy. It is valid to approach therapy with most people assuming that they may only need half a dozen sessions to get what they need. This was a radical insight for people like me who were trained to provide everyone with long-term psychotherapy.

I have long advocated using simple clinical measures for monitoring outcomes during therapy. There are many reasons to recommend this, but one is that you can see that most people benefit from therapy after a few sessions regardless of what treatment is provided. There are many satisfied people leaving treatment early, and they are not taking a “flight into health.”

My hope is that people continue to create new therapies, programs and products. Measurement of results does not mean that anything goes. We should be figuring out how to constantly get better clinical results, and this requires more than just measurement. I would argue we need creativity in design with minimum complexity. Unfortunately, clinicians are prone to creating elaborate systems.

New product design

I have worked on the development of new clinical products for a few decades, both from within large companies and as a consultant to start-up companies. Inventors want to consider every angle, answer every question, build in enough guidance for easy navigation of the experience. Clinicians often add an extra dose of complexity, typically through allegiance to some underlying clinical theory.

One of my first experiences with this dynamic was in developing models for case management. In retrospect the best approach might have been an outline of essential goals coupled with caseload expectations. The early products instead included unwarranted detail on the clinical basis for movement among various levels of case management, diagnostic issues and minutia on interventions.

A clinically naïve person has an advantage here. They are more likely to construct details around the essential design and then focus on everyday issues like convenience and comfort of the experience. Clinicians will obsess about clinical change measures, while non-clinicians focus on satisfaction and qualitative indicators of success. There is a place for both, and neither should crowd out the other.

The clinician’s weakness is a fascination with the clinical ingredients for a product. This is the path to excessive complexity. A good product considers the user’s experience, ways to boost engagement, accessibility for those with limited education, recognition of culture and ethnicity, and the many non-clinical features that motivate and help people. Clinicians sometimes wear blinders focusing them only on the clinical practices that can be validated as empirically supported.

Essential Practices

I had a solid education in the theory and practice of cognitive behavioral therapy (CBT), and I believe that I helped people in therapy sessions using these techniques even though my expertise is quite basic when compared with true experts in this approach.

I am familiar with the research on the effectiveness of online CBT programs, and my hunch is that people do not rigorously complete all the modules offered by these digital programs. Yet clinical improvement is found across dozens of studies on digital CBT.

It could be argued that my patients would have benefited more from a genuine expert, and similarly, that people profit from digital CBT programs to the degree they utilize them. However, my impression is that people respond to the essence of CBT – challenging distorted thoughts to reduce dysphoric moods – and this powerful experience is therapeutic. Marginally greater gains from implausible scenarios don’t matter – true experts are few, and people rarely use every available resource.

Clinical innovation often starts with a core theory or practice that is built into many phases, elements and steps to establish a comprehensive model. This establishes the appearance of a more scientific construct, and it may help others mold it into a salable clinical product. Yet this is not necessarily progress. You can build a clinical system around almost any idea, but the idea is not necessarily made better. I will illustrate this with a brief review of the history of crisis theory and management.

Superfluous systems

The origins of crisis intervention (CI) can be found in work done with survivors of the Cocoanut Grove fire in Boston in 1942. Crisis theory brought us new clinical terms like emotional equilibrium and hazardous event. We can distill all this jargon into an essential thought today – people in crisis can benefit from timely sessions to focus on immediate thoughts and feelings triggered by recent events.

Crisis work became more complex in the 1980s with the development of critical incident stress debriefing (CISD), only to morph into the larger category of stress management (CISM). While CI was implemented in clinic-based programs, CISD and M became highly successful products sold as part of employee assistance programs in which clinicians went to the trauma scene.

The research on CISD is mixed, and CISM has quelled only some of the negative press. Yet research is less my concern than the model’s intricacy with multiple phases, treatment elements, and certification programs for experts. Many people who experience or are exposed to trauma could benefit from talking with a therapist. Is the rest of the complexity in theory and practice adding value? Not much.

The right tools for responding to a crisis are basic psychoeducation for everyone and counseling sessions for some using their free EAP benefit. Clinicians with good intentions gave us elaborate theory and practice. A product designer starting today might just develop a few engaging digital tools on decreasing stress and building resiliency. Research shows most people cope fine on their own.

Let’s not overengineer. We need licensed clinicians for complex patients, and we should let them use their skills and not burden them with practices that systematize. When developing new programs and products, be sure clinical exactitude doesn’t impede engagement. Sometimes clinical protocols get distilled to their essence over time. Anyone interested in a used training guide on brief therapy that I am putting on sale?

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

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