Therapy Without Therapists

Task-shifting, manualized treatment, community health workers, digital therapy—the fourth industrial revolution for mental healthcare is already here. Unsurprisingly, it’s bad for both therapists and patients.

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.

Whether referred to as the division of labor or task-shifting, the effect of this atomization is the same: it cheapens labor power. As Harry Braverman describes in Labor and Monopoly Capital: “Translated into market terms, this means that the labor power capable of performing the process may be purchased more cheaply as dissociated elements than as a capacity integrated in a single worker.”

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.

Medicine had a head-start, but mental healthcare has also been radically transformed by an increasing division of labor and the cheapening of the labor force. The dawn of the neoliberal era ushered in dramatic changes to healthcare that had a profound impact on psychotherapy. Broad political-economic shifts in the provision of mental healthcare starting as early as the 1950s transitioned the delivery of psychotherapy from publicly-funded state psychiatric hospitals to private, for-profit hospital chains. The advent of managed care—institutional arrangements developed in the 1970s to ration healthcare—and the production of pharmacological treatment reshaped the mental health workforce and introduced the imperative to cut costs and prescribe psychiatric medications in lieu of psychotherapy.

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.

As with other task-shifting transformations in healthcare, this enables psychiatrists to work at their highest degree qualification (prescribing drugs) with lower-earning social workers and clinical psychologists performing what is considered to be simpler labor (therapy). The intensification of the division of labor means that fewer high-paid psychiatrists are needed to offer mental health services. Here, again, Braverman is instructive, for he perceptively articulates the rationale of this intensification:

In the mythology of capitalism…[this] is presented as an effort to ‘preserve scarce skills’ by putting qualified workers to tasks which ‘only they can perform,’ and not wasting ‘social resources.’ It is presented as a response to ‘shortages’ of skilