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Myrna M. Weissman, Ph.D.
Professor of Epidemiology in Psychiatry,
Chief Division of Clinical and Genetic Epidemiology,
College of Physicians and Surgeons of
Columbia University and The New York State Psychiatric Institute,
1051 Riverside Drive – Unit 24,
New York, NY 10032
Voicemail (212) 543-5880, Fax (212) 568-3534
Email: mmw3@columbia.edu
William C. Sanderson, Ph.D.
Professor of Psychology
Hofstra University
Hempstead NY 11549
Telephone: (516) 463-5633
psywcs@hofstra.edu
CITATION: Weissman, M.M. & Sanderson, W.C. (2002). Problems and promises in modern psychotherapy: The need for increased training in evidence based treatments. In B. Hamburg (Ed), Modern Psychiatry: Challenges in Educating Health Professionals to Meet New Needs New York City: Josiah Macy Foundation. Posted by permission of Josiah Macy Foundation. Copyright by Josiah Macy Foundation.
Abstract
I. Introduction
II. Definitions and Rationale for Focus
III. Advances in Psychotherapy
Specifying Treatments in Manuals
Training the Research Therapists
Evaluating Treatments
IV. An Overview of Evidence-Based Psychotherapy
Criteria to Determine Evidence-Based Treatment
Depression
Bipolar Disorder
Anxiety Disorders
Schizophrenia
Description of Two Evidence Based Treatments
Cognitive Behavior Therapy
Interpersonal Psychotherapy
V. Learning Evidence-Based Treatments
Residency and Graduate Programs
Psychiatry
Psychology
Social Work
Continuing Education
VI. Implications in the Evolving Health Care
Managed Care
Clinical Practice Guidelines
VII. Recommendations
VIII. Concluding Comments
Acknowledgments
References
Appendix: Psychotherapy Use in the U.S. in 1987 and 1997
Abstract
Over the last 15 years there has been considerable progress in the specification of psychotherapy and then testing it in controlled clinical trials. As a result, there is an increased availability of evidence-based psychotherapy (EBT) and an increased recommendation for their use in official treatment guidelines. Data from the Medical Expenditure Panel Survey (see Appendix) shows that the demand for psychotherapy has not lessened over the last decade. However, the number of visits has decreased, psychotherapy is more often used in combination with medication, and there has been an increase in the number of patients seeing non-medically trained therapists, especially social workers. There is a clear gap between these research developments, practice guidelines, and the actual training in EBT for the three major providers (psychiatrists, psychologists and social workers). If research advances in the practice of psychotherapy are to be translated into improving services on a large scale, an accelerated change in the education and training of practitioners is needed. This paper will review the advances in specifying the essential ingredients of psychotherapy, training therapists for research studies, and the efficacy of these treatments from controlled clinical trials. To the limited extent that this information is available, the content of psychotherapy training programs (i.e., residency, graduate school) and continuing education requirements will be examined to determine the level of training in EBTs. Recommendations for closing the research and practice gaps include:
I. Introduction
Although we are not certain about what goes on in the real world practice of psychotherapy, what hints we have suggest that there is a substantial discrepancy between the availability of psychotherapies with evidence for efficacy (based on controlled clinical trials) and their use in clinical practice by the three professional groups providing most of the psychotherapy; psychiatrists, psychologists and social workers (e.g., Taylor, King, & Margraf, 1989; Goisman, Warshaw, & Keller, 1999; Plante, Andersen, & Boccaccini, 1999; Addis & Krasnow, 2000; Sanderson, Hiatt, & Schwartz, 2001). The discrepancy between research evidence and clinical practice begins with the education and training of practitioners. In part, this is due to the recency of the evidence base for psychotherapy. However, if research advances in the practice of psychotherapy are to be translated into improving treatment services on a large scale, an accelerated change in the education and training of practitioners is needed.
This paper will make the following points: (1) There have been significant advances in the technology and testing of psychotherapy; (2)Evidence-based psychotherapeutic treatments (EBT) exist for the range of psychiatric disorders; (3) These treatments are somewhat different than traditional psychodynamic or supportive approaches in that they are usually time-limited, specified in manuals and tested in clinical trials; (4) Psychotherapists are not using evidence-based approaches, mainly because many, perhaps the majority, of clinical graduate/residency training programs do not emphasize training in them; (5) Training programs are not emphasizing treatments endorsed by Clinical Practice Guidelines which have been developed to increase quality of care; (6) The failure to train students, the future practitioners, in EBT will leave psychotherapy vulnerable in the new health care environment, where accountability is paramount; (7) Improvement in the dissemination of evidence-based approaches needs to begin with the education of the next generation of health professionals. Current practitioners can “catch up” with guided continuing education programs. However, no criteria for the content or quality of these programs in EBT exist.
II. Definitions and Rationale for Focus
We use the term psychotherapy to refer to a host of different approaches with differing theoretical and conceptual underpinnings conducted by a range of professionals with differing educational backgrounds and training. By psychotherapy, we mean an intervention in which a verbal exchange between therapist and a patient or client is the main mode of treatment. By evidence-based treatment (EBT), we mean psychotherapy that has been defined in a manual and tested for efficacy in a controlled clinical trial. When we describe EBT we also include the systematic diagnostic and clinical monitoring assessments that are part of EBT.
While the Macy Conference entitled the program “Modern Psychiatry,” challenges in educating health professionals was the full topic. We will follow their implicit lead and focus not only on psychiatrists but also on psychologists and social workers.
As of the year 2000, the mental health worker data indicated that there were approximately 40,000 psychiatrists, 58,000 psychologists and 155,000 social workers. While we realize that not all of these mental health professionals practice psychotherapy, there is evidence to suggest that a large number of adults receive psychotherapy from all three. The evidence comes from a national survey (Medical Expenditure Panel Survey-MEPS) which was conducted by the Agency for Health Care Research and Quality (AHRQ). The survey was based on a national probability sample of approximately 35,000 individuals in 14,000 households (An expanded description of Methods and relevant Results of our analysis of the survey data can be found in the Appendix.). The survey found that 3.2% of the adult population reported receiving psychotherapy in 1987 and 3.6% reported receiving psychotherapy in 1997 (no significant difference between years). However, visiting a medical doctor (psychiatrists were not separated out in the survey in 1997) or social worker became more common; seeing a psychologist remained the same and seeing another type of non-M.D. provider became less common. Although the “popularity” of psychotherapy (as reflected by the number of persons seeing a professional for psychotherapy) did not increase from 1987 to 1997, those receiving psychotherapy in 1997 (as compared to 1987) had significantly fewer visits (see Table 1 in the Appendix). The likelihood of psychotherapy users receiving psychotropic medication nearly doubled (31% in 1987 to 58% in 1997) (see Table 2 in the Appendix). These data, to the extent they reflect current practice, suggest that short-term psychotherapy administered by non-M.D.s combined with medication is the new trend in treatment. Since psychiatrists were not separated out from medical doctors it is likely that the increase in psychotherapy sought from M.D.s reflects an increase in use of primary care physicians. The data suggest that training M.D.s and non-M.D.s in EBT is needed if the scientific advances are to be effectively translated into scientifically sound therapeutic and preventive programs.
