Alternatives to Medicalizing Our Field: A Brief History

Managed care began in our field in the 1990s as insurance costs escalated for newly insured behavioral health conditions. Inpatient care was the initial focus. Facilities had proliferated to take advantage of new coverage with high maximums and no oversight. New managed care companies countered with authorization protocols and medical necessity denials. The medical model was the context for debate.

Discussions of medical necessity, both then and now, focus on needing a safe environment for crisis stabilization. Physicians review diagnoses and adjust medications during psychiatric stays (addiction treatment tends to be more programmatic than medication driven), which tend to be more indefinite than for physical medicine. Psychiatric crises presumably stabilize as a byproduct of inpatient work.

In the 1960s, community mental health centers incorporated protocols for managing crises from a psychosocial perspective. Crisis intervention asks why someone deteriorates at that moment. It clarifies the specific meaning of the crisis for that person. It is a form of therapy focusing on resolving the specific issues provoking the crisis. Hospital care is a last resort and diagnosis a secondary concern.

Many people need hospitalization for safety, but some are hospitalized unnecessarily. Crisis intervention stabilizes through focused outpatient work that prevents the need for confinement. Yet we will err in many placement decisions until outpatient care is easily accessed for those in acute distress. Only when urgent outpatient stabilization is a prevalent option will all levels of care get used judiciously.

Managed care soon turned to outpatient care with a focus on diagnosis and therapy type. This medical (or diagnosis-based) way of thinking also exists in academia. Therapy researchers began in the 1970s to validate therapy techniques for specific diagnoses. Cognitive behavioral therapy (CBT) excelled in refining techniques and proving their value. Some experts became quite prescriptive with directives modelled after prescribing medicine.

CBT researchers gave us treatment manuals, practice guidelines, and other tools for ensuring quality. The implications of such work may not be readily apparent to busy clinicians, and so it is helpful to listen to a clear voice on this topic, David Barlow. This distinguished psychologist has suggested dividing the work in our field in a radical way. His view of psychosocial solutions is rooted in the medical model.

Barlow proposes differentiating “psychological treatments” for specific disorders from “generic” care. He believes generic therapy for personal growth is discretionary, falling outside “any healthcare system” and best funded privately. This is deeply troubling. All such therapy is valuable. Some might best be shifted to primary care, but regardless, much worthwhile therapy is not focused on a diagnosis.

Barlow’s approach is quite compatible with managed care. They both envision a need for inspectors, one focusing on medical necessity criteria and the other on a list of validated psychological treatments. This work also overvalues technique and undervalues the therapy relationship. Therapists drive more of our clinical results. Lastly, Barlow’s work opens a potential pathway to mandating how we treat clients.

Other researchers offer a different path. While Barlow asks if treatment works for a specific disorder, others ask if evidence shows treatment is working for a specific client. This requires monitoring results with patient self-report measures during therapy. This potentially leads to aggregating results by clinician and provider system, which offers accountability and transparency without mandates.

Let us consider an evolving new business, digital therapeutics. These products grew from CBT. The industry began with the goal of disseminating valuable therapeutic services, and its products are now widely available, even as part of pharmacy benefit management (PBM) formularies. CVS Health and Express Scripts have digital health formularies for many problems, including depression and insomnia. The medical model emerges again.

Clever marketing suggests that the algorithm is replacing the molecule in these digital formularies. This may be the apotheosis of medicalizing psychotherapy. CBT is conceived as being comparable to a pharmaceutical’s mechanism of action as techniques resolve the cognitive-behavioral deficits in mood disorders. Digital products are now promoting CBT algorithms as inexpensive psychological treatments.

Health plans are eagerly buying these cheaper algorithmic versions of CBT. Should they seek to integrate digital and live services? Why not substitute digital therapies for in-person therapies? Let us hope digital products do not cannibalize in-person services, but we should assume nothing. Given the right financial crisis in healthcare, various service cuts and substitutions will be tempting.

Medical and psychosocial frameworks understand problems in different ways. Each illuminates an aspect of life, and we should utilize both. However, let us compare the pros and cons for each approach as clinicians and as businesspeople. Getting locked into medicalizing our field might be a poor business plan. Psychosocial solutions will be better at times. Every client deserves the right option for their care.

Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.

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.