The Evolution of Psychotherapy: Coordinates for a New Destination
We need a more compelling way to promote psychotherapy to the public. We also need a new context, a new setting in which people are introduced to therapy. In this new environment, they will not encounter the old “50-minute hour” hidden away in a private office. They will be greeted by therapists who see behavior as an essential part of one’s health status. They will encounter a new primary care.
Psychotherapy is remarkably efficacious, and yet people must cope with stigma, cost and access issues to find it. We can start to change this by demystifying what we do and expanding the sources of help. We should then reposition much of our workforce into the primary care setting to address a multitude of problems, many of them everyday problems of living.
Why is this a moment to consider such change? Psychotherapy is mature. It no longer faces fundamental debates about insurance funding or which therapy model is best. Behavior change is widely understood as the missing ingredient for improving the health of populations. We are primed for a vast expansion of therapeutic services via digital modalities. Primary care needs our help.
There is stigma associated with mental illness, even its most familiar type, depression. Treatment of these disorders with psychotherapy is also stigmatized. The discussion of personal, often painful thoughts and feelings is less common than taking a pill, even though success is comparable without the side effects. Psychotherapy is poorly understood, but we can reverse this and make it more accessible.
Clarity and wider acceptance start with a simple answer for why people should consider psychotherapy. The American Psychological Association offers broad guidance: “Do you ever feel too overwhelmed to deal with your problems? If so, you're not alone.” After a long list of potential problems, we find that therapy can help. So, is that it, a problem list? We might need to distill this a bit.
Psychotherapy impacts how we live our lives. The act of living, or behavior, might be viewed as the broad canvas for our work. People may seek help for many reasons, but we can encapsulate them as behavior change. We should elevate this idea as the essence of our health services, spanning behavioral disorders and health behaviors. It is universal, non-pathological, and destigmatizing.
Innovators will still develop new models and techniques. This is good, but no longer defines the phase we are in as a field. Any successful modality is welcome. The field should encourage many solutions to flourish, from in-person to virtual to digital content. Yet the foundation must be in-person services at the entry point to care, which is primary care. Behavior change is critical to health status.
Research shows that the most important driver of outcome is who provides therapy, not which techniques they use. We want the best healers, and so our system of care should be continually tracking outcomes. We also know it is best for people to start therapy confident that their therapist knows their background, culture, or ethnicity, and so we need a diverse supply of healers.
The primacy of behavior change in health status leads us to primary care as the setting for our services. These are the frontlines for the emergence of depression and other behavioral disorders. This is where people present somatic issues that originate in psychic stress. This is where health behaviors go largely unchecked as the catalyst for chronic (and hugely expensive) medical conditions.
The next decade will hopefully witness a revitalization of primary care. It is at risk of collapse today from a diminishing physician workforce. Yet it is more likely to see organizational and financial reconstitution under one of the many redesign plans being discussed. Behavioral healthcare should be part of any solution, allowing primary care to realize more fully its original vision of being comprehensive.
We need psychotherapists in the primary care setting fulfilling a new role that we might call primary care psychotherapist (PC-Psy). Gone are the extended sessions in favor of brief interventions, and the power of the therapeutic alliance is leveraged over many years. Therapists are trained to agree upon goals and tactics for change. Physicians expect patients to accept treatment plans after brief discussion.
Psychotherapy has been hidden behind a veil of privacy, and this adds to its mystique and inaccessibility. We need our most talented young clinicians to step forward and innovate for this new stage. It is fine to preserve the private office for those who desire it, but the future belongs to a platform for change that rejects any sense of shame. Change is hard enough without a burden of judgment.
Psychotherapy will continue to evolve in theory and practice. Yet the challenge now is to rebrand and reposition the powerful healthcare resource it has become. The field will be better served today with more of our colleagues moving to the frontlines of healthcare and learning how to modify their skills for that setting. This is the most important area for innovation for the next decade.
A watershed moment means that what goes before it is radically different from what follows it. This could be one of those moments. The PC-Psy idea is more than simple reform. It is a complex and formidable goal. Yet we can leverage the power of psychotherapy to fundamentally reframe our field. We do this by locating psychotherapy at the point in healthcare delivery where it can do the most good.
Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.