III. Advances in Psychotherapy
The increased availability of efficacy data on psychotherapy has largely been due to developments over the last 15 years in the specification of the essential treatment strategies in manuals and the development of programs to standardize the training of therapists providing treatment in these trials. While some practitioners in the field who received adequate training use some of these procedures, training in these procedures have not become an integral part of most educational programs (e.g., graduate school, residency). As a result, in many cases, the availability of these treatments is limited to clinical research centers where the treatment is being evaluated.
Specifying Treatment in Manuals.
At one time, the diversity of psychotherapists’ approaches to patients discouraged research on psychotherapy. Each therapist and patient was considered unique. There was no way to define what was going on in the office with a given patient. Psychotherapy was considered an art that could not be addressed by science. Treatment manuals constitute a marked departure from this thinking and a small revolution in the ability to conduct clinical trials. Manuals operationalize the procedures in that they provide technical specifications with scripts for interventions and guidelines on what should be covered (Hibbs & Jensen, 1996; Luborsky & DuRubeis, 1984). Treatment manuals can teach experienced psychotherapists to adapt their styles to a particular approach. Audiotaping or videotaping provides an objective record of how the therapist delivers the treatment allowing raters to review and score for treatment adherence. A manual can make psychotherapy a relatively uniform, and thus testable, treatment.
Manuals have become a virtual requirement for psychotherapy studies. Some studies have shown that the therapist’s degree of adherence to the manual is significantly associated with patient improvement. In order to facilitate dissemination of EBT, a list of manuals and information on how to obtain them has been compiled (Woody & Sanderson, 1998).While over 100 EBT manuals for adult psychiatric disorders have been identified (cf. Chambless & Ollendick, 2001), a large majority of them are adaptations of cognitive behavioral therapy (CBT) and to a lesser extent, interpersonal psychotherapy (IPT). The modifications were made in order to apply the treatment to a clinical presentation of a particular disorder or age group. CBT and IPT will be described later.
Training Therapists
Procedures for training therapists to administer these “manualized” treatments have been developed in order to accelerate their testing in clinical trials (Shaw et al., 1999; Weissman et al., 2000). Typically, training programs involve: (a) the reading of the manual, (b) attendance at a didactic course, (c) supervision of several cases by a clinician trained in the approach using actual video or audio tapes of the sessions, and (d) evaluation of competence. There is evidence that reading a manual alone is not a substitute for psychotherapy training and that supervised clinical experience is critical. From a practical perspective, this is best accomplished in graduate or residency programs when therapists in training are being supervised regularly. It is possible to develop well-planned continuing education programs to fill this need for practitioners in the field. A manual does not teach therapists basic psychotherapy skills such as how to listen, hear, empathize, and handle one’s own feelings and distortions. Manuals teach trained therapists a particular strategy. It is relatively easy for experienced therapists to learn specified therapies. The limitations are usually only ideologic.
Evaluating Treatments
Treatment manuals, training programs, and therapist competency criteria maximized internal validity and were necessary technologies to begin testing the efficacy of psychotherapy in controlled clinical trials.As a result of these efforts, there has been a substantial increase during the past 15 years in the number and quality of studies supporting the efficacy of several psychotherapies. These EBTs cover the full-range of psychiatric disorders. Efficacy studies evaluating treatment manuals is an essential link in determining how well a treatment works for a given disorder (cf. Chambless et al., 1998; Nathan & Gorman, 1998; Weissman et al., 2000).
The next challenge is determining how well these treatments generalize to clinical practice where patients often do not have a single diagnosis, where practitioners in the community must be used, and where training programs must be simple and cost-efficient (effectiveness research). While effectiveness research is in its infancy the existing data generated thus far support the use of EBT in clinical practice (Wade, Treat, & Stuart, 1998; Sanderson, Raue, & Wetzler, 1999; Franklin, Abramowitz, & Kozac, 2000; Tuschen-Caffier, Pook, & Frank, 2001; Antonuccio, Thomas, & Danton, 1997; Otto, Pollack, & Maki, 2000). Nevertheless, much research remains to be done to modify treatment manuals and training procedures. For example, treatment manuals must be modified to take into account comorbid diagnoses. In addition, training procedures used in efficacy studies must be modified to improve their efficiency and then the validity of streamlined training needs to be determined. This work is underway and will have considerable relevance to the psychotherapy training of practitioners in the future.
IV. An Overview of Evidence-Based Psychotherapy
Comprehensive reviews exist which have identified psychotherapies that have been specified in a manual, have specific criteria for training and competence evaluations, and have supporting data from controlled clinical trials (e.g., Chambless et al., 1998; Nathan & Gorman, 1998; Weissman et al., 2000). Chambless and Ollendick (2001) recently completed the most extensive review in that they integrated the efforts of eight workgroups (from the U.S., U.K., & Canada) focused on identifying empirically supported psychotherapies. Although the criteria used to define EBT were not the same for each workgroup, overall, the criteria used tended to be conservative. For a treatment to be defined as empirically supported by any of the workgroups, support from at least one rigorous randomized clinical trial was necessary.
Based upon Chambless and Ollendick’s (2001) “review of reviews” it is accurate to say that at least one evidence based treatment (and sometimes several) exist for the full spectrum of psychiatric disorders including:
Chemical Abuse and Dependence
Depression
Other Disorders
(Because of space limitations, many other less common disorders have been left off, see Chambless & Ollendick (2001) for a complete list).
Evidence-based psychotherapies are not efficacious for all conditions (for example, interpersonal psychotherapy has been shown to be ineffective in two clinical trials with opiate abusers). However, for several disorders psychotherapies have been shown to be as effective as psychotropic interventions (e.g., panic disorder, major depression, bulimia-nervosa). Thus, having psychotherapy available as an alternative to medication is important for patients who do not want to take medication (e.g., pregnant or lactating women), who cannot tolerate medications (e.g., side-effects, adverse reactions), as well as for patients who are not responsive to medications. For other disorders, psychotherapy is an invaluable adjunct (but not a solo treatment) to medication (e.g., bipolar disorder, schizophrenia), enhancing medication compliance, reducing residual symptoms, and decreasing relapse.
In this section we highlight data on the efficacy of specific EBT for several commonly occurring psychiatric disorders.
