Beyond the Constraints of Categorical Thinking: Issues of Treatment

Editor’s note: Second in a 3-part series. | Part I

Think like a therapist. This appeal is meaningful to many of us but hard to explain to most in healthcare. An opportunity for clarification occurs when attention is drawn in monthly awareness campaigns to those with various medical conditions. Many in our field have valuable clinical insights related to those chronic disorders, but only some are tied to the distinctiveness of thinking like a therapist.

September is Pain Awareness Month. Behavioral healthcare experts generally take the opportunity to emphasize that many pain sufferers need our help. They note pain is both physical and emotional, citing statistics on the co-occurrence of depression. This naturally leads to an invitation to provide integrated care, starting with a way to identify those patients with a co-occurring behavioral health diagnosis.

This focus on screening and diagnosis is the clue that one is not thinking like a therapist. It is more characteristic of how a psychiatrist thinks. The biomedical model rests on diagnosis, and so care follows sorting pain sufferers into DSM diagnostic categories. Yet diagnosis may not be best for deciding who gets attention. Categories of clinical severity may be no better. What about therapy vs. medication?

Many people with subclinical conditions experience great psychological distress, and they merit care. Therapy helps. It can ameliorate pain. Is therapy mainly for mild to moderate distress? No. Research shows the severely distressed benefit greatly. Afterall, therapy helps many acutely suicidal people. What about the common guidance to combine medication and therapy for severe cases?

This position obscures a few things. Therapy is generally seen as the junior partner in this arrangement, and yet many people benefit from one modality and not the other. Integrating them is a belief with some empirical support and a great many exceptions. Research reveals what is generally true, what works on average, but clinical care is about helping a specific person. Categories guide us only so far.

Thinking like a therapist stands out partly by not being beholden to categorical thinking. Psychiatry has expertise in sorting and matching. There is a skill in sorting by diagnosis and by the severity of a condition, to be followed by matching these categories to the best type of medication. This is different from the therapist who prefers talking with everyone and individualizing every episode of care.

The biomedical model creates a map for clinicians to follow with markers for diagnosis and associated treatments. The psychosocial model focuses more on relationships and conversations that are hard to predict or pin down. Nonetheless, psychotherapy is remarkably efficacious. Therapists engage people and explore their problems, hoping this unique, nonjudgmental relationship provides value.

Meet Our New Champions for Psychotherapy

These are not new ideas. Therapy is hardly a novelty at this point, and programs for chronic conditions like pain are often multidisciplinary with a team psychologist or social worker. Is this not putting therapeutic thinking to work? It is in some cases. However, clinical programs often seek efficiency by becoming guideline-driven (more generic than individualized) and using lower cost paraprofessionals.

Is there a better way to use therapy? For earlier intervention in the progression to chronic pain, therapists might routinely talk with patients in primary care. These would not be patients selected for anxiety, depression, or substance use disorder. They would be patients with pain among other complaints. They would have thoughts, feelings, and behaviors ready to change to improve their overall health.

Some people with pain will respond well to therapy. Some PCP practices will achieve better overall health by targeting early therapy responders vs. clinically depressed patients. It is not either-or. Benefits flow from thinking like a physician or like a therapist. Yet unlike the dominant medical model, the psychosocial needs champions. Leaders of disease awareness campaigns could be fine recruits.

Therapy helps people become more resilient in the face of life’s stressors, be they physical or mental.  Whatever the medical condition, many patients can use the enhanced coping skills provided by therapy. Therapy for chronic medical patients should be common, not just as an ancillary service for co-occurring issues, but as a powerful tool in their medical care. One need not check a DSM diagnostic box to apply.

Organizations raising awareness need a new bullet point. Input from a therapist can be beneficial for patients at all stages of their illness. Not everyone needs formal therapy. Many can benefit from brief contacts in primary care. Therapy is highly individualized, yet broadly effective. Monthly awareness campaigns should be touting therapy and joining the vanguard for placing therapists in primary care.

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