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Every Outpatient Clinic Can Use This Playbook to Outperform Specialty Programs
Do we get the best care from programs specializing in specific problems? Most of us probably think so since our medical system excels in specialty care. The medical model starts with a diagnosis, and so we presume a program with diagnosis-based solutions will perform best. Those assumptions do not always hold in our field. Can we design a hypothetical general clinic that could outperform a specialty one?
We must first clarify the role of medication in such a comparison. Medication is important for a subset of clients and, for the sake of this comparison, we will assume equivalent skills and results in managing medication. This thought experiment related to program performance (general vs. specialty) is focused on the benefits from psychotherapy, the common service provided to everyone.
Diagnosis triggers the first key research question. Does research find therapies designed for a specific diagnosis more effective than others? The answer is no. Many clinicians are not familiar with meta-analytic statistical procedures that compare treatments. They have been misled by only knowing about studies validating diagnosis-based therapies like CBT (cognitive behavior therapy), but the research is unambiguous on this point.
Research finds that psychotherapy is “remarkably efficacious,” but no specific therapy produces more improvement than another. This is true for anxiety, depression, substance use, and every other condition studied. The person delivering therapy drives more change than other factors studied.
The next basic issue is measurement itself. We cannot compare clinics without measuring clinical results. While measurement-based care (MBC) should be today’s norm, we are not quite there yet. This hypothetical clinic should include client self-report questionnaires throughout each care episode. Digital solutions can make the administrative process minimally burdensome.
Research may not support the superiority of therapies tailored for specific diagnostic conditions, but meta-analytic findings highlight a different pathway for top results. A factor critical in every good outcome—a strong therapeutic alliance—can be measured and targeted for improvement. The client questionnaire should include a few questions on alliance. This enhances the standard MBC process.
Two simple interventions are derived from the measurement of alliance. First, if it appears the alliance is weak or deteriorating, the best clinical response is to focus on the alliance in an effort to strengthen it. This may involve reconsidering treatment goals or exploring if the client has experienced an empathic break. Without a better alliance, the outcome is in danger.
The other option to routinely implement in a general clinic is changing therapists. As noted, outcomes are driven by the person delivering care more than by the therapeutic techniques used. This is how therapy diverges from the medical model. A therapist cannot have a good fit with every client. Many clinics assign cases without attention to fit, and facilitating transfers (on rare occasion) can address this.
Every client counts in total MBC calculations, but clients vary in their statistical impact on results. In fact, results are largely driven by clients with the most severe distress at intake since they have more opportunity for improvement in a statistical sense. They can drive the most change for a population. MBC especially focuses on clients with severe scores who are off track and need special attention.
Divided care is a key issue in our field. Clinics will perform better when every clinician can address the full range a client’s behavioral issues, from mental health to substance use and health behaviors. It is ideal for all such issues to be addressed in an integrated or consolidated way since they are inseparable for the client. “Referring out” often means the issue is dropped without any intervention.
Specialty programs may measure results but are usually most attentive to technique. That is, they tend to focus primarily on adherence to clinical guidelines or a set of techniques. The belief is that outcomes will be optimal if protocols are followed. While the evidence cited previously does not support that belief, this focus by specialty programs tends to dimmish attention to MBC and impact results.
MBC means letting a client’s degree of clinical improvement drive treatment duration. Many people respond well to a few sessions and can safely end care as they prefer, not after the required number of visits in a given specialty protocol. Conversely, those responding more slowly need encouragement to stay as long as necessary to improve.
The final factor that might favor general clinics relates to staffing. While not common today, the hypothetical clinic rooted in MBC would routinely insist clinicians achieve acceptable clinical results for their clients overall (https://societyforpsychotherapy.org/are-you-any-good-as-a-therapist/). The small minority of therapists failing to do so should be supported and mentored, though not indefinitely. Care (and therapists) should be judged on results, not adherence to a specialty model.
Needless to say, specialty programs could excel by taking the pathway highlighted here. We know much about what drives outcomes, and every program should leverage that knowledge. Executives may not deliver care, but they can use this playbook to maximize results for every person in their program.
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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