Depression. Both IPT (Weissman et al., 1979; Elkin et al., 1989) and CBT (cf. Glaoguen, Cottraux, & Cucherat, 1998; Elkin et al., 1989 have been shown to be as effective in reducing symptoms as psychotropic medication for acute treatment of major depression (Depression Guideline Panel, 1993). However, the onset of action is slower for psychotherapy. An amalgam of CBT and IPT (cognitive behavioral-analysis system of psychotherapy) has been shown to be effective in the treatment of chronic depression, and when combined with medication, increased the response rate from 55% to 85% (Keller et al., 2000).
Depression is associated with a high relapse rate. When administered less intensively (approximately once a month) following an acute phase of weekly treatment, both IPT and CBT have been shown to decrease the rate of relapse and recurrences (Frank et al., 1990; Jarrett et al., 1998).
Although not as extensive, controlled trials have also supported the use of IPT and CBT for the treatment of adolescent depression (Brent et al., 1997; Rosello & Bernal, 1998; Mufson et al., 1994, 1999) and late-life depression (Sloane et al., 1985; Reynolds et al., 1999).
Psychotherapy has also been shown to be an efficacious treatment for depression secondary to other problems. For example, IPT has been shown to reduce depression for depressed HIV-positive patients (Markowitz et al., 1995), and both IPT and CBT have been shown to be effective in reducing depression in patients with marital dysfunction (O’Leary& Beach, 1990; Foley et al., 1989).
Bipolar Disorder. IPT and CBT for bipolar disorder target: 1) social/interpersonal events that may be triggers or consequences of bipolar episodes (e.g., interpersonal disputes) and/or 2) mediating mechanisms (such as distorted cognitions, disrupted circadian rhythms). A social rhythm regulation component was added to standard IPT (Interpersonal and Social Rhythm Therapy – IPSRT) to address the specific issues in treating bipolar patients (Frank, Kupfer, Ehlers et al., 1994; Basco & Rush, 1995; Miklowitz & Goldstein, 1997). These treatments are considered adjuncts in combination with medication (e.g., Lam, Bright, Jones et al., 2000). The effectiveness of these psychotherapies in combination with medication for bipolar disorder is currently being tested in a large-scale, multisite study.
Anxiety Disorders. Treatment manuals based upon the principles of CBT exist for each of the anxiety disorders and include several common components: psychoeducation, cognitive restructuring, relaxation strategies, and exposure procedures. These strategies are tailored to address the specific psychopathology associated with each disorder.
There is a considerable body of evidence from controlled studies supporting the efficacy of CBT for the range of anxiety disorders (cf. Nathan & Gorman, 1998 for a comprehensive review): agoraphobia (e.g., Chambless, Foa, Groves, & Goldstein, 1979), generalized anxiety disorder (e.g., Barlow, Rapee, & Brown, 1992), obsessive-compulsive disorder (e.g., Fals-Stewart, Marks, & Schafer, 1993), panic disorder (e.g., Barlow, Gorman, Shear, & Woods, 2000), social phobia (e.g., Heimberg, Liebowitz, Hope, et al., 1998), and posttraumatic stress disorder (e.g., Foa, Rothbaum, Riggs, & Murdock, 1991).
Schizophrenia. Efficacy studies of psychotherapy for schizophrenia typically compare two or more treatments in patients who are also receiving antipsychotic medication. Psychotherapy is seen as an adjunct to medication. The focus of outcome is relapse prevention rather than symptom reduction at post-treatment. EBT of schizophrenia can best be viewed as attempts to decrease the patient’s vulnerability to relapse by remediating deficits (e.g., social skills training); increasing medication compliance (e.g., providing patients with skills to discuss side-effects with their doctor rather than just discontinuing medication); and reducing stress in the family (e.g., decreasing expressed emotion, providing problem-solving strategies for resolving family conflicts).
Social skills training can lower relapse rates in patients with schizophrenia. In a study by Hogarty, Anderson, and Reiss (1986), patients being treated with medication who received social skills training had a significantly lower relapse rate than those who received individual supportive psychotherapy (20% vs 41%). Overall, when compared to treatment as usual, behavioral, supportive, and systems based family intervention strategies were efficacious in reducing relapse rates in patients with schizophrenia (e.g., Falloon, Boyd, & McGill, 1984; Leff et al., 1985; Schooler et al., 1997). The efficacy of the various family interventions (behavioral, supportive, & systems) appear to be equivalent (Baucom, Shoham, Mueser, Daiuto, & Stickle, 1998). Indeed, the only direct comparison of two evidence-based family interventions found that supportive family therapy and behavioral family therapy were not significantly different. These findings are not surprising considering the family intervention strategies across the three theoretical orientations share many common essential treatment components (Baucom et al., 1998). There is evidence that family therapy involving the use of insight-oriented techniques and focusing on the past is not beneficial in reducing relapse (Kottgen, Sonnichsen, Mollenhauer, & Jurth, 1984) and can be associated with negative outcomes (McFarlane, Link et al., 1995).
Description of Two Evidence-Based Psychotherapies
There are a variety of psychotherapies that have been shown to be efficacious for at least one disorder. However, most are variants or modifications of two modes of psychotherapy– interpersonal therapy (IPT) and cognitive behavior therapy (CBT), which have had the most testing.
Cognitive Behavioral Therapy. CBT is based upon the premise that emotional disorders stem from distorted, negative thoughts (cognitions) and maladaptive behaviors. The theoretical and empirical source of CBT based on a cognitive model of emotional disorder and on learning theory have been discussed (Beck et al., 1975; Beck, Emery, Greenberg, 1985; Lewinsohn et al., 1986). CBT utilizes strategies to change cognitions(e.g., to reduce harsh self-criticism that may lead to depression, andcatastrophizing about events that may lead to anxiety) and behaviors (e.g., decrease phobic avoidance, increase assertiveness) related to the patient’s psychopathology. While cognitive and behavioral methods are aimed at different psychopathological processes, in fact, they have an overlapping effect (i.e., cognitive methods may produce a change in behavior, and behavioral methods may produce a change in cognition). Thus, in CBT, the therapist focuses directly on modifying thoughts and behaviors. CBT is relatively brief (usually four to eight weeks) and CBT differs from traditional forms of psychotherapy in the following ways:
Interpersonal Psychotherapy (IPT). IPT was first developed as a time-limited based treatment for depression by Klerman et al., 1984 and has been subsequently modified to deal with different types of mood and non-mood disorders (see Weissman et al., 2000 for an update). The theoretical and empirical source is based on Bowley’s attachment theory and the body of research showing the relationship loss of attachment, stressful life events and development of symptoms (Klerman et al., 1984). These clinical findings are now under investigation using modern techniques of neuroscience such as studies on the long lasting effects of stress exposure on physiology, brain structure, function, and a growing body of animal research on behavioral and biological effects on potent stressors occurring at specific point in development (Costello et al., In press). The basic premise of IPT is that, irrespective of their cause, psychiatric disorders usually occur within a social and interpersonal context. Thus, in IPT therapists teach patients to understand the relationship between the onset and fluctuation of their symptoms and current problems and to find ways of dealing with their interpersonal problems. IPT treatments differ from traditional forms of psychotherapy in a number of ways as follows:
V. Learning Evidence-Based Treatment
Results of our efforts to learn about current educational curriculum, training and continuing education as it pertains to psychotherapy will be presented. Clearly, a comprehensive review is needed.
