Restoring Psychotherapy as the First Line Intervention in Behavioral Care (Book Review)

Editors: Nicholas A. Cummings & William D. O'Donohue
Publisher: Ithaca Press, 2012, 326 pages. ISBN 978-0-9839121-1-8
Reviewed by: James L. Rebeta, PhD, Weill Medical College of Cornell University

Multidisciplinary Healthcare Reform: Will Patients Be Left Behind?

While the title suggests a restoration of traditional psychotherapies to their historic place of prominence, we are instead presented with a compelling commentary on a legacy of advocacy for individuals who receive “interventions that are less effective, less safe, often more costly” and not infrequently with serious and at times lethal side effects (p. 1). The implicit challenge to all psychologists who pick up this volume is to enter into collaborative, constructive discussion about how we as a profession with our diverse empirical, analytic and evidence-based skills can make substantive contributions to patient care. Selfishly and more broadly, the potential reader might wonder how this work might impact what we as psychologists teach, how we render clinical service, or what services might we as patients expect to receive from other disciplines in healthcare.

We psychologists — academic scientists, professional practitioners, public interest psychologists and others — frequently use professional meetings to obtain multiple perspectives that might enrich our work. These gatherings by their nature afford attendees scientific breadth and occasionally depth on a range of topics of varying personal interest, but this same message may be difficult to convey in narrative format, which is the case with this work edited by Drs. Cummings and O’Donohue. As such, complementary and confusing vantage points are often the rule and sometimes the appeal and challenge of such gatherings and also of this work. Nonetheless, current healthcare reform and ongoing debate frame the March 2011 presentations at a conference of the same name as the book title and argue for overlooking the occasional frustrations of a sometimes unevenly edited transcript. The potential reader should approach the volume with this in mind.

Dr. Cummings has long advocated for better behavioral health treatments. Here, he and other contributors cover the remedicalization of psychiatry, the explosion of the use of psychiatric medications, especially by a preponderance of non-psychiatric physicians, and their promotion by pharmaceutical advertising sometimes influenced by ghost-written research claims.  Especially chilling is the documentation of the primacy and overuse of medication interventions in vulnerable populations, viz., children, seniors, and the seriously mentally ill. In this context, the citation of a 2004 New England Journal of Medicine editorial from the International Committee of Medical Journal Editors provides strong support for the case against selective reporting of clinical trials as “it distorts the body of evidence available for clinical decision-making” (De Angelis, et al., 2004, p. 1250). The constructive corrective forcefully proposed by these journal editors would embody the accountability and transparency in clinical research for which several of this work’s contributors argue. However, bolstering the case made with the statement — “It is simply no longer possible to believe much of the clinical research that is published or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion that I reached slowly and reluctantly over my two decades as editor of The New England Journal of Medicine” (p. 121) — may be an example of uneven editing that can frustrate the reader. While it captures the spirit of the editorial position of thirteen journal editors, its attribution to Dr. Catherine De Angelis, the first listed alphabetically, is confusing as she was editor-in-chief of the Journal of the American Medical Association at that time. Further, the reader will not find that statement in the reference cited, but can locate it in Dr. Marcia Angell’s concurring commentary on the situation that appeared in 2009, and she had been editor of The New England Journal of Medicine.

The context for the importance of behavioral health intervention is cast in terms of “the economics of disruption or how the new replaces the old” and is based on the work of economist Clayton Christensen as it applies to healthcare (p. 31). Herein is no apologia for clinical practice in any sense of treatment as usual. Rather, the reader is prodded to examine questions for which the contributors’ conclusions and recommendations but demonstrate the enormity of the task unfolding and the paradigm shift needed if truly integrated behavioral healthcare is to be achieved.  Advocating the goals of patient safety, education, and preferences; developing an effective array of treatment interventions tailored to prioritized physical and behavioral health problems; timelier, more efficient and accessible care delivery by competent professionals; outcome efficacy at lower cost — these are the pillars of a training paradigm for the future. Dr. Cummings, with others, has sought to develop interventions informed by these issues at Arizona State University which builds on decades of experience with the Biodyne model of integrated care and psychotherapy. This model was pioneered by Cummings “in the late 1950s in Kaiser Permanente and subsequently refined over the course of five decades in the Hawaii Medicaid Project and in the training and supervision of hundreds of psychologists in the American Biodyne managed care company” (p. 247). Cummings et al. stress the importance of such challenges and the opportunities for psychology. Others have stressed equally urgent challenges such as a 42% increase in overall chronic illness prevalence projected to occur between 2003 and 2023 (e.g., Bodenheimer, Chen, & Bennett, 2009) or projected demographic shifts that Rozensky (2012) noted would result in “a doubling of the number of those over the age of 65 from 40.2 million in 2010 to 88.5 million by 2050” (p. 32). In either case, the prospect of confronting such problems with an unprepared healthcare workforce alone seems daunting. 

This conference distillation is not an easy read. There are many premises to be met in restoring psychotherapy to a first-line intervention in behavioral healthcare and perforce each contributor had to be highly selective in developing a summary perspective. This volume’s extended attention to the development of the current medicalization of behavioral healthcare even insinuates itself into a discussion of non-medication treatment alternatives.  For example, John Caccavale’s chapter on treatments, outcomes and cost effectiveness of psychotherapy as the first line treatment for behavioral disorders (pp. 127-143) mentions that of the five most costly conditions in the period of 1996 to 2006 — “cardiac disease, respiratory disorders, cancer, metabolic disorders and mental disorders” (pp. 137) — mental and trauma-related disorders saw the largest healthcare expenditure increase and, of course, are the traditional channel for behavioral health dollars. Behavioral health specialists do make substantive contributions to treating the narrowly defined psychological conditions, but there is less attention given to the fact that their interventions can be applied to select medical conditions as well. Others have been more explicit in outlining how and where they have been applied (e.g., Chambless & Ollendick, 2001). The inclusion of a discussion moderated by O’Donohue that took place between Caccavale and David Antonuccio responding to each other’s remarks and to wide-ranging questions from participants seems a less-than-perfect fit and may serve to illustrate the aforementioned unevenness in satisfaction that conference attendees often report. Much of this discussion begs the question of how psychologists outside of the medicalized model of treatment can increase their collaboration and how they might effect the changes needed which are listed herein.

"We as psychologists and, at some point, as patients ourselves have vested interests in the outcome."

Perhaps at its most disappointing, this work does not provide either comprehensive or targeted solutions to the widely recognized need for interdisciplinary, community-based linkages and interprofessionial education (cf. Wilson, Rozensky, & Weiss, 2010).  Nor does it do much to amplify a model that encompasses “a frame of reference, an interpersonal education for [a] collaborative, patient-centered practice framework” (p. 8) with linkages at and among individual, organizational and systems levels to provide an integrated and cohesive answer to the needs of the patient/family/population that others have proposed (D’Amour & Oandasan, 2005). 

This volume is at its best when it describes a behavioral care training paradigm for the future (pp. 223-264), one “designed to meet the emerging needs of healthcare reform to produce clinicians who are able to provide clinical services in integrated care settings with the explicit goal of improved clinical outcome and demonstrating medical cost offset” (p. 257). These contributions must span a range of settings, empower the patient, demonstrate positive outcomes at lower cost, and provide efficient and timely services to a wider range of ill- and underserved individuals.  We as psychologists and, at some point, as patients ourselves have vested interests in the outcome. If we accept the challenge, then this volume may help to guide our future training and soberly reflect on the difficulties of our past.

References

Angell, M. (2009, January 15). Drug companies & doctors: A story of corruption [Electronic version]. The New York Review of Books, 56, (1).  

Bodenheimer, T., Chen, E., & Chen, H. D. (2009). Confronting the growing burden of chronic disease: Can the U.S. health care workforce do the job? Health Affairs, 28, 64-74.

Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological interventions: Controversies and evidence. Annual Review of Psychology, 52, 685-716.

D’Amour, D., & Oandasan, I. (2005). Interprofessionality as the field of interprofessional practice and interprofessional education: An emerging concept. Journal of Interprofessional Care, 19 (Suppl.1), 8-20.

De Angelis, C., Drazen, J. M., Frizelle, F. A., Hugh, C., Hoey, J., Horton, R., et al. (2004, September 16). Editorials: Clinical trial registration: A statement from the International Committee of Medical Journal Editors. The New England Journal of Medicine, 351(12), 1250-1251.

Rozensky, R.H. (2012). Health care reform: Preparing the psychology workforce. The Register Report, 38, 32-37.

Wilson, S.L., Rozensky, R.H., & Weiss, J. (2010). The advisory committee on interdisciplinary community-based linkages and the federal role in advocating for interprofessional education. Journal of Allied Health, 39(3, Pt. 2), 210-215.

Reviewer Notes

James L. Rebeta, PhD, is a psychiatry faculty member at the Weill Cornell Medical College and a clinical neuropsychologist at New York-Presbyterian Hospital. With a private practice as well, he is the 2012 president of the Manhattan Psychological Association.

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