How Our Clinicians Can Help Fix the US Health Care System

Donald Berwick, MD, is an eminent health care reformer known for promoting lofty yet pragmatic goals. He helped launch quality improvement in healthcare, created the prominent “Triple Aim” framework, and recently outlined a health improvement plan focusing strictly on the social determinants of health.¹ He stresses that these determinants are far more important to health status than health care services.

He is one of many physicians in recent years to prioritize social determinants. He highly values biomedical remedies but argues they get too much attention. In this spirit of being ambitious, realistic, and socially focused, an alternative strategy for health care reform will be offered here. It is grounded in the biopsychosocial approach to health care and focuses on how our field can provide such solutions. 

Many experts have pronounced our health care system “broken.”  While endless solutions are offered, our field can provide a path that is both unique and powerful. Yet our clinicians must be willing to modify existing services to achieve the scale needed. Our health care system may be “broken” for many reasons, but 1 essential fix is a clinical refocusing that includes broad access to psychosocial solutions.

Psychotherapy:  Well-Validated and Ready for Innovation

While psychiatry focuses largely on biomedical solutions, the behavioral health care field also incorporates powerful psychosocial interventions, starting with psychotherapy. It took a century to mature, but we now understand therapy. It is a socially-based experience of psychological healing. It is founded on a trusting relationship called a therapeutic alliance that is uniquely nonjudgmental.

The work of each therapist is informed by an explanatory clinical model. Each major model is effective due in large part to common features (like empathy) found across all therapies.²  Confusion remains about the self-proclaimed superiority of certain therapies. Why? Each study validates a specific therapy, rarely comparing approaches side by side, and we currently know therapists drive results more than techniques.

We now have greater clarity about therapy due to meta-analysis.³ This statistical method was first used in the 1970s to synthesize results of multiple studies and broadly analyze therapy as an enterprise. Also, we have proven therapy is best when therapists monitor clinical progress empirically and incorporate this feedback into treatment. This knowledge can now be used to establish innovations beyond traditional therapy. 

Innovation follows many lines of questioning—such as the location, modality, duration, and socio-cultural context for psychosocial care. Key locations emerging are primary care and pharmacy settings. Virtual and digital modalities seem here to stay. Can duration be reduced? Even if the 50-minute hour remains an option, conversations maxing out at 15 minutes can be valuable for many. 

Psychotherapy is interpersonal at its core, but there are also socio-cultural dimensions to the work. Psychological suffering is partly rooted in these dimensions, and this is why expanding our professional and peer ranks with clinicians of diverse backgrounds has been so important. Similarly, Sue’s textbook on helping culturally diverse clients (with 8 editions over 4 decades) is critical for all therapists.⁴

What’s in a Name?

Therapy is a 50-minute hour by definition. We need new terms for a future when this is not the norm. What do we call therapists practicing in new ways and new settings? Since it is often easier to adjust to initials than a new name, one possibility is PST as a shorthand for Psycho-Social Therapist. The key point is breaking with the many expectations about therapy and validating new practices with a new name.

Psychosocial solutions are distinct from the ten “root cause” determinants of health Berwick highlights such as food and housing security. He is appealing to leaders of our multi-trillion health care industry to shift resources to areas where disadvantaged groups can derive health benefits. Who benefits from our solutions? Every primary care patient is potentially a beneficiary.

These reforms will be challenging to realize, not due to shaky ideas but rather rigid institutions. It is widely accepted that social and psychological factors can promote either health or illness.

The 2 big impediments are the following:

1. the medical model’s dominance and its tendency to overshadow the psychosocial;
2. the fact that such institutional changes always happen slowly.

Reformers like Berwick know this. They suggest the overarching message be a clear one that leaders can easily communicate. The behavioral healthcare field must replace a medical bias with a commitment to the biopsychosocial approach. We can impact both health and health care dramatically if we spread psychosocial solutions as widely as we have distributed medications. 

Therapy must be modified into an array of social psychological solutions that scale better than traditional sessions. We must ensure socially informed clinicians help underserved communities on par with everyone else. Our field can direct a major overhaul of our broken healthcare system, but no one will ask us to do this. Our own leaders must step up to promote this message and push for change.

References

1. Berwick DM. Getting Serious About Producing Health: The Ten Teams Challenge. JAMA. 2022;327(19):1865-1866. doi:10.1001/jama.2022.6921
2. Hubble A., Duncan B., Miller S., The Heart and Soul of Change: What Works in Therapy. American Psychiatric Association; 1999.
3. Wampold B, Imel Z, The Great Psychotherapy Debate: The Evidence for What Makes Psychotherapy Work. Routledge; 2015.
4. Sue DW, Sue D, Neville H, Smith L. Counseling the Culturally Diverse: Theory and Practice. 8. Wiley; 2019.

Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as President at ValueOptions and Chief Clinical Officer at PacifiCare Behavioral Health.