In principle, the majority of providers of psychotherapy (i.e., social workers, psychologists, and psychiatrists) would probably agree on the necessity of providing empirical support for their interventions. The public expects to receive an effective treatment from these licensed professionals. Hence, one would expect that training programs would embrace evidence-based treatments. However, we will show that one major obstacle to the use of evidenced-based treatments is their near absence in many training programs for psychologists and social workers and in residency training programs for psychiatrists. This lag may be due in part to the recency of the evidence, although some is due to ideologic differences. Training efforts are more vigorous in Canada, Great Britain, Holland, Iceland, Germany and Spain where calls for workshops, individual training and supervision in EBT by psychiatrists, general practitioners (in Canada) and psychologists have been overwhelming. This view is based on personal experience and not systematic survey.
Residency and Graduate Training
Psychiatrists. Accreditation criteria for psychiatry residency programs set forth by the Accreditation Council for Graduate Medical Education (2000) does not emphasize training in evidence-based psychotherapy but is further along than the other professions in that CBT will be included in the new accreditation criteria. The psychotherapy criteria emphasize training toward competency in brief therapy, cognitive-behavioral therapy, combined psychotherapy and psychopharmacology, psychodynamic therapy, and supportive therapy. Thus, manualized evidence-based psychotherapies, such as those identified in clinical practice guidelines, are not emphasized and psychotherapy that has not been subjected to clinical trials testing is included. According to Dr. Lisa Mellman (personal communication, 7/2/01) who is a member of the American Association of Directors of Psychiatry Residency Training, the plan is to continue to move in the direction of defining and standardizing competency criteria rather than emphasizing training in specific psychotherapies. This approach has some value in that general therapeutic skills will be emphasized. With this background learning manualized psychotherapy is considerably easier if such a mechanism to do so was in place. We could not find any surveys of actual residency training practice in psychiatry. It will be interesting to see how these new criteria are implemented.
Psychologists. Guidelines set forth by the Committee on Accreditation (1996) of the American Psychological Association state that training should be based upon “the science of psychology” but allow programs to state their own “philosophy of training.” As a result, programs may choose to ignore evidence-based approaches that are not consistent with their philosophy of training. The guideline does not mention training in manualized, evidence based approaches as a priority, although it does note that “students should be trained in implementing intervention strategies (including training in empirically supported procedures).” Thus, while there is mention of scientifically evaluated treatments, overall, the document is vague and does not emphasize the importance of training in the specific empirically supported approaches defined above.
One would expect psychologists to be particularly receptive to EBTs since a large portion of the development and testing of these treatments was initiated by psychologists. However, a survey of clinical psychology doctoral programs and internship programs revealed that training in most EBTs is lacking (Crits-Christoph, Frank, Chambless, Brody, & Karp, 1995).
For example, two of the first-line treatments for depression listed by the AHCPR Depression Treatment Guideline, CBT and IPT, are not universally taught in graduate and internship training. Specifically, among clinical psychology internship programs – the place where clinical psychologists receive the bulk of supervised clinical experience – only 59% of programs provided supervision in CBT for depression, and a mere 8% of programs provided supervision in IPT. University doctoral programs were somewhat better, with 80% offering supervision in CBT and 16% in IPT.
Having supervision available does not mean that students are required to receive it. As a result, these numbers do not indicate that 80% of students are, in fact, receiving training in cognitive therapy. For example, based upon personal experience as a faculty member at Rutgers University, although training in cognitive therapy for depression is available, only about one-quarter of the students seek supervision in this modality. Thus, the percentages are likely an overestimation of the total number of clinical psychology students actually receiving training in these approaches.
If one examines the training in EBTs for other disorders, the numbers are even lower (Crits-Christoph et al., 1995). For example, the survey revealed that only 22% of adult focused internship sites provide supervision in IPT for bulimia and only 3% required it, 14% (2% required) in CBT for social phobia, 22% (4% required) in Exposure/Response Prevention for OCD, 25% (3% required) in family education programs for schizophrenia, 26% (4% required) in exposure treatment for phobias, and 54% (8% required) in CBT for panic disorder.
The numbers reflecting psychotherapy training students receive in graduate school are not very different from internship training: 21% provide supervision in IPT for bulimia, 19% in CBT for social phobia, 48% in Exposure/Response Prevention for OCD, 22% in family education programs for schizophrenia, 59% in exposure treatment for phobias, and 70% in CBT for panic disorder. (The survey did not ask doctoral programs to note if they required the treatment, thus those data are not available, but as noted above, the actual number of students receiving training in these approaches is likely to be considerably lower).
Since most of these treatments represent a first-line intervention for the respective disorder (with some of the treatments being the only empirically supported psychotherapy, such as exposure/response prevention for OCD), it is not as though training in that approach is being eschewed because of training in another evidence-based approach.
Social Workers. The Educational Policy from the Council on Social Work Education (1999) does not prescribe any particular curriculum for psychotherapy or counseling (Mullen, personal communication, 2001). Students are expected to become competent and effective practitioners and to evaluate research studies and apply relevant findings to their practice. There are no guidelines on including empirically based approaches in the training. Since most clinical training occurs through fieldwork, it is unlikely that students receive any training in EBTs. We could not find data on actual training in EBT or on the use of guidelines in social work graduate programs. However, the writing of Mullen & Bacon, both social workers, on the adoption and implementation of evidence-based effective treatments and quality control in social work practice are relevant (Mullen & Bacon, In press-a and b). They conducted a pilot survey of a large urban voluntary mental health/social service agency, which they stated was known for its quality of services and training. While social workers were the main providers of service, the staff included psychiatrists and psychologists. The sample survey was small (N=124) and the response rate poor so results must be viewed cautiously. A survey of a large sample of social workers that are members of the national organization is underway. In light of the absence of other data, the preliminary observations drawn by the authors are interesting. The authors focused on practice guidelines as they believed these were central to the implementation of EBT. The three mental health professions represented in this survey were strikingly different in their knowledge of practice guidelines and EBT. Psychiatrists were relatively well informed whereas social workers were poorly informed, typically not even aware of the existence of practice guidelines. Psychologists were somewhere in-between. Once told what practice guidelines were, social workers were inclined to be open to their use. Social workers generally were not using research findings or research methods in their practice. Psychiatrists and to a lesser extent psychologists were using findings and methods of assessment. Many social workers did not read the research literature or even other professional literature. Psychiatrists read this literature frequently. Social workers were heavy users of consultation, much more so than the other professionals who functioned more autonomously. Social workers frequently sought guidance from supervisors and other consultants who were viewed as repositories of knowledge based on experience. Given the low use of research methods and infrequent reading of professional literature, Mullen & Bacon conclude that it is unlikely that social work practitioners will be influenced significantly through these routes. Rather, supervisors and consultants seem to be the most promising conduit for knowledge regarding practice guidelines and other forms of evidence-based practice for social workers. Social workers appear to be open to guidelines so long as they are perceived as helping to improve practice, but their preference is for guidelines that represent professional consensus rather than research evidence. A few social work practitioners deviated from this norm, appearing to function more autonomously through behaviors similar to those of the psychiatrists in the sample. These social workers expressed preference for evidence-based guidelines and they had higher frequencies of reading research articles and professional publications. They concluded that these social workers may be important resources for dissemination of evidence-based practice knowledge within social work organizations. It is likely that their training has provided them with research skills relevant to practice. These findings, they conclude, have implications for technologies needed to assist practitioners in identification and use of evidence-based guidelines; for quality control and accountability; and for education.
