New Horizons for Psychotherapy Beyond Clinical Disorders

Psychotherapy is not a product of medicine. Physicians have been key figures in its evolution, and many consider it part of the medical model in which they were trained. However, this is a misconception. Therapy is a product of the psychosocial model. Yet this is an abstract way of explaining a simple point. Therapy is valuable for many problems that are not clinical disorders or pathological in nature.

It is odd that this basic idea is misunderstood by many in our field. Therapists have been helping people with less severe problems for generations. Clinicians committed to helping people with the most severe problems (or DSM disorders) have tolerated this disparity, often considering those therapists working on non-pathological personal problems somehow less competent.

The best way to destroy this myth is to place therapy in the setting where many of us believe it initially belonged, namely, primary care. The conundrum in primary care is that PCPs routinely identify problems that require behavior change. However, PCPs have few tools at their disposal. They need therapists, who might be referred to as behavior change specialists.

The journey to primary care has been long. Many initially recognized a role for therapists in primary care when the behavioral elements in chronic medical conditions were understood. People with diabetes and hypertension often need to lose weight. Yet changing health behaviors can be as difficult as resolving various mental health and addiction problems. Behavior change specialists are needed.

The other awakening relates to the high rate of comorbid behavioral disorders for people with chronic conditions. Medical costs escalate as undetected and untreated disorders like depression develop. Again, the justification for turning to psychotherapists and psychiatrists for help has seemed clear. Yet this is the tip of the proverbial iceberg. Consider another problem, medication non-adherence.

In the words of former Surgeon General C. Everett Koop, “drugs don’t work in patients that don’t take them.” He chose a witty approach to an alarming problem. Studies show half of us do not take medications as prescribed, costing around $290 billion annually in unnecessary medical expenditures. Nearly 1/3 of people fail to fill their prescriptions. These are preventable clinical and financial problems.

We know that changing this behavior could prevent unnecessary hospitalizations, trips to the ER, and the need for more expensive care. Some people are confused about the need to consistently take meds for chronic problems. Others fear side effects. Practical problems like money and access can play a role. Some people have psychological conflicts about the doctor’s order that usually stay hidden.

Given the size of the problem, many solutions have been tried. This includes practical solutions like patient reminders and copay adjustments, as well as clinical discussions with doctors, nurses and pharmacists. Clarification of clinical issues may be needed at times, but an exploration of dysfunctional attitudes and beliefs is critical for many. We are learning this now with COVID vaccine skepticism.

The WHO made a startling claim long ago. Solving this problem could have a greater impact on the health of a population than any improvement in specific medical treatments. This is still true. A new approach is needed. Psychotherapists may be the missing ingredient. Like many big health-related problems, there is no psychological disturbance involved. Yet a behavior change specialist is needed.

A therapist finds individualized solutions to medication non-adherence. Many people dislike taking pills due to experiences that left distorted ideas and attitudes. Therapists focus on personal motivations. This is similar to diet and exercise. There are profound health benefits from successful behavior change. Focusing on non-pathological problems is valuable, both clinically and financially.

It was once bold to suggest that we need therapists in primary care to treat mental health problems. The horizon is now much bigger. Therapists are healthcare professionals with expertise in thoughts, feelings, and behaviors, all of which impact health status. We can help people in myriad ways, often related to mental health and addiction, and sometimes just by helping people follow doctor’s orders.

Therapists should be leaders in maintaining a primary care culture focused on behavior change. The refrain is true, that there is “no health without mental health.” Yet this is too limited. We are not bringing the mental health banner to primary care. We are promoting the critical, lifelong pursuit of behavior change as the key to health. This concept captures the broad mission of primary care.

Health improvement, and the centrality of behavior change to achieving it, also reframes the mission of psychotherapy. Mental health is a marker of a different time in the history of our field. It was an early phase of discovery focused on one type of suffering and dysfunction. We can now expand that focus. Our field is a healthcare discipline. Sometimes the focus is mental health, sometimes not.

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