Providing Therapeutic Conversations, At Scale, in Primary Care
Might therapeutic conversations be made available at scale? The technical term “at scale” means having a solution in the right proportion to solve a problem. This usually entails large quantities of a given solution. One of our field’s operational challenges is whether therapeutic interactions might be shortened, though certainly not for everyone. Shorter visits could potentially help more people.
Should every modification to therapy be explicitly validated? We may have ample research to support some changes, especially if the goal is not to replace therapy. We have unconscionable levels of behavioral needs not being met today. Very brief visits might provide some benefit for many. Such therapy-like contacts may not scale well in isolated, private offices, but they could in primary care.
Let us understand this from a medical perspective. Medical authorities give wide berth to clinical judgment. Consider a daily reality in the medical world. When medications are found to be safe and effective for specific indications, doctors can use them for other nonapproved purposes (off-label) as they see fit. Medications are also widely disseminated for the prevention of disease.
Heart disease exemplifies this. There are more than 21 million prescriptions for statins annually. Doctors prescribe them largely due to risk factors and not the presence of disease. The medical community supports this urgent approach for the sake of prevention. Some experts, like Robert Aronowitz, have raised alarms:
We have experienced the ascent of a risk-dominated experience of ill health, one characterized by fear, uncertainty, and lack of control, whereas in the past, pain, loss of function, and other symptoms were more central. Along with this, we have more and more public health practices, medical interventions, and consumer products that are largely risk reducing and risk controlling rather than treating symptoms or curing disease.
Prevention has been extended so far as to warrant radical measures like organ removal (eg, mastectomy). Such interventions are based on risk calculations left to the judgment of doctor and patient. Aronowitz may caution that this “quest to cure fear and uncertainty” may be going too far, but such concerns do not interfere with the respect for a doctor’s judgment or the urgency of prevention.
Pills can be distributed so effectively that prescriptions can exceed a problem’s size. Eradicating depression is an example. Our conundrum today is that while PCPs miss some people with depression, they often prescribe antidepressants for marginal signs of depression. Many scripts go unfilled or unused. Yet, quality improvement efforts never diminish support for a physician’s clinical judgment.
Psychotherapy has been found to be safe and effective. Its large effect size of 0.8 makes it “remarkably efficacious,” and it can help a wide range of problems without side effects. The largest driver of these results is the therapist doing the work. Should we not be deciding how to deliver this powerful solution more efficiently? Yet little work is underway to offer therapy-like services at scale.
The forces of tradition may be slowing experimentation with therapy. Yet, there is no hurdle to offering variable units of time by non-professionals. Many primary care offices employ health coaches. It is not always clear what training or background they bring to the work, but they are much cheaper than a therapist. This likely drives their growing use, even though their outcomes are largely unmeasured.
A new intervention is gaining traction that scales well. Digital therapeutics (DTx) are widely available, either direct to consumers, sponsored by health plans, or by prescription. The therapeutic exercises of DTx (especially cognitive behavior therapy) have been analogized to being like the molecules of a medication. This analogy misses the mark because the therapist, not the technique, is the largest driver of change in therapy.
What about brief interventions by licensed therapists? They are not easily productized. Pills and digital exercises are tidy and scale with ease. Human encounters might be scalable, but with less ease. The therapy components are well-known—a therapeutic alliance with empathic, nonjudgmental listening—but replication is not simple. So, while therapists may drive more results, techniques are an easier sell.
Three clinical factors should drive the use of therapists in primary care: the robust validation of therapy, respect for clinical judgment, and the urgency of early intervention. Interaction with a therapist might help many face issues and find new solutions. How much longer should we tolerate delayed treatment (eg, starting substance use disorder care at a point comparable to late-stage cancer) when therapists are ready today?
Solutions are needed at scale because behavioral problems are ubiquitous. Let us provide our best resource—our people—and titrate the dosing. Therapists know brief conversations with them will not change everybody, but they can also connect people with DTx and formal therapy. There is no reason to wait for new research. Many people are desperate. Many clinicians having healing capabilities.
References
Aronowitz R. Risky Medicine. Chicago University Press; 2015.
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 the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
