Demanding Better Psychotherapy

Psychotherapy is undergoing a veritable revolution.  And if you're not paying attention, you could miss opportunities to change attitudes, spend less, and save lives.

For nearly a century, the field of psychotherapy (which includes cognitive behavioral therapy and other modalities common in the treatment of chronic pain) has been deemed a subjective and ethereal art based on human relationships, perception of progress, and patient self-reported outcomes. Therapists argued such things couldn't be measured, objectified, or codified.  This feels intuitive to most of us - how can the assessment and treatment of behaviors, thoughts, emotions, and reactions be reduced to mere data points, bar graphs, or pie charts.  Contemporary medical evidence appears to suggest these modalities are efficacious and that's sufficient for most of us to accept the status quo in the field.

The latest issue of The Atlantic Monthly contains an article by Tony Rousmaniere, What Your Therapist Doesn't Know.  Recognize that last name?  Only after reading the article and penning the first draft of this post did it occur to me to reach out to the estimable Peter Rousmaniere to ask if Tony was any relation.  In fact, Tony is Peter's oldest son.  I should have guessed.

In the article, we learn about feedback-informed treatment (or FIT).  In a space where 25 percent of patients drop out of therapy (likely higher among chronic pain cases, but that's just a guess on my part) and 5 to 10 percent of patients actually get worse during the course of treatment, wouldn't it be nice to be able to quantify, and perhaps even predict, patient progress?  Turns out, over 50 different (and, I suppose to some extent, competing) feedback systems have been developed over the past 20 years.  Most involve detailed questionnaires administered to patients and designed not only to measure progress, but also to help therapists identify blind spots (like when a patient might be offering less than truthful feedback directly to the therapist... or about to drop out of treatment... or getting worse).  One such feedback system was able to predict - with 85% accuracy and after only three sessions of therapy - which patients would deteriorate.  

New medical technologies, practice techniques, and methodologies can take a long time to be adopted into every day clinical application.  Rousmaniere discusses the history of the thermometer - at one point, taking a patient's temperature and using that data as a tool in diagnosis was considered heretical and potentially dangerous to the practice of medicine (in that it might make doctors lazy and dull their skills as diagnosticians).

The time has clearly come for injecting data, metrics, and objective performance feedback into psychotherapy.  And since payers are hearing the constant drum beat of "psychosocial... mental health... CBT...", the thought occurs to me that the least we can do, if we're going to pay for this apparently efficacious intervention, is demand feedback-informed treatment for injured workers.  We would demand no less in virtually every other area of medicine.

Why settle here?

Michael
On Twitter @PRIUM1

The Opposite of Addiction is Not Sobriety

At the close of the blogger panel in Dana Point last week, Mark Walls asked each of the panelists what we thought needed to change in workers' compensation.  There's a lot of potential material there, I know.  And my co-panelists - David DePaolo, Bob Wilson, and Tom Robinson - all offered great suggestions that included more meaningful engagement with injured workers and simplifying the system with the aim of focusing on what matters most.

I took the "personal soap box" approach to answering the question.  Here's what I said (actually, here's what I meant to say):

I think that we, in workers' compensation, will spend the next 10 years paying for the sins of the last 10 years.  While we may have a (slightly) better handle on medication management for new injuries today, we spent the last 10 years paying for too many drugs to be given to too many patients.  And, as a result, for the next 10 years, we're going to be looking straight into the abyss of addiction.  

We better learn how to deal with it because ignoring it is neither a clinical nor an economic option for payers.  Payers didn't write the prescriptions, but they did pay for them.  Resulting cases of dependence and addiction are natural extensions of medication treatment that long ago ceased to have any chance of resolving the underlying injury, but has instead led to a life (if you can call it that) completely consumed by the need for more drugs.

I don't have a silver bullet solution to offer here.  This is going to be hard and it's probably going to be expensive.  But if we do it right, as an industry, we can create models for how other systems (group health, municipalities, even countries) approach the issue.

Here's a place to start:
http://www.ted.com/talks/johann_hari_everything_you_think_you_know_about_addiction_is_wrong
My colleague, Scott Yasko, sent out a TED talk on addiction that I found fascinating.  Leave the political questions aside for a moment (the speaker, Johann Hari, offers some interesting thoughts on decriminalization, but don't get distracted by that...) and focus instead on the underlying psychosocial argument he's making.  (I should also acknowledge that Hari has a checkered past as a journalist, but his thoughts here are well-researched and profound... and presumably his own).  If you stick with it until the end, you'll hear him conclude:

"The opposite of addiction is not sobriety.  The opposite of addiction is connection."  

Does that make you think differently about how we might approach the issue of addiction in workers' compensation?

Michael  
On Twitter @PRIUM1

A Lesson in Chronic Pain Management from Friedrich Nietzche

"He who has a why to live for can bear with almost any how."  

I bet you've never seen a Friedrich Nietzsche quote in a work comp blog post before.  I came across this in a book recently, but I've also seen it plastered on social media and an occasional wall poster. Leaving aside for a moment the fact that the quote is almost always taken out of context (Nietzsche wasn't exactly the most uplifting philosopher of the 19th century), the quote still offers insight into the most difficult and frustrating dynamic of chronic pain management: 

The psycho-social disposition of the injured worker.  

How can we ask injured workers to take fewer pain meds... how we can ask them to engage in non-pharmacological therapies... how we can ask them to go through the weaning process... how can we ask them to contemplate a life that might not be totally pain free... if they lack the why.  If they don't have a job they're excited to get back to... if they don't have a supportive family or social environment... if they haven't worked through the devastating and often latent effects of childhood trauma... if they haven't dealt with co-morbid conditions like depression and obesity... then how can we ask them to change?   

No structure can be rebuilt on a faulty foundation.  And the life of a chronic pain patient cannot be rebuilt without addressing the underlying cause of the chronicity.

So what do we do?  Massachusetts has outlined a pretty compelling approach to addiction prevention and treatment in that state.  The Governor's Opioid Working Group has put together a comprehensive document built around 12 core principles (the detail behind each is contained in the document):

1. Create new pathways to treatment
2. Increase access to medication-assisted treatment
3. Utilize data to identify hot spots and deploy appropriate resources
4. Acknowledge addiction as a chronic medical condition
5. Reduce the stigma of substance use disorders
6. Support substance use prevention education in schools
7. Require all practitioners to receive training about addiction and safe prescribing practices (see my post from Monday on this topic)
8. Improve the prescription monitoring program
9. Require manufacturers and pharmacies to dispose of unused prescription medication
10. Acknowledge that punishment is not the appropriate response to a substance use disorder
11. Increase distribution of naloxone to prevent overdose deaths
12. Eliminate insurance barriers to treatment     

Are you thinking "this is intended for a group health / medicaid audience in the state of MA"?  Think again.  Most, if not all, of these principles should apply to us in workers' compensation.  If we don't get serious about treating the whole individual, we'll have little hope of making progress in the fight against prescription drug misuse and abuse. 

Michael 

On Twitter @PRIUM1