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Tailor Our Field’s Identity With Measurement-Based Care
It is time for our field to establish a coherent identity. This might seem challenging given our diverse problems, services, and perspectives. We have effective biological and psychosocial solutions, making our field both a medical specialty and one proficient in interpersonal healing practices. Yet we can integrate all of this into a comprehensible whole.
Our field involves considerable subjectivity, as exemplified in the critical role of relationships, but it is fundamentally a scientific venture because it is grounded in empirical measurement. The path to coherence is adhering to the practices of measurement-based care. Our care is highly personal, but it is measurable. To understand our field, it is best to start with what drives clinical results.
What Drives Outcomes?
Psychotherapy is “remarkably efficacious” and relationship factors account for more of the outcome than the techniques used. This is a robust finding still ignored by many. Why? It seems partly driven by identity concerns. Many prefer the scientific image of using objective therapeutic procedures, much like medications.
Yet this is a false image of both science and the medical model. Each can comfortably embrace subjectivity to the extent we measure and monitor it. This is measurement-based care.
Empathy and therapeutic alliance clearly drive results. We may prefer more easily defined, technical explanations for our work, but few clinical areas oblige—not even medication management. The mechanism of action for psychotropic medications is still unknown, but this also applies to other medications. Yet other murky drivers of outcome, often ignored but well known, demand attention.
Prescribing is complicated by the effects of placebo. Researchers in the past discarded it as being unwanted interference with the clinical effects being studied. Yet placebo effects are now a separate field of study, and deeper analysis shows placebo effects to be driven by the individual clinician and to be as powerful as some medication effects. Wampold’s summary of this literature is illuminating.
Placebo effects are best understood as a component of overall clinical results. Not all benefits from medication derive from the biological compound. We have psychiatrist effects, much as we have therapist effects, driving part of the outcomes from treatment. It is often a large part. Clinicians are vital in behavioral healthcare. Our field is founded on relationships and communication.
These findings are disappointing from a rigidly medicalized view. Some tend to simplify medical care by assuming that once a treatment is validated, care delivery is incidental—only the treatment itself matters. Yet we now know the fallacy of assuming such uniformity in care. The psychiatrist matters, almost as if each one provides a different pill. These findings do not contradict the medical model.
Our Commitment to Individualized Care
We can claim a solid scientific foundation for our field not just because of initial clinical trials validating our interventions. Our empirical testing of outcomes in the real world also demonstrates scientific rigor. This second type of empirical commitment should be a pillar of our identity. Our core message to the public should be our ability to show strong clinical results in everyday psychotherapy and psychiatry.
Our executives need to seize the opportunity here. The public may understand our wide range of services, but we need people to understand how we are both a deeply personal and yet thoroughly scientific field. They must realize our care works for many reasons, and one is the skill of clinicians. The personal fit with a clinician is an issue in all of healthcare, but especially in behavioral healthcare.
Executives also need to drive some institutional changes. We are not yet routinely producing empirical results for our clinical work. Promoting objective results for every service would go far to reassure a skeptical public. People still need to be convinced our stigmatized field works. We have no cures. Results vary by practitioner. Yet we can show aggregate results that are comparable to other fields.
How do we bring coherence to our identity? We align ourselves with empirical science. While we start by validating our treatments, we cannot claim a distinctive identity simply because we have evidence-based practices. We must also measure results in the real world to know which clinicians are getting the best results and which patients are benefiting as expected.
Measurement-based care is the gold standard. It means clinicians make adjustments during the process of care if patients are not improving as expected. Care is guided by the patient’s response to generally effective interventions.
While a given treatment might work in general, we must know how it works for each individual. Real-time data should guide the best possible result for each person. A coherent identity will congeal for our field when we make measurement-based care our core, unifying principle. This identity is aspirational but within our reach. Our field’s complexity then becomes a more positive feature—individualized care.
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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