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Solving Our Access Problem Could Entail Giving More People Less Help
Every field has heartbreaking stories associated with the clinical conditions under its care. The behavioral field is unique for appending 2 additional levels of suffering. Stigma compounds the pain of behavioral disorders with various forms of social disgrace, while multiple barriers to accessing care complicate the process of finding services when ready.
Executives are not care providers, nor do they have the tools to end stigma, but they are accountable for improving access to care. However, access has been as resistant to remedies as stigma. We lack agreement on the size of the problem or the approach to solving it. Experts tend to focus on the population segment they know best, and the issue is rarely discussed comprehensively.
How Many People Could Use Help?
Businesspeople often assess a problem’s size by estimating its magnitude rather than through precise calculation. Getting oriented to a problem calls for judgment and perspective more than computation. This lesson was driven home for me in a business meeting years ago. My company managed employee assistance program (EAP) and behavioral health benefits for a national employer, and the discussion centered on utilization.
Our presentation proudly showed service utilization inching upward. An exasperated executive discounted this with a basic question. What percentage could use help? After some discussion, we all agreed that roughly half the population could use help if every type of distress is included. The executive suggested we were finally in the right ballpark and had years of hard work ahead of us.
The Pitfalls of the Medical Model’s Approach
Many discussions of access today start with SAMHSA’s research finding that 20% of adults experience mental illness each year. Experts presume any plan for improving access must flow from epidemiology since our healthcare system is built on a medical model that starts with diagnosis. However, our field is unique and this model fails in at least 4 critical ways:
- Integration. Our field’s most promising integration with primary care is the collaborative care model. It targets people with significant depression or anxiety. It will presumably help people with other conditions at some future date. Yet that date may never appear for many in need. This model has always been limited to improving care for people with major diagnoses in this setting. It is ill-suited for tackling the pervasive problem of access.
- Resources. Funding campaigns in our field that focus on specific diagnoses can inadvertently set up competition. This approach makes more sense in medicine. Advocates focusing on cancer or heart disease start from a basis of medical care being well-funded. Behavioral healthcare is chronically underfunded, and resource allocation is like a zero-sum game. We divide funding pies that are far too small, and increasing a few diagnostic slices is no solution.
- Scope. The category of “other” behavioral issues is enormous, and so we ignore millions of people by focusing on major diagnostic categories. The “other” category includes pre-clinical and non-diagnostic suffering. This encompasses people with partial symptoms of conditions like major depression, those with adjustment disorders, and those with unhealthy behaviors driving chronic physical illnesses. Are we prepared to compare and prioritize the suffering of people with various problems?
- Inseparability. Behavioral issues are pervasive, just as our thoughts, feelings, and behaviors are pervasive. A behavioral component can be found in the course of treating most physical ailments. A high-functioning medical system should deal with these components as they arise. Confining behavioral care to specialty practices is a losing proposition. A better approach would be to spread behavioral specialists throughout the healthcare system. This did not happen for historical reasons—our field developed in isolation.
The Right Tools for the Job
A diagnostically based approach also misses the mark in terms of services. Traditional services were developed for the minority of people able to penetrate multiple care access barriers (e.g., stigma, cost, convenience). They were not conceived for everyone in need.
All efforts to help people with psychological distress are surely welcome. Some will always need traditional services, but others may benefit from less help. The medical model starts with diagnosis and chips away at needs with the prevailing solutions. Rationales for lesser solutions are rarely considered. Business starts from the enormity of the problem and tries to find ways to give more people some help.
The study of psychotherapy outcomes gives us guidance here. Many people improve clinically after a few sessions. Our field was built on a medical belief in providing a fixed course of care. However, clients have a different view—many use fewer visits as they feel sufficiently improved. Let us learn from them as we explore new solutions.
The access problem’s scope requires solutions that scale well—for example, brief therapist interventions supplemented by digital services. Business can facilitate innovation and help clinicians create new services. Some may be as simple as brief empathic conversations.
We have never lacked innovators in our field, but they must be focused on the right problem. Access is that problem.
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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