Proof of delivery
An interview with Alan Kazdin
New Therapist spoke to to Alan E. Kazdin about his thoughts on rebooting psychotherapy’s delivery methods to reach a greater proportion of those in need. This is what he had to say.
New Therapist: Your article addresses the ways in which psychotherapy can be re-envisioned to provide alternative delivery vehicles, approaches and ways of collaborating to provide mental health services. But it makes little reference to the other forces that have a very significant impact on the way in which the psychotherapy marketplace is evolving. Of particular note among these developments is the increasing dominance of psychopharmacological treatments as a first-line treatment for many of the most commonly occurring disorders, e.g., depression. How do you believe this growing reliance on drugs is impacting on the psychotherapy market and what, if anything, do you recommend as a response to it?
Alan E. Kazdin (AEK): Psychopharmacological treatments often are a first line treatment for many psychological disorders and sources of dysfunction. Yet, there are several influences that make psychotherapeutic interventions still viable, needed, and in some cases strongly preferred. Among these influences:
In short, therapy is alive and well.
Perhaps the more pertinent feature is that the marketplace is influenced by the nature of how therapy is usually delivered. Individual one-to-one, in-person psychotherapy, whether psychodynamic or cognitive-behavior therapy, and whether evidence-based or not, is expensive, in addition to not being able to reach most people in need. There are now many treatments (e.g., forms of expressive writing, many self-help treatments, and those available as self-help, 24/7 on the Web) that have evidence in their behalf that are much less expensive to administer and have greater reach (penetration in the population among those in need). The market place forces on psychotherapy can be influenced by the model of delivery, i.e., how psychosocial interventions are delivered. I have advocated a portfolio of models to reach more people and most of these models have a much lower cost of delivery. That can influence what treatments are provided and reimbursed. More accessible and effective treatments could greatly influence public interest in obtaining services and third party payers’ interest in reimbursing those services and reimbursing for psychotherapy if those more readily obtained services have been tried but more is needed.
NT: You have challenged the notion that time-intensive, slow, one-on-one psychotherapy is still as relevant as it once was, instead proposing more innovative approaches to deliver services to users thereof. Some might argue, though, that the superficiality of the internet, the impersonality of many of its media and the short-term nature of many of the treatments you pose are at risk of dumbing down therapy to a manualised, computerised delivery of psycho-educational materials. How might your respond to this suggestion?
AEK: A concern, especially among those of us trained in some variation of one-to-one, in-person individual therapy, pertains to the possible limits of these more novel models of delivery. Will the therapy be superficial and diluted, and will the effects be transient? These are legitimate arguments if framed as empirical questions. As framed, evidence does not suggest that more deliverable treatments, by lesser trained professionals, and via the web, for example, are any less effective or any less durable than individual, in person therapy. There are natural tensions to emerge as individual therapy is viewed as a (i.e., just one) model, rather than the only or even main model of delivering services.
In the USA, there is a great concern about reimbursement for psychological services (individual psychotherapy). Advocating a portfolio of interventions that is less costly and pointing out that evidence does not indicate a doctoral level mental health professional is needed are, understandably, not viewed as friendly. My attention is focused on the scope of the task (reducing the burden of mental illness, scaling up interventions to actually reach people in need). We do not begin with individual psychotherapy; rather we begin with that challenge and what is needed to meet it.
From the patient’s perspective, many patients are much more likely to adhere to treatment and be comfortable with more readily administered treatments than individual, in-person psychotherapy. We have known for decades that patients often reveal more about themselves in computerized assessment than with a live therapist. Now we have a related situation. Current generations are extremely comfortable, used to, and interested in treatments that might involve smartphones, tablets, and “apps” and so on. Also, some treatments that are not very feasible for wide spread use (e.g., biofeedback) now can be administered via smart phone. It is likely that patients, more than mental health professionals, will find novel models of delivery user friendly. Indeed, the notion of a portfolio of models of delivery will not only make treatments more accessible to those in need, but provide choices among models for some of those individuals.
This year there was a breakthrough study on the prevention of HIV in Kenya that involved suburban, urban, and rural villages. The intervention was text messaging since most people have access to cell phones. The intervention was very effective in preventing HIV, all through texting. The intervention was shown to be feasible, to have enormous reach, and to have palpable impact on adherence to medication and risk of spreading disease. There is unrealized potential here in relation to fostering mental health and enhancing daily functioning in the USA using models like this that can reach people in need.
In short, the delays in getting novel models of treatment to the public may well be due to inherent delays in the mental health professions and its institutions (e.g., training in graduate work, internship programs). There will be understandable concern about the work force (who can deliver treatment), jobs and reimbursement, and changing training program. Yet, pressure will come from other forces. For example, the World Health Organization (2008) published a report on “Task Shifting,” that focuses on mobilizing personnel worldwide to deliver health care services. The personnel are individuals who can be trained and then supervised to deliver interventions that would not otherwise be provided. Randomized trials suggest the success in scaling up and delivering effective treatments. We in psychology have known for some time that doctoral level training is not needed for the delivery of psychological services and that individuals not trained at this level can be just as effective. More influences now such as the unmet need for services in the US and worldwide and the available of more models of delivery are likely to influence psychological services.