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Beware Shortcomings in a Strategy of Psychotherapy Specialization
How should executives think about hiring therapists with sub-specializations versus general therapists? Do specialists merit a higher level of trust and independence, or should every clinician’s performance be routinely assessed? In medicine, specialists are elite technicians in high demand with high levels of trust. Should performance ratings be limited to generalists who work with everyone seeking help?
This may seem like a clinical issue, but it is a high-priority executive decision. Our field has long resisted measuring outcomes, and trust in specialists could prolong our time in the dark. Measurement-based care (MBC) should apply to every behavioral clinician in every setting. Moreover, let us not succumb to the mistaken belief that outcomes are driven by technical expertise, the presumed hallmark of specialists.
Our field’s embrace of the medical model is one reason our trust in techniques is high—many believe therapy can be molded as an objective intervention with strict guidelines, much like medical procedures. Putting aside the more subjective nature of our field, we should not see the medical model as infallible. In fact, its objectivity sits on a major fault line: the routine exclusion of many social groups in research.
One-Size-Fits-All: An Underappreciated Health Inequity
A recent JAMA article describes an “underappreciated health inequity” in medical care. Healthcare today is organized around diagnosing and managing discrete diseases, but sadly, much of our evidence is based on flawed studies with underrepresented groups (e.g., women, and racial and ethnic groups). This limits the general applicability of these results:
One-size-fits-all health inequity occurs when data obtained in nonrepresentative populations and on select sets of interventions and outcomes are assumed to apply to everyone. The clinical consequence is that individuals are expected to adhere to so-called evidence-based care that is of uncertain benefit and not focused on what matters most to them while their own health priorities are largely ignored.
The alternative proposed is a “tailored emphasis on what matters to individuals.” We should start with our client’s health priorities rather than the presumably common path set by limited medical evidence. This is not simply out of respect for a client’s priorities, but also because of the uncertainty of the evidence. The lack of data representing all groups could make it misleading for some patients.
Weak Evidence Will Ultimately Deflate Enthusiasm for Techniques
Medicine’s neglect of these groups (and their health inequities) is an issue well understood by practitioners in behavioral health. While therapists may vary in their cultural sensitivity, our field has emphasized the importance of social and cultural determinants of health. The diversity of human experience, much of it socially driven, is in the foreground, not the background for our field.
The medical model may facilitate psychopharmacology, but it constrains psychotherapy. We do not need therapies that minimize the social determinants of health or techniques that ignore cultural fit. Therapeutic work is all about personal details. Therapy wrestles with our idiosyncrasies. Techniques should be seen as offering a general schematic of the process, not a recipe to be followed.
These concerns emerge from inquiring how well the medical model fits psychotherapy, but the evidence from psychotherapy research should end our speculation. Techniques do not drive much of therapy’s noteworthy success (its 0.8 Effect Size is large), and more clinical change can be attributed to the “common factors” found in most therapies—e.g., therapeutic alliance and empathy.
Should we try molding therapy to a medical framework with manualized therapy guidelines that mimic medical procedures? Should we analogize therapy techniques to the ingredients in a medical remedy? Elevating techniques this way is a bold (and crude) imitation of medicine, but it will ultimately be undone by its weak rationale and the lack of clinical evidence.
Hire Licensed Staff and Measure Their Results
Our field should not expend resources ensuring clinicians adhere to expert guidelines. We should not follow medicine’s path of valuing specialists over generalists and promoting technical expertise as the goal of training.
Specialists should pursue whatever technical or population-specific training interests them but with a data-driven understanding of our field. Clinical success is less technique-based than many experts have believed, and results are better measured than predicted based on clinical degrees or training.
Executives should certainly not refrain from hiring specialists—the research tells us that the person choosing a generalist or specialist path matters more than the path itself. How can an executive ensure all clinicians get acceptable results? Hire professionals who seem engaging and caring, as always, and give preference to those prepared to use MBC systems to improve their work.
Urgency may not be great today, but these issues will become increasingly so as our field consolidates with health systems. While our psychosocial solutions are as essential as chemical ones, they are marginally understood in most healthcare systems. Our diversity and core values should be highlighted for these systems. We have generalists and specialists, but we validate our work every day with MBC.
Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health.
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
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