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Executives Have a Key Role in Rightsizing the Utilization of Therapy
Research shows clinical judgment is often not reliable for telling how much psychotherapy a person needs. This is one of many reasons for implementing measurement-based care (MBC). It adds objective evidence for estimating treatment intensity. Also, external factors (e.g., financial considerations) can influence therapy’s duration, and executives must be alert to patterns of overutilization and underutilization.
A challenge for outpatient care is ensuring it is available and accessible for anyone in need. Executives must attend to specific social groups facing more barriers than others. Access and utilization goals must be individualized, both at client and societal levels. Some groups need executives to take extra measures to ensure access. Some clients need monitoring systems to make certain they get sufficient services.
Staff welcome efforts to improve care access and health equity, but some clinicians react negatively when client level utilization is addressed by MBC systems. This is partly because clinical training has not prepared therapists for aspects of MBC. Also, MBC may seem more clinical than administrative in its goals, but executives are pivotal in shaping its quality improvement features.
Completing a “Course of Therapy” Is Not Always Relevant for Psychotherapy
Therapists tend to think psychotherapy has a beginning, middle, and end, regardless of their preferred therapy model. They believe people need a course of therapy, much as people need a course of treatment for conditions ranging from bacterial infections to cancer. Some therapy models even have a recommended number of sessions. Do people need a certain “dose” of therapy to get well?
If you approach this question from the perspective of clients entering therapy, a clear answer emerges. People want relief. They are getting help because their psychological distress became too great. Many are unaware of clinical concepts like depression or anxiety, but they know how they feel. When a certain amount of relief is found, many are prepared to end therapy. They care little about dose.
This helps explain why 1 session is the most common number completed. Most therapists are unfortunately taught to see only 1 session of therapy as a failure, but it is often just the opposite. Some episodes of therapy do not immediately reduce distress, and so people may leave without much relief. Yet another group of clients quickly find what they need, and so quitting is a reasonable decision.
These findings were established in real-world therapy settings decades ago. Most people leave therapy when they have improved to their own satisfaction, and for many this entails just a few visits.
More recent confirmatory studies have found that a single visit “can represent either successful and satisfying treatment or unsuccessful and unsatisfying treatment,” suggesting by way of explanation that some clients may leave therapy due to “relatively fast rates of change.”
When executives implement MBC, the system can differentiate good from bad outcomes for clients ending therapy abruptly after a few visits. This is a critical function. Therapists generally have little idea why clients do not return, and yet executives can determine from MBC data if the best course is to do nothing or to facilitate outreach to encourage more treatment.
Executives Need Optimistic Therapists and Dispassionate Data
Therapists are generally optimistic that their work will have a positive outcome. This is not a problem, unless their optimism clouds the reality of an episode going poorly. Michael Lambert’s research encountered this misplaced optimism repeatedly, and as an early architect of MBC, he came to believe a major reason for having MBC systems is to flag deteriorating clients at risk for having a poor outcome or ending therapy prematurely.
Lambert was amazed to repeatedly find that therapists are unable to identify these at-risk cases on their own. Yet he was delighted to find that clinicians given this feedback from MBC could make necessary adjustments and persist in therapy with these clients to have a good outcome. It is still not a reality that most therapists acknowledge, mostly because they are unaware of this research and do not use MBC.
Risks should be monitored during therapy, using complex statistical analyses and benchmarks for expected change. Executives should own these MBC processes and educate therapists on using feedback during therapy. The recommendations are clear but general in these cases—therapists should re-evaluate the treatment plan, ensure the client does not stop abruptly, and work toward improvement.
High Performing Clinics Rely on Collaboration
Outpatient utilization is not a purely clinical concern. Executives want to support clinicians in their work by managing issues like risk, utilization, and access that rely on good data and advanced analytics. MBC makes good therapists better. Every healthcare specialty aspires to providing “evidence-based care,” and this goal cannot be reached in real-world behavioral settings unless MBC is a core component.
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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