Recognize Implications of Prioritizing Access to Behavioral Services as Top Goal
Ranking priorities entails moving some important goals to secondary status. For example, improving behavioral services is worthwhile, but this goal potentially loses importance and funding if improved access to care gains primacy. While no person or entity actually ranks our field’s priorities, we should candidly recognize the implications of choosing our goals.
The scale of need driving care access is best captured by imagining an iceberg. The visible part, carefully subdivided into numerous DSM categories, has broadly unacceptable access rates. Those for substance use disorder (SUD) treatment (barely above 10%) are among the most egregious. The iceberg’s underside, vast and vaguely understood, includes millions of distressed and dysfunctional people with unmet and uncounted needs.
What are some implications of access being our top priority? We need to recognize the following realities:
- Services that scale well are needed—new services that do not scale are a low priority.
- Existing services warrant less attention because they are largely effective and have processes available for enhancement.
- Access is not a technology problem, as some would suggest, but rather a clinical problem.
Solutions That Scale
“At scale” means solutions fit the scope of the problem. Pills scale well, but therapeutic conversations less so. A new psychotherapy will not help us meet our care access goals, but shorter sessions, less frequent sessions, and group sessions help us scale. Setting matters. Primary care expands access better than isolated therapy offices. People also matter, and aspiring therapists are not hard to find.
The path to training and licensing new therapists has a clear starting point. Many people are abandoning their pursuit midway. They cannot afford the tuition debt, uncompensated internships, and poorly paid work enroute to a license. Medical school debt is a well-publicized problem, but therapists in the making are stymied every day. We need a plan to get them to their goal. This gets far too little attention today.
Clinicians are driven to improve the solutions they use, and so ideas abound on how to improve therapy while improving access gets mostly lip service. We need more leaders in our field stating that while both are important, priorities need to be flipped. Access will never improve as an afterthought, nor will it improve with a single tactic. We need resolve and a multifaceted plan.
Enhanced Therapy Outcomes
Shifting our priorities to access does not mean leaving existing services in a state of mediocrity. The definitive work on psychotherapy outcomes describes therapy as “remarkably efficacious,” and researchers have been pleading with clinicians for decades to measure their results to achieve maximum benefits for clients. Prioritizing care access means leaving everyday services in fine shape.
Measurement-based care (MBC) is commonly misconstrued as measuring end results, but MBC’s value is giving clinicians findings from client measures during treatment. For example, clinicians may see evidence care is off-track and premature termination is a high risk. Researchers find clinicians usually do not identify these risks on their own. When alerted, therapists can help clients stay engaged.
Clinical trials show therapy to be quite effective, and therapists are more likely to achieve benchmark results by employing MBC. Being attentive to feedback from client measures is generally helpful. It is especially so with complex cases. Enlightened behavioral executives are implementing MBC for wide clinical use, while also recruiting new staff by finding all-but-licensure (ABL) candidates.
Tech In Perspective
New technologies are advancing our field. Digital therapeutics are available to consumers 24/7, and research shows they produce very good outcomes. AI-based products can create notes summarizing clinical sessions and ratings of common techniques used by trainees in therapy sessions. More products are coming as technical capabilities advance and they find appropriate use cases.
Executives and clinicians must guide the use of such technology. They should be guided by priorities, as discussed above, and decide how tech products fit into the suite of solutions. Many entrepreneurs see access as a problem for technology to solve, but this is backwards. Professionals should drive care in all its forms and modalities, and they should ensure tech-enabled solutions meet quality standards.
Technology has wide capabilities and access is a common use case. For example, technology using cell phones can detect possible depression based on qualities of voice, language, or activity level. However, therapists in primary care can already detect more people with depression than they have resources to help. Let us remember access is a clinical problem and tech products can be distracting shiny objects.
The Primacy of Care Access
We have failed to improve access because we have not prioritized it. We should not wait for advances in technology to solve it. The problem is driven by many factors and will require a range of solutions. Therapy is effective today, and we can even improve outcomes as we turn our attention to access. Let us direct our energies to getting more people help. That help will not always look like today’s services.
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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