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Business Can Revitalize the Science of Psychotherapy as Medicalization Threatens It
Psychotherapy has a mixed reputation in the medical world. While valued, some physicians view it as unscientific and out of step with the medical model. At the same time, many therapists are ambivalent about the medical model’s value for behavioral health problems. Most are grateful that therapy qualifies as sufficiently medical for insurance billing, but many therapists disavow providing a medical procedure.
These debates are subdued and require no resolution for now, but therapists bristle whenever critics disparage their work as being a luxury or discretionary service not warranting insurance coverage. Therapy is sometimes dismissed as more art than science, or as a non-medical, occasionally helpful service.
When pressed to identify useful therapy practices, physicians usually cite guideline-driven protocols like cognitive behavior therapy (CBT). While based partly on misconstruing CBT as uniquely supported by evidence, their support also derives from CBT being easily understood and pragmatic. Completing step-by-step repairs to dysfunctional beliefs is less threatening to most people than exploring private feelings.
Mental and substance use disorders carry social stigmas that readily attach to therapy itself. While the medical model offers a solution for stigma, medicalization is a double-edged sword in this regard. It legitimizes serious mental illnesses and addictions as diseases “like any other,” but leaves non-serious mental illness (SMI) problems in limbo. An extreme version of medicalization is also used by some to undermine therapy.
A Crude Medical Divide
Therapy as a general practice has robust evidence supporting its effectiveness, but this approach to healthcare may seem antithetical to the medical model. A medical approach starts with diagnosis. General therapy may be offered to people who present with a range of symptoms and conditions. Such treatment is not closely tied to a specific diagnosis but is remarkably effective at providing clinical improvement.
Is violating the diagnostic premise for medical care a fatal flaw? Many believe so and would accordingly categorize therapy in 2 ways: medical and non-medical. The medical category includes diagnosis-specific protocols (e.g., varieties of CBT) provided by licensed therapists, while non-medical services would include general psychotherapy and various supportive interventions by unlicensed caregivers.
This is not an official dichotomy, but it captures the radically different opinions about therapy that exist. Highly specialized therapies, especially for severe conditions, fit expectations for medical services. By contrast, general therapy seems non-medical despite its strong research evidence. If adopted as policy, this logic would ultimately exclude therapy from insurance coverage.
There is another problem with this narrow, medicalized view of psychotherapy. Other important types of scientific study exist that do not fit into the medical model. The scientific model has nurtured many discoveries in psychology. Hypotheses are tested in rigorous empirical studies, and knowledge is accumulated that does not fit the medical model’s framework of diagnosis and treatment.
How Business Can Revitalize the Science of Psychotherapy
How do we respond to the medical reasoning that denigrates some therapies? Psychotherapy research studies will not shake proponents out of this extreme medical view. Indeed, this medicalized perspective might best be seen as an ideological view that actually distorts the medical model. It may appeal to some, but it is better labelled medicalization than a legitimate form of medical thinking or study.
Combatting this medicalized view requires executives, not academics. First, we need executives to widely implement measurement-based care (MBC), and then we need them to champion MBC as the scientific approach to therapy.
It is time to face that therapy without an MBC system is less scientific. The routine use of MBC should ultimately become a requirement of insurance-based healthcare. There is no need to debate advocates of medicalization. It is unclear how many exist, and the real concern is empowering their views. MBC puts therapy on a stable scientific foundation, and it fits a measurement-based healthcare culture.
The medicalization of therapy could have dire consequences, especially in an environment demanding cost reduction. One way to reduce non-medical therapy costs is to exclude them as non-covered services. Such concerns may be largely paranoia today, but putting therapy on solid scientific footing with MBC shows foresight. Therapists will also find that MBC adds a sense of security to clinical practice.
Psychotherapy can be a lonely pursuit for the clinician, and MBC provides a comforting guidance system. It identifies clinical risks that are often undetected and supports decisions about when to end services. While rich in clinical information, these systems require executives to build and use them to their full potential. From data collection to clinical feedback, they rely on advanced technology and analytics.
MBC reaffirms that therapy is an empirical science, and it reassures payers that the results from the real-world services they fund can be analyzed in detail. The best response to the medicalization of psychotherapy resides in the reporting executives can share with payers, professionals, and the public. When every episode of therapy is tied to valuable evidence, ideological views will wither away.
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.
References
Insel T. Healing: our path from mental illness to mental health. Penguin Press. 2022.
