Patient-centered solutions increase access to behavioral healthcare

Many healthcare proposals have been advanced in recent years with the label of being “patient-centered.” They are certainly welcome since we have long been provider-centered in our healthcare delivery systems. This applies to the clinical orientation of healthcare professionals and to the operational priorities of business executives in healthcare.

The main question in an evolving patient-centered world is whether our services and processes have been designed with the convenience of the provider or the patient in mind.

Unfortunately, many of our current patient-centered solutions largely provide lip service to this idea. Patients ask: Can you deliver my healthcare quick and easy, cheap and convenient, painless and with good results? Patients don’t start with the current system of healthcare and question how to reform it. They start with simple expectations and hope to get them met.

There are times when very serious problems have relatively simple solutions. Pre-clinical conditions like pre-diabetes and pre-hypertension can be stopped in their progression with lifestyle changes. People taking a daily aspirin can prevent deadly heart attacks. People with congestive heart failure can learn to weigh themselves daily and adjust their diet to ensure that they do not go into a medical crisis. It turns out that we have similar examples in the behavioral health field. However, the difference is that the magnitude of the need for behavioral health is many times greater than that for any other health concern. Behavioral healthcare conditions are the highest cost, most prevalent, and most disabling in the U.S.¹

While our actual spending on behavioral healthcare conditions is greater than for any other class of health disorders, the larger concern is that most behavioral conditions are not recognized or treated, and the universe of conditions is quite large. The Centers for Disease Control and Prevention (CDC) estimates that 50% of the people in the U.S. will develop a behavioral healthcare condition in their lifetime. Yet in behavioral healthcare, we are hopelessly overmatched by the prevalence of problems if the only solution is to build a professional workforce to care for all the people with behavioral healthcare conditions.

The good news is that we can significantly help many people without growing the professional workforce.

As both an alternative and a supplement to the professional workforce, we can expand two existing solutions:

1) non-professional, peer services, and

2) web/mobile or digital self-care tools.

These are truly patient-centered services—cheap, convenient, and effective—and they are both scalable. Widely available peer services, focused on every source of psychological suffering, are not in place today, but are quite feasible since we have a long history of providing peer support. Digital services are a burgeoning industry that can help people with various levels of psychological distress at low cost, and the financial industry is already pushing this solution closer to maturity.

Empathic peer support

People without professional degrees who have overcome behavioral health problems have a great deal to offer those who struggle as they once did. The evolution of peers helping peers with mental health problems actually started in the public sector with a focus on helping people with serious mental illnesses. The stories are inspiring, and the adoption by public governmental agencies and mental health organizations is accelerating, and they all recognize that the road to recovery and resiliency is not possible for many people without the guidance of a peer. Medications are fine, but peer support can be grand. We need to reduce symptoms and increase functionality at the same time.

There is no current groundswell of activity to get more peers certified to help others with less serious disorders. Yet this should happen to the extent that we recognize half the population needs some type of support. Many people lead very productive lives, despite intense anxiety, self-hatred, loneliness, and personal isolation, and we need to establish ways to help these people apart from weekly visits to a psychotherapist. The good news is that we can, but the demand has not yet reached a level to produce new models for empathic peer support.

Another important point is that the mental health field has gone through a process of certifying peers as well prepared to offer support and guidance. This is in contrast to the many internet communities that have evolved in recent years for peer support—often without certification, oversight, structure, or protection for the most vulnerable. It is important to start by identifying people who might have a healing impact on others, rather than just a way to aggregate communities of people who may have commonalities.

The first misconception people have when non-professional solutions are introduced is that this will only be beneficial for people with mild to moderate problems. This misconception is rooted in a failure to understand how people with behavioral health conditions actually improve. The medical model trains us to think that in order to get a positive clinical result we need a specific dose of treatment to guarantee that response—often called a dose-response model. Take X milligrams of this medication to eliminate that pathogen. This has never been shown to be true for psychosocial treatments like psychotherapy and motivational interviewing.

