Therapy Without Therapists

Americans have been getting sadder and more anxious for decades, and the economic recession and social isolation from COVID-19 have accelerated these trends. Despite increased demand for mental health services, those who seek treatment can’t get it. Most people seeking care overwhelmingly prefer psychotherapy over medication, yet they are more likely to be prescribed an antidepressant, often from their primary care provider.

The reasons are fairly obvious. Therapy is expensive. Private insurance companies don’t want to pay for unprofitable, long-term services provided by highly skilled (i.e., high-priced) professionals. When insurance companies do reimburse therapists for their services, they do not pay a living wage. Nor can therapists afford the prohibitive barriers to managing insurance claims—therapists report that most of their patients pay out-of-pocket for therapy or receive minimal insurance coverage for mental health services. When healthcare is privatized, socially useful services are scarce or nonexistent. The solution is equally obvious. Healthcare should be a universally-available public good.

Unsurprisingly, the healthcare industry has reframed this straightforward problem and its straightforward solution to turn a profit. According to industry leaders, the problem is not that a market-driven healthcare system unequally distributes much-needed care. Rather, the problem for them is that the provision of mental health services is not entirely subsumed by capital’s law of motion. Mental healthcare, by their logic, ought to be further scientifically managed to cut costs and increase efficiency.

Due to the economic imperatives of the system, clinical scientists and health service researchers have done their part to rationalize this logic. Designing brilliant studies, these scholars tell industry leaders what they want to hear—that the future of mental healthcare means fewer clinicians, less care, and more automation. At the National Institute of Mental Health Services Research Conference in 2018, Gregory Simon, a psychiatrist and public health scholar for Kaiser Permanente, warned of the coming transformations in the delivery of mental healthcare:

While the fourth industrial revolution has been transforming commerce and industry, and most of science, mental health services remain confidently ensconced in 19th century Vienna [displays an image of Sigmund Freud]. But not for long. The revolution is coming to us.

According to Simon, the fourth industrial revolution will involve the intensification of the division of labor through methods such as task-shifting and the widespread use of digital technologies. Dr. Simon prophesied that mental health “consumers” will soon ask their voice-activated devices: “Alexa, should I increase my dose of Celexa?” Dr. Simon needn’t have looked too far into the future. The transformations he anticipated have already radically reshaped the provision of mental healthcare—a revolution that has transpired behind the backs of both therapist and patient alike.

The Division of Labor in Mental Healthcare

In the past several decades, healthcare in the US has increasingly resembled an assembly line, with the labor process atomized into its component parts and assigned to different workers. Task-shifting is the preferred term by health service researchers for this increasing division of labor. It refers specifically to the process by which tasks from professionals with higher qualifications are delegated to those with fewer qualifications or to a new cadre of employees trained for the specific healthcare service. Recently clinical tasks have not just been passed on to lesser-skilled workers, but also to lay people and even to patients themselves. (...)

Task-shifting is already the norm in medicine and is only increasing as the US faces a shortage of physicians. It is common for patients to visit their doctors and have their body weight and blood pressure measured by medical assistants, to have their blood drawn by phlebotomists or nurses, and to have their responses to physicians’ questions be recorded by medical scribes. This increased division of labor means that physicians only work at the top of their degree qualifications and lesser-skilled workers perform simple clinical tasks at a lower cost. For fairly routine visits, like yearly check-ups, physicians are increasingly being replaced by physician assistants. According to the US Bureau of Labor Statistics, the median annual salary of a physician assistant is $112,260 whereas the median salary of a physician is $208,000. It is no wonder that as health systems Taylorize medicine, physician assistants are one of the fastest growing professions in the country.

To further deskill laborers and make them appendages to machines, biotechnology firms have developed products that automate these routine clinical tasks (e.g., blood pressure monitors, automatic brain scan image processors, etc.). Under a scientifically managed healthcare system, healthcare services are spread across many hands, reducing continuity of care. The proliferation of non-physician medical roles decreases total compensation for healthcare workers, but most importantly this increased fragmentation often reduces the quality of care, putting patients at risk. (...)

Due to the financial incentives introduced by the managed care system, psychiatrists—who earn an average of $220,430 per year after eight years of medical training—rarely conduct psychotherapy and devote most of their time to disseminating psychopharmacological treatments. They have been replaced by a cheaper labor force of lesser-educated clinicians. The majority of psychotherapy is now provided by clinical social workers, who receive two years of graduate training and earn an average annual salary of $50,470, followed by a long distance by clinical psychologists, who attend five to seven years of school and earn an average annual salary of $87,450. (...)

The Rise of Community Health Workers

The latest “innovation” to deskill mental healthcare workers has been to displace professionals entirely. Researchers have increasingly propagated the effectiveness of training lay people to provide brief therapy in lieu of licensed mental health providers. Though the stated rationale for training non-professionals, termed community health workers, is to integrate knowledge from traditional healers and communities to provide culturally competent care, their real function is to cut labor costs and put money back in the hands of corporate hospital chains. (...)

Community health worker models often draw inspiration from volunteer programs formed in resource scarce, low-and-middle-income countries in response to the lack of public or private infrastructure for mental healthcare. For example, one of the most revered volunteer community health worker models, Nepal’s Female Community Health Volunteer (FCHV) program, has been widely lauded for its expansive base of over 50,000 volunteers who offer counseling and necessary health services to women and families across the country. The FCHV is partly responsible for Nepal’s sharp declines in child and maternal mortality rates, and the public hospital system has integrated these exemplary volunteers into their service model.

However impressive the work of these women, it should go without saying that they should be adequately remunerated. Further, if they are providing essential health services, the care they provide should be incorporated into the public health system, not contingent upon a reserve army of volunteers. As several social scientists have noted, attempting to import public health models from resource-scarce contexts to high-income countries is ethically dubious, particularly if the model hinges on the exploitation of an unpaid workforce. The US has the necessary infrastructure and resources to adequately hire and compensate professionals. The imposition of scarcity and cheap labor in the US is a policy decision, not a rational response to real material constraints.

by Briana Last, Damage |  Read more:

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