Continuing Education.
No formal process exists to disseminate and train practitioners in the use of EBTs (Calhoun, Moras, Pilkonis, & Rehm, 1998). Clinicians trained ten years ago are unlikely to be up-to-date with the newer, evidence-based psychotherapies, since the data supporting EBTs have appeared in the past 10 to 15 years. Continuing Education (CE) Programs have the potential to fill this void.
Workshops are given on EBT at the annual National meetings of psychiatrists and psychologists. Periodically CE workshops outside the professional organizations are offered. However, none of the mental health groups require updated training in EBT. The decisionis left to the individual. There is no way to insure the transfer of these treatments to established practitioners or to set standards or monitor quality. Since experienced clinicians are already overworked by changes in healthcare delivery they may feel negative about yet another requirement, time burden or a possible restriction in practice.
Other obstacles to updated training exist. While there is a dearth of information on this topic, those that exist are primarily limited to psychologists but may apply to social workers and psychiatrists. For the most part practicing psychologists tend not to believe that evidence based treatments (and related procedures such as practice guidelines, structured or validated assessment procedures) are useful in their clinical practice (Addis & Krasnow, 2000; Plante et al., 1999). The most frequent reasons stated are that EBT limits creativity and does not take individual patient needs into account.
VI. Implications in the Evolving Health Care System
The gap in the transfer of EBTs from research to clinical practitioners will impact on the viability of psychotherapy as the healthcare system evolves. The National MEPS data presented above show a decrease in visits for psychotherapy and a dramatic increase in the use of psychotropic medication (see Appendix). The increasing penetration of managed care and the proliferation of clinical practice guidelines and treatment consensus statements have raised the stakes for accountability. The failure to train practitioners in EBT so that they are available to the general public may lead to the disappearance of psychotherapy as a treatment despite data supporting its efficacy.
Managed Care. Managed care organizations (or any other system monitoring the utilization and cost of service such as HMOs, captivated contracts with providers, etc.) are reshaping the practice of psychotherapy. In the traditional fee-for-service model, decisions about the cost and length of treatment were primarily functions of choices made by the doctor and patient, with the allocation of resources (i.e., cost of psychotherapy) being of less concern to the clinician. In fact, the fee-for-service model encouraged the provision of service, as more service created more income. However, in response to the increased costs of psychotherapy and, in particular, to the perceived “endless” nature of psychotherapy, managed care organizations are pressuring clinicians to allocate decreasing amounts of service.
To date, the focus of managed care organizations’ cost cutting has been almost entirely on limiting the number of sessions a patient receives. However, in order to compete, managed care organizations will also have to focus on the quality (effectiveness) of psychotherapy, as they strive to satisfy both the consumer (i.e., patient), and payer (e.g., employer providing health benefits). In essence, managed care organizations must balance their motivation to cut costs with effective clinical outcomes. Simply reducing the length of treatment may not accomplish this goal and lead in turn to both consumer dissatisfaction and increased costs down the road (as the severity of the disorder may increase and become less responsive to treatment). Thus, concern for the effectiveness of an intervention will eventually temper the managed care organizations’ focus on economics. Ultimately, managed care organizations will be interested in clinicians providing the “optimal intervention: …the least extensive, intensive, intrusive and costly intervention capable of successfully addressing the presenting problem.” (Bennett, 1992).
Clinical Practice Guidelines. Clinical practice guidelines and treatment consensus statements have also impacted upon the practice of psychotherapy. As noted by Smith and Hamilton (1994) “Guidelines are now being developed because there is a perception that inappropriate medical care is sometimes provided and that such inappropriate care has both health and economic consequences” (p. 42). Guidelines are developed to ensure that patients uniformly receive the optimal intervention (whether it is a type of medication, surgical procedure, or psychotherapeutic intervention).
The Agency for Healthcare Policy and Research (AHCPR) with the Public Health Service is a federal agency involved in clinical guideline development. Only treatments with documented efficacy from randomized controlled trials are emphasized. As a result, the recommendations of the clinical practice guidelines are quite clear. For example, consider the wording from the AHCPR guideline for Depression (Depression Guideline Panel, 1993), which states that, “[when psychotherapy is to be selected as the sole treatment], the psychotherapy should generally be time-limited, focused on current problems, and aimed at symptom resolution rather than personality change as the initial target. Since it has not been established that all forms of psychotherapy are equally effective in major depressive disorder, if one is chosen as the sole treatment, it should have been studied in randomized controlled trials.” In addition to endorsing specific treatments for depression that have sufficient empirical evidence (e.g., cognitive behavioral therapy [CBT] and interpersonal psychotherapy [IPT]), the report goes on to state: “Long-term therapies are not currently indicated as first-line acute phase treatments”(p.84).
Consensus statements are also influential in determining which treatments should be delivered. In 1991, a Consensus Development Conference on the Treatment of Panic Disorder sponsored by the National Institute of Mental Health and the Office of Medical Applications of Research, National Institutes of Health was held. The available scientific evidence from clinical trials determined the merit of various treatments (Wolf & Maser, 1994). A number of specific treatments were judged to be effective for panic disorder, including several pharmacological compounds and CBT (cf., Panic Consensus Statement published in Wolf & Maser, 1994). The Panic Consensus Statement is clearly negative on the use of treatments not supported by empirical evidence. “One risk of maintaining individuals in nonvalidated treatments of panic disorder is that misplaced confidence in the therapy’s potential effectiveness may preclude application of more effective treatment.” The statement also spells out a specific concern about the use of psychotherapies without demonstrated effectiveness for panic disorder: “The nature of the therapeutic relationship makes it difficult for the patient to seek additional or alternate treatment.”