If you take two people with comparable psychological levels of symptom severity and impairment, one may respond very well to six sessions of psychotherapy while the other may need 26 sessions to achieve comparable gains. Another way of thinking about this is that some people respond to support and guidance, while others need engagement with a knowledgeable professional.

People differ in terms of what generates a positive outcome for them, as well as how significantly they respond to a particular service or intervention. This may not fit neatly into a dose-response model, but it is well understood by those grounded in the science of behavioral healthcare.

Let’s shift to a focus on substance use disorders since depression and anxiety are not the only behavioral health conditions amenable to these alternative solutions. The addiction treatment field certainly does not need an introduction to peer support since they created it with the 12-Step program. However, only a small percentage of people with addictions avail themselves of this community support.

Even more problematic is the state of our professional treatment industry. Our institutional addiction treatment system is much like one for treating stage-four cancers. We wait for people to get so advanced in their addiction that we are caught in a shuffle between various residential treatment facilities, usually at a distance from the patient’s home. Intensive outpatient treatment in the person’s community is an effective modality, yet hard to find.

Engaging digital self-care tools

We should continue with a focus on addiction and begin to explore the value of digital self-care tools. People in earlier stages of addiction are curious about what is happening to them, but they are often not interested in seeing a behavioral health professional to discuss their curiosity. Web and mobile tools are ideal for satisfying people’s curiosity about a wide range of issues. We are in the early stages of developing interventions via web, mobile, telephonic , and video modalities that better match the interests of people in need. However, the utilization and power of these alternative modalities are increased when caring people introduce and guide the use of these tools. In other words, we need empathic peers guiding people to use engaging self-care tools.

We can proudly embrace the science supporting this direction for healthcare delivery. There are countless studies supporting the efficacy and effectiveness of cognitive behavioral therapy (CBT) for a wide range of disorders. The reality is that CBT delivered online is as effective as face-to-face treatment, and this is not surprising since it is a skill building intervention that one learns through clinical exercises.² The therapy is well suited to adaptation to digital tools.

Many start-up companies today are offering these digital tools, but the critical question is how to get people to use them. Will people respond to marketing campaigns for these tools or do we need another approach?

Marketing campaigns are fine, but ultimately we will need a trained non-professional workforce guiding people to use the many wonderful tools that are evidence-based. The caring guide points out a module on how to address negative thinking using cognitive behavioral therapy techniques, or the supportive peer—who has been there and done that—shows how the stages of change research suggests that people don’t stop using drugs and alcohol through sheer willpower. A need for face-to-face services with a behavioral health professional will continue to exist for many people, but we should be thinking about how to amplify that traditional model and how to replace it for a certain segment of the population. We also need to recognize that many behavioral health conditions are chronic disorders. People recovering from addiction are prime candidates for embracing digital self-care tools in their continuing care plans. They can consult their mobile phone on the spot for their personalized plans on how to manage cravings and triggers, along with a list of resources to consult when they need support.

Another way to view healthcare today is through the prism of results. If you can get a diabetic’s hemoglobin A1c within normal range through better diet and exercise, then that is an intervention with positive healthcare results. In the future people will think it odd to classify this as a wellness intervention or a behavioral intervention—health is health, and the silos will eventually mean nothing. We also need to bring down the silos of professional societies. While we will always value the healing capabilities of professionals, we will increasingly understand that empathic peers and engaging self-care tools can help many of us achieve better health.

Let the entrepreneurs among us drive this forward. We need a more diverse group of certified peers available to those in need, and we need the investment in alternate healthcare modalities to explode. We are only now approaching the tipping point for peer, digital, and other alternative modalities for health. People will appreciate their convenience and cost in comparison with professional office visit. 

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

1. Roehrig, C., “Mental disorders top the list of the most costly conditions in the United States: $201 billion,” Health Affairs, 35:6, June 2016.
2. Titov, N., Andrews, G., and Sachdev, P., “Computer-delivered cognitive behavioural therapy: effective and getting ready for dissemination,” F1000 Medicine Reports, 2:49, July 2010.