Understanding the Psychotherapy Gap Through the Eyes of Our Community Partners
Internet Editor’s Note: Dr. Courtney Benjamin Wolk and colleagues recently published an article titled “The implementation of a team training intervention for school mental health: Lessons learned,” in Psychotherapy. You can access a copy of their journal article here.
Psychotherapy as a field is no stranger to controversy, so let’s start with where we all agree. If you are a member of Division 29, chances are you believe in the mission of this organization which is to make the benefits of psychotherapy accessible to all. Next, we may agree that individuals with mental health needs should have access to high quality treatments that are consistent with what science tells us is most likely to work for them given their constellation of needs (i.e., evidence-based treatments). Some have argued persuasively that clinical psychologists have failed as a guild to achieve a significant impact on clinical and public health because most individuals in this country, particularly our most vulnerable citizens served in the public sector, do not have access to efficacious treatments like cognitive-behavioral therapy (Baker, McFall, & Shoham, 2008). If psychologists and psychotherapy researchers have devoted hundreds of careers to the development, testing, and dissemination of their treatments, why do inequities in access to high quality psychotherapy persist? There are many reasons the public sector has struggled to scale up evidence-based psychotherapies; two of the most significant barriers may be funding and workforce limitations.
Public Sector Challenges
Despite the fact that one in five Americans has a mental health condition in any given year and one in two Americans can expect one over the course of their lifetime (Kessler et al., 2003), funding and reimbursement for mental health care is limited in both the private and the public sectors. Medicaid is the single largest payer in the United States for behavioral health services and reimbursement rates are usually less than those in the private marketplace. Additionally, there were substantial cuts in state aid following the financial crisis of 2008 that have yet to be restored. The dire financial straits of the mental health care delivery system have led to a crumbling infrastructure in mental health treatment organizations, particularly outpatient settings. Because most outpatient programs are under-resourced, they are poorly situated to invest in evidence-based practices (despite policy emphasis to do so) because they are struggling to keep solvent (Stewart et al., 2016). The workforce in public mental health consists largely of master’s level clinicians. Productivity requirements are high, and the pay is low. Not surprisingly, staff turnover is often quite high.
Addressing the Psychotherapy Gap
In order to make a dent in the psychotherapy gap and re-establish clinical psychologists and psychotherapists as leaders in mental and behavioral health care, we propose increasing our efforts in low-resource settings where we can achieve the greatest impact. While some may be quick to blame community clinicians for not delivering evidence-based psychotherapies, we argue that clinicians are generally doing their best in really challenging situations with very limited support and resources. We have not done enough to equip and support our front-line clinicians. It is important to remember that our psychosocial interventions are complex and require more than one-off workshops and trainings to deliver them competently. We need to invest more in pre-service training and ongoing professional development in evidence-based practices if we want to see our evidence-based practices more widely implemented.
The problems facing the public mental health sector are considerable and there are no easy fixes. Major changes in policy and reimbursement may be needed to overhaul a system that is currently failing to meet the needs of our most vulnerable. But these changes aren’t going to happen overnight and there are steps that psychologists can take now. Implementation science offers some guidance for how to maximize our impact. Implementation science is a relatively new field that aims to promote the systematic uptake of research findings and other evidence-based practices into routine care to improve the quality and effectiveness of health services (Eccles & Mittman, 2006). Implementation scientists are working hard to understand how best to increase uptake of psychotherapy evidence-based practices in communities. While we still have a lot to learn, we do know that training alone is insufficient to produce long term behavior change and that context drives much of professional and organizational behavior (Eccles & Mittman, 2006). Too often front-line clinicians are blamed when treatments don’t work or when evidence-based practices aren’t delivered, but there are a lot of things outside of an individual clinician’s control at play here too. Let’s try to do a better job understanding those challenges and partnering with clinicians and organizations to develop solutions.