As clinical guidelines and treatment consensus statementscontinue to emerge for a wide array of emotional disorders, they will have a significant impact upon the way clinicians practice psychotherapy. In effect, these documents set standards of care, which if ignored, leave the clinician both ethically and legally vulnerable. Health insurance companies and managed care plans are now providing their practitioners with copies of guidelines and asking that they be followed. For example, Merit Behavioral Care Corporation, in a letter to their providers (July 14, 1997), stated the following: “Consistent with national standards, the Medical Affairs Committee of MBC endorses clinical practice guidelines.” They then provided references to specific treatment guidelines created by the American Psychiatric Association for schizophrenia, major depression, substance abuse, and bipolar disorder.
Managed care and clinical practice guidelines are placing increasing pressure to deliver psychotherapies that are cost-effective and empirically supported (Sanderson, 1995). Practitioners have not been concerned about scientific testing and accountability. As practice guidelines become the “standard of care,” accountability will be essential. Ultimately, treatments without supporting efficacy data are less likely to be reimbursed (Trabin, 1994).
VII. Recommendations
This review has highlighted the progress in the specification of psychotherapy including an emphasis on time-limited treatment; development of training procedures for research; and their testing in controlled clinical trials. As a result, there is an increasing availability of evidence-based psychotherapy and an increased recommendation for their use in official guidelines and within the managed healthcare industry.
Clinical practice also is changing. While the number of persons seeking psychotherapy has not changed over the last decade, the course of treatment tends to be shorter and there has been an increase in psychotherapy provided by social workers. Unfortunately, the three mental health professional groups (psychiatrists, psychologists and social workers) who provide most of the psychotherapy have received little training in EBT, with social workers having the least exposure.As a result, there is a substantial gap between research evidence, clinical practice and graduate training in these treatments. Furthermore, there is no mandate for continuing education in EBT for practicing professionals. While workshops in EBT are held at professional meetings, their quality and content are not monitored. They are voluntary and there are no procedures for follow-up or credentialing participants. Ironically, social workers, the group that has played an increased role in providing psychotherapy during the past decade is the least likely to have training in evidence-based procedures. Thus, the gap between research and practice does not appear to be decreasing with the accumulating body of literature and proliferation of treatment guidelines. The following are our preliminary recommendations to begin to close the gap between research and the practice of psychotherapy.
Recommendation #1. There is a dearth of information on the specific content of psychotherapy training within residency (psychiatry) and graduate (psychology, social work) training programs. As a first step, we recommend that an in depth study be conducted to determine what is currently included in the respective residency and graduate training programs. What is required of trainees and what is actually achieved? Is training in EBT part of the program? If so, what is the nature and quality of this training? In order to accomplish this, program heads, faculty members, and students/residents should be surveyed to have a clear understanding of the content of training from multiple vantage points.
Recommendation #2. While there have been reviews of efficacy studies in psychotherapy, the field is moving ahead rapidly and thus, there needs to be regular, systematic evaluations of the literature to determine the latest evidence-based psychotherapeutic treatments.In addition, none of the reviews to date have been conducted with a view towards improving training or dissemination of EBT. Few studies have systematically catalogued the training and experience of the mental health professionals providing the treatment within the study. Therefore, we recommend that efficacy and effectiveness studies should be reviewed to determine the current status of EBTs. What is the state of the evidence? Have efficacy studies been replicated? How many treatments have effectiveness studies supporting their use in the field?What work is in progress? What is the level of education and training of the therapists? What is the nature of the training utilized for therapists in research studies?
Recommendation #3. With information gathered from Recommendations 1 and 2 as a background, we recommend that key decision makers in residency training and graduate programs, Deans, Department Chairs, training directors, representatives from national health care organizations and consumer groups be assembled to review the data and develop policy and strategies for implementation. Perhaps the independent Institute of Medicine (IOM) could convene this group to review the data; develop a consensus as to steps needed to implement training in EBT; including plans for training material and a model curriculum.
Recommendation #4. Policy about CE requirements should focus on developing continuing education requirements in EBT for professionals. The following questions must be addressed. What format should the training include? What competency requirements and credentialing are needed? These decisions need the involvement of major professional organizations as well as the national and international organizations that have emerged around the leading EBTs (e.g., The Academy of Cognitive Therapy & International Society for Interpersonal Psychotherapy are developing competency criteria).
Recommendation #5. While the actual core curriculum for training in EBT will need to be determined by each discipline,in addition to training in the clinical application of EBTs, a core curriculum should include information on the method for systematic assessment of the patient’s signs, symptoms and diagnosis (e.g., use of reliable and valid symptom rating scales); information on how treatments are tested so that practitioners can evaluate the validity of new treatments as they emerge; information on how treatment manuals are developed; the indications and contraindications for the various EBTs; current treatment guidelines so that clinicians know what treatments are recommended by expert panels; and current efficacy data so that clinicians can learn to evaluate the quality and strength of the supporting studies. For the non-medical clinician, information on psychotropic medication and indications for referrals for evaluation and treatment should be included.
Some attention should be given to specialty psychotherapy training in residency and graduate training programs. For example, a psychiatry resident interested in molecular genetics, a social work student in community action or a psychology student in experimental testing may get an introduction to content whereas trainees who specialize in patient/client treatment would get more intense training and supervision in EBT.
We realize that mental health specialty is only a portion of social work practice. However, social workers come into contact with large numbers of people who have comorbid mental health problems where appropriate identification and possible referral for treatment may be most useful.The amount of psychotherapy provided by social workers is increasing and we expect this trend will continue. Yet social workers have the least training in evidence based procedures. In light of these trends we recommend that special attention be given to social work education.
Recommendation #6. With regard to actual training, we recommend that the general core therapeutic skills of EBT continue to be taught in residency and graduate programs. This content is only informally taught in social work graduate school during supervision. Therefore, the content and quality of social work supervision needs to be reviewed and some shortening of fieldwork might accommodate the new material. Once core evidence-based psychotherapy skills have been taught, training in specific EBTs should be initiated, especially for commonly occurring disorders. In order to accomplish this, it makes sense to follow the training procedures developed for research protocols. These include reading the manuals, didactic review of material, and case supervision using video or audiotapes. In light of the psychotherapy recommendations from a variety of independent clinical practice guidelines, we tentatively recommend that the core training include CBT and IPT. Training in the various adaptations of these treatments, as well as other specific behavioral techniques, family interventions, and group methods could be added for practitioners who want to specialize in psychotherapy.
VIII. Concluding Comments
We realize that this new material may appear to overburden already compact training programs and will require some modification of current training. Also, clinicians already dealing with the restrictions on their practice may find these recommendations just another added We also realize that the gap is in part due to the recency of the data and to the many pressures training programs have had to deal with as a result of the changing health care environment. However, findings such as those by Goisman et al. (1999) showing that the use of evidence based procedures have not increased over a ten year period, despite a substantial amount of supporting data and the proliferation of treatment guidelines, are quite disappointing and suggest that a more deliberate intervention is necessary if we are going to close the gap between research and practice. Moreover, the increased penetration of managed care and the proliferation of guidelines will increase accountability. The failure to increase EBT and to train clinicians so that these treatments are available to the public could lead to the disappearance of psychotherapy as a treatment.
