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What Do You Specialize In?

March 02, 2020

Specialization by behavioral healthcare professionals is largely self-proclaimed, rather than being subjected to review and certification by a board of experts. An evaluation of what is being proclaimed might be worthwhile, and the need for specialty certification should periodically be assessed. Categories of specialization can range from technical expertise to population focus.

Is being a generalist a sign of low motivation? Should every clinician in our field aspire to being more than just a psychotherapist? Is the ideal career path to achieve a foundation as a generalist and then focus on a specialty in order to provide the greatest clinical value to patients? Is it fair to say that being a therapist is basic, but the serious professional specializes in something like CBT or DBT?

Many clinicians focus their energy and training on specialty populations. We hear from many patients that they are more comfortable knowing a clinician largely works with people like them. This may mean focusing on groups defined by age, gender, sexual orientation, or problem type. Specific therapeutic techniques are occasionally involved, but the key expectation is more group knowledge and sensitivity.

We must also wonder to what extent specialization is influenced by medical norms. For example, an internist can select from 20 different areas for specialty certification. It is reasonable to ask whether behavioral healthcare professionals should pursue such a path. Should we adopt the view that a certified specialist has the highest level of skill?

The uniqueness of psychotherapy

The licensed psychotherapist is a specialist in a broadly applicable procedure. Learning about distinct populations or problems is fine since this adds knowledge to core psychotherapeutic capabilities. We should aid clinicians in expanding their focus, but this is not a process of specialization comparable to medicine. The differences appear when you focus on why physicians specialize.

Physicians specialize to learn specific treatments. They may also be interested in different patient groups, but the specialty generally requires training in procedures and techniques that a generalist is less equipped to perform. The healing aspects of psychotherapy do not change with a specialty focus. We may tweak our approach somewhat, but that does not change the essence of psychotherapy.

Training for every therapist includes when to consult with more experienced colleagues and when to refer clients to another clinician. This is not a substitute for specialty training. It is a recognition that all therapists have gaps in their background, training, and interpersonal skills. As a professional, one’s scope is broad. Psychotherapy is specialized interpersonal work requiring a single license to practice.

If anything, society may benefit if we encourage therapists to use their skills more broadly rather than focusing on a specific group. For example, we need psychotherapists bringing their skills to people with addictions of all types and to people with a wide range of unhealthy behaviors. A stronger argument can be made for an expansion to new groups needing therapy rather than an intensification of focus.

The dissemination of psychotherapy

While the argument for a proliferation of specialties in line with medicine may be weak, there is another medical parallel to consider. Physicians are free to consider FDA-approved medications for “off-label” use since their value for an existing condition has already been proven. Psychotherapy is no different in this regard. We should be searching for other uses of psychotherapy in healthcare.

One clear difference lies in the ownership of psychotherapy. There is no patent holder. Distribution is cumbersome. This has undoubtedly dampened enthusiasm for wider delivery of this highly effective solution. Unfortunately, too many leaders in the field are also caught up in debates over which therapy model is most effective, despite decades of research suggesting each one is comparable in effectiveness.

Debate over the superiority of various therapies leads to another complication. Some worry about “fidelity” when therapy is implemented in new clinical settings. Their solution is to have clinicians follow a manual detailing clinical protocols. This approach is overly focused on techniques rather than on the therapist providing care. Research points to the therapist as the more critical variable.

There will always be a role for those seeking new models of psychotherapy and those modifying existing ones to new problems. Cognitive behavioral therapy has now been modified for everything from mood disorders to SUD to smoking cessation. This is all good, except for the fact that CBT seems to be roughly on par with other therapeutic approaches for these problems.

Empirically validated clinicians

Real world solutions merit real world data. First, we should insert psychotherapy wherever it might help people change maladaptive behaviors and improve health. We should then measure the clinical results in psychotherapy. This obviates the need to modify therapeutic techniques or assess fidelity to clinical protocols. We can then aggregate those results and determine effectiveness at the clinician level.

When these variables are combined – the wide promotion of psychotherapy, the use of empirically validated clinicians, the expansion of therapy to populations and problems with unique features – we have a model for the path forward. Rely on clinicians with the best outcomes and mentor those with below average results. Educate all clinicians on unique patient features to understand in their work.

We don’t need to divide psychotherapy into specialties requiring separate certification. Nor do we need new therapies for every new population we seek to help. Existing standards for how psychotherapists manage patients with challenging or unfamiliar features work just fine. They can consult and make referrals as needed. We can track their clinical progress in aggregate and at the individual clinician level.

Let’s remember the foundation from which these principles emerge. A psychosocial framework produces powerful solutions, even though they may fall short of curative biological solutions. We need to appreciate the uniqueness of this orientation to mold the best interventions and clinicians possible. Mimicry of the medical model only diminishes the impact and value of a psychosocial model.

What do you specialize in?

The proud answer to this question should be psychotherapy or counseling. If the answer is one of many equivalent therapy techniques, like CBT, should that answer be imbued with additional pride? While it is praiseworthy to complete intensive training programs, it does not justify promoting oneself as having uniquely effective technical skills. Remember, psychotherapy is remarkably efficacious.

We should resist imitating our medical colleagues. The work is quite different. We should all be prepared to explain the psychosocial model. Numerous bodily systems necessitate a specialty focus for physicians, while the psychosocial model primarily requires expertise in social communication and helping people change persistent behaviors. Let’s reject imitation to enhance our social status.

Clinicians will continue to work with specific groups (defined, for example, by age, gender, sexual orientation or problem type) based on their own personal identification, interest, and knowledge. They remain psychotherapists first and foremost. Being asked about your specialization is an opportunity to educate people on the highly effective specialty treatment we call psychotherapy.

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

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