The Case for Compassion and Partnership
It’s easy to blame “incompetent clinicians” or think we can fix them up to fidelity with a manual or a training or two. It is important to remember, however, that clinicians in public systems are generally underpaid and work in challenging, under-resourced conditions with people living in poverty. Their jobs are really hard. Additionally, psychotherapies aren’t simple; they are multi-component complex interventions that can prove challenging for well-trained clinicians to delivery with the “worried well” let alone with patients with housing, food, and safety insecurities. So, let’s stop blaming clinicians for not consuming and delivering our treatments and let’s look at how we can make our product work better for clinicians in low-resource contexts (Stewart, Beidas, & Mandell, in press).
How do we do this? We do this through community-academic partnerships, which are a bedrock of implementation science (Pellecchia et al., 2018). We go to the front lines to help support clinicians in implementing evidence-based practices in the challenging contexts they work in and to ask and understand what gets in the way of evidence-based practice delivery (spoiler alert - it’s not just lack of training!). If we don’t acknowledge the myriad of factors that contribute to poor evidence-based practice implementation in community settings and work together with compassion with these organizations and clinicians, we will continue to lose ground as a guild, and evidence-based psychotherapy will be delivered primarily to those who can pay out of pocket (depriving many of effective treatment) or worse, will fade away. So, instead of throwing up your hands when our evidence-based practices aren’t being used, consider engaging your community to understanding the challenges clinicians and organizations face to implementing evidence-based psychotherapies - if your time and skillset allows, try to help. And as a field, let’s do a better job of developing and disseminating treatments that can be flexibly implemented with fidelity (Kendall, Gosch, Furr, & Sood, 2008) in settings with low resources and high needs so that we can maximize our impact.
Cite This Article
Wolk, C. B.& Stewart, R. E. (2019, September). Understanding the psychotherapy gap through the eyes of our community partners. [Web article]. Retrieved from https://societyforpsychotherapy.org/understanding-the-psychotherapy-gap-through-the-eyes-of-our-community-partners
Baker, T. B., McFall, R. M., & Shoham, V. (2008). Current status and future prospects of clinical psychology: Toward a scientifically principled approach to mental and behavioral health care. Psychological Science in the Public Interest. 9(2), 2008, 67–103.
Eccles, M. P., & Mittman, B. S. (2006). Welcome to implementation science. Implementation Science, 1(1), 1-3. doi:10.1186/1748-5908-1-1
Kendall, P. C., Gosch, E., Furr, J. M., & Sood, E. (2008). Flexibility within fidelity. J Am Acad Child Adolesc Psychiatry, 47(9), 987-993. doi:10.1097/CHI.0b013e31817eed2f
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Koretz, D., Merikangas, K. R., … Wang, P. S. (2003). The epidemiology of major depressive disorder: Results from the National Comorbidity Survey Replication (NCS-R). JAMA, 289(23), 3095. https://doi.org/10.1001/jama.289.23.3095
Pellecchia, M., Mandell, D. S., Nuske, H., Azad, G., Wolk, C. B., Maddox, B.B., … Beidas, R.S. (2018) Community–academic partnerships in implementation research. Journal of Community Psychology, 46, 941-952. https://doi.org/10.1002/jcop.21981
Stewart, R. E., Adams, D. R., Mandell, D. S., Hadley, T. R., Evans, A. C., Rubin, R., … Beidas, R. S. (2016). The perfect storm: Collision of the business of mental health and the implementation of evidence-based practices. Psychiatric Services (Washington, D.C.), 67(2), 159–161. https://doi.org/10.1176/appi.ps.201500392
Stewart, R. E., Beidas, R. S., & Mandell, D. S. (in press). Stop calling them laggards. Psychiatric Services.
I agree with your overall mission. I’ve been working as a clinician and researcher to disseminate evidence-based practices. But I think your recommendation to engage more with community clinicians is not the answer. It’s been tried already many times. All attempts so far at voluntary implementation have, for the most part, been failures, and we have made one contribution to document it (Miron D, Scheeringa, MS (2019). A Statewide Training of Community Clinicians to Treat Traumatized Youths Involved with Child Welfare. Psychological Services 16(1), 153-161, 2019 Feb., doi 10.1037/ser0000317). Higher reimbursement incentives would help but haven’t been tried yet. The only feasible solution appears to be non-voluntary implementation through requirements by government, agency, corporate, and insurance policies. That will be unpopular with a subset of folks but the industry of psychotherapists has proven resistant to adapt.