Acknowledgements
The authors appreciate the help of Drs. Lisa Mellman, Ronald Reider, Edward Mullen and Mark Olfson, who provided information on training and clinical practice and Marc Gameroff who analyzed the Medical Expenditure Panel Survey data and prepared the Appendix for this paper. All are from Columbia University. We have tried to be as objective as possible in presenting our views but since our backgrounds could color our views we want to openly describe them. William Sanderson is trained in clinical psychology; is on the psychology faculty at Rutgers University and has a private practice. Myrna Weissman is trained as a social worker and an epidemiologist; is on the psychiatry and public health faculty at Columbia University and is a developer of interpersonal psychotherapy.She does not have a private practice.
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APPENDIX
Psychotherapy Use in the U.S. Civilian
Non-institutionalized Population in 1987 and 1997
Marc J. Gameroff
Myrna M. Weissman
This appendix presents an analysis comparing psychotherapy usage in the U.S. in 1987 and 1997. The data sources are the Household Components of the 1987 National Medical Expenditure Survey (NMES) and the 1997 Medical Expenditure Panel Survey (MEPS), two national probability surveys conducted by the Agency for Healthcare Research and Quality (AHRQ) on the financing and utilization of health care services in the U.S.Both surveys are designed to provide statistically unbiased estimates of utilization by the civilian non-institutionalized population of the U.S in a single calendar year. NMES was conducted in 1987 only, and MEPS has collected data continuously since 1996. Public use data files for calendar year 1997 were recently released and were used for the current analysis. Detailed information about sampling, survey design, reporting sources, and survey items related to demographics, health status, and health care utilization, are available in print form for NMES (e.g., Cohen, DiGaetano, & Waksberg, 1991; Edwards & Berlin, 1989) and on the World Wide Web for MEPS (e.g., AHRQ, Jan., Feb. 2001). An excellent introduction to MEPS can be accessed at http://www.meps.ahrq.gov/whatis.htm.
Analysis
Rates of Psychotherapy Use
The percentage of the population receiving psychotherapy in 1987 and 1997 was on average 3.4%, with no significant difference between years (see Table 1). However, visiting a medical doctor or social worker for psychotherapy became more common, and seeing another type of non-M.D. provider became less common. Although the overall “popularity” of psychotherapy did not decrease, those receiving psychotherapy in 1997 had fewer visits. This trend was essentially limited to therapy provided by psychologists and other non-M.D.’s. However, visiting another type of non-M.D. provider was also less common in the population in 1997, while psychologists provided therapy to an equal proportion of the population in 1987 and 1997.
Table 1. Percentage of the Civilian U.S. Population With Psychotherapy Usea, and Mean Number of Visits Per User, 1987 and 1997
% With
Psychotherapy Use
Mean Number of
Visits Per User
Psychotherapy Provider Typeb
1987
(N=34,459)
1997
(N=32,636)
1987
(n=993)
1997
(n=1,136)
Medical doctor (M.D.)
1.6
2.3****
4.0
3.9
Psychologist
1.1
1.3
3.4
2.5*
Social worker
0.3
0.5*
0.7
1.2
Other non-M.D.c
0.9
0.5***
2.7
1.3**
Any provider type
3.2
3.6
10.8
8.9*
Note. Figures are national estimates based on weighted data from the 1987 National Medical Expenditures Survey (NMES) and the 1997 Medical Expenditure Panel Survey (MEPS). SUDAAN software was used to account for the complex survey design. Year effects are tested with c2analysis (% with psychotherapy use; df = 1) or linear regression (mean number of visits per user; df = 1).
aPsychotherapy users were those who made at least 1 visit to a provider in an office-based practice or a hospital outpatient unit where “psychotherapy/mental health counseling” was the main reason for the visit (NMES) or where “psychotherapy/counseling” was among the services received (MEPS). bRows labeled with particular provider types are not mutually exclusive, as a portion of psychotherapy users (16.4% in 1987 and 23.6% in 1997) saw more than 1 provider type. cThe most commonly given titles included: “therapist,” “counselor,” “mental health counselor,” “occupational therapist,” “physical therapist,” and “nurse/nurse practitioner.”
*P < .05. **P < .01. ***P < .001. ****P < .0001.
Rates of Receiving a Psychotropic Medication
While for psychotherapy users the mean number of visits decreased between 1987 and 1997, the likelihood of receiving a psychotropic medication almost doubled, from 31% in 1987 to 58% in 1997 (see Table 2). Naturally, this trend was pronounced among individuals receiving psychotherapy from medical doctors (47% in 1987 to 71% in 1997), however rates also increased sharply for individuals seeing psychologists, social workers, and other types of non-M.D. providers, from about 25% in 1987 to 50% in 1997. Among those in the population who did not receive psychotherapy, the likelihood of receiving a psychotropic prescription was below 7% in both years but showed a statistically significant increase.
Table 2. Percentage of the Civilian U.S. Population With At Least One Psychotropic Prescription During the Year, Among Psychotherapy Usersa and Non-Users, 1987 and 1997
Psychotherapy Use and Provider Typeb
% Receiving
Psychotropic Rx
1987
1997
Received psychotherapy…
…from a medical doctor
46.5
71.4****
…from a psychologist
24.9
47.3****
…from a social worker
27.6
54.2**
…from another type of non-M.D.c
24.9
52.1****
…from any provider type
31.2
58.1****
Did not receive psychotherapy
5.5
6.8****
Note. Figures are national estimates based on weighted data from the 1987 National Medical Expenditures Survey (NMES) and the 1997 Medical Expenditure Panel Survey (MEPS). SUDAAN software was used to account for the complex survey design. Year effects in this table are tested with c2 analysis (df = 1).
aPsychotherapy users were those who made at least 1 visit to a provider in an office-based practice or a hospital outpatient unit where “psychotherapy/mental health counseling” was the main reason for the visit (NMES) or where “psychotherapy/counseling” was among the services received (MEPS). bRows labeled with particular provider types are not mutually exclusive, as a portion of psychotherapy users (16.4% in 1987 and 23.6% in 1997) saw more than 1 provider type. cThe most commonly given titles included: “therapist,” “counselor,” “mental health counselor,” “occupational therapist,” “physical therapist,” and “nurse/nurse practitioner.”
*P < .05. **P < .01. *** P < .001. ****P < .0001.
Demographic Characteristics of Psychotherapy Users
The demographic profile of psychotherapy users in the U.S. did not change considerably between 1987 and 1997 (see Table 3). For instance, the ratio of females to males was roughly 3:2, and the racial/ethnic distribution of users was fairly stable within and across provider types. Across years, the vast majority (86%) of users were non-Hispanic Whites, and about two-thirds of users were middle to high income. However, the average user in 1997 was somewhat older, with this trend most pronounced among people who saw medical doctors and social workers. In 1997, psychotherapy users had more public and less private health insurance coverage, which was reflected sharply among those who saw psychologists. Psychologists were also the only provider group to be seeing a increased percentage of lower-income clients in 1997.
Payment Sources for Psychotherapy Visits
Out-of-pocket payments for psychotherapy decreased between 1987 and 1997, with the mean proportion dropping from 51% in 1987 to 37% in 1997 (see Table 4). The proportion paid by private insurance sources went from 29% to 35%, and the public insurance share rose from 20% to 28%. Medical doctors were the only provider type whose psychotherapy services received a reliably higher proportion of private insurance payments in 1997. Services by psychologists and other non-M.D. providers showed the most robust increase in proportion of payments made by public insurance sources.
Table 3. Demographic Characteristics of Psychotherapy Usersa in the Civilian U.S. Population, 1987 and 1997 Visitors to
All ProvidersVisitors to
Medical DoctorsbVisitors to
PsychologistsbVisitors to
Social WorkersbVisitors to
Other Non-M.D.’sb,c Characteristic1987
(N=993)1997
(N=1,136)1987
(n=502)1997
(n=756)1987
(n=313)1997
(n=379)1987
(n=86)1997
(n=135)1987
(n=275)1997
(n=169)Age (%)****** **** 0-1721.718.716.918.123.421.228.615.822.814.9 18-4456.950.955.245.860.055.461.751.959.660.8 45-6417.525.921.329.715.221.77.830.215.622.3 65+3.84.56.76.41.41.81.92.12.02.0 Gender (%) Female60.159.459.859.962.960.453.264.860.964.8 Male39.940.640.240.137.139.646.835.239.135.2 Race/ethnicity (%) Hispanic4.86.26.56.24.24.65.38.62.95.9 African Am., non-Hisp.6.06.98.67.34.45.33.91.76.09.2 White, non-Hisp.87.385.883.185.989.988.786.489.887.983.4 Other, non-Hisp.1.91.11.80.61.51.44.50.03.21.5 Marital status (%) Married47.945.245.547.347.843.147.343.347.436.8 Single/Sep/Div/Widow52.154.954.552.752.256.952.756.752.663.2 Health insurance (%)d** ****** Private77.770.573.168.286.471.581.974.971.464.1 Public only15.021.020.225.09.718.111.216.218.326.6 None7.38.66.86.83.910.56.98.910.49.3 Family income (%)e ** Poor to low income32.033.736.638.323.131.526.030.941.537.2 Middle to high income68.066.463.461.776.968.574.069.158.562.8
Note. Figures are national estimates based on weighted data from the 1987 National Medical Expenditures Survey (NMES) and the 1997 Medical Expenditure Panel Survey (MEPS). SUDAAN software was used to account for the complex survey design. Year effects in this table are tested with c2 analysis (df = number of categories of the demographic characteristic – 1). Significant year effects are underlined.
aPsychotherapy users were those who made at least 1 visit to a provider in an office-based practice or a hospital outpatient unit where “psychotherapy/mental health counseling” was the main reason for the visit (NMES) or where “psychotherapy/counseling” was among the services received (MEPS). bColumns labeled with particular provider types are not mutually exclusive, as a portion of psychotherapy users (16.4% in 1987 and 23.6% in 1997) saw more than 1 provider type. cThe most commonly given titles included: “therapist,” “counselor,” “mental health counselor,” “occupational therapist,” “physical therapist,” and “nurse/nurse practitioner.” sup>dPrivate = any private insurance coverage during the year; Public only = any public insurance coverage during the year (no private coverage all year); None = no private or public coverage throughout the year. ePoor to low income = Below poverty line to less than 200% of poverty line; Middle to high income = 200% or more above poverty line.
*P < .05. **P < .01. ***P < .001. ****P < .0001.
Table 4. Average Proportion of Psychotherapya Expenditures Paid Out of Pocket and By Private and Public Insurance Sources, 1987 and 1997 All VisitsVisits to
Medical DoctorsVisits to
PsychologistsVisits to
Social WorkersVisits to
Other Non-M.D.’sbPayment Source1987
(N=10,112)1997
(N=10,010) 1987
(n=3,730)1997
(n=4,541)1987
(n=2,964)1997
(n=2,865)1987
(n=676)1997
(n=1,166)1987
(n=2,742)1997
(n=1,438)Out of pocket (%)c50.937.4****47.033.9****53.539.4***52.539.853.140.1*Private insurance (%)28.535.1**24.934.0***31.938.128.235.627.127.2Public insurance (%)19.727.6***26.532.114.422.5*19.324.618.332.7**
Note. Figures are national estimates based on weighted data from the 1987 National Medical Expenditures Survey (NMES) and the 1997 Medical Expenditure Panel Survey (MEPS). SUDAAN software was used to account for the complex survey design. Year effects in this table are tested withc2 analysis (df = 1). Some columns do not sum to 100% because of rounding error.
aPsychotherapy users were those who made at least 1 visit to a provider in an office-based practice or a hospital outpatient unit where “psychotherapy/mental health counseling” was the main reason for the visit (NMES) or where “psychotherapy/counseling” was among the services received (MEPS). bThe most commonly given titles included: “therapist,” “counselor,” “mental health counselor,” “occupational therapist,” “physical therapist,” and “nurse/nurse practitioner.” cProportion paid by self or family.
*P < .05. **P < .01. ***P < .001. ****P < .0001.
References (for the Appendix)
Agency for Healthcare Research and Quality (Jan. 2001). Content Summary of the Household Interview. AHRQ Publication No. 01-P006. Rockville, MD. CA. http://www.meps.ahrq.gov./factsheets/fs_summhcintv.htm
Agency for Healthcare Research and Quality (Feb. 2001). MEPS Fact Sheet. Rockville, MD. http://www.meps.ahrq.gov/whatismeps/bulletin.htm
Cohen, S., DiGaetano, R., and Waksberg, J. (1991). Sample Design of the 1987 Household Survey. National Medical ExpenditureSurvey Methods 3. Agency for Health Care Policy and Research, Publication No. 91-0037. Rockville, MD: Public Health Service.
Edwards, W. and Berlin, M. (1989, September). Questionnairesand data collection methods for the Household Survey and the Survey of American Indians and Alaska Natives (DHHS Publication No. PHS-89-3450). National Medical Expenditure Survey Methods 2, National Center for Health Services Research and Health Care Technology Assessment. Rockville, MD: Public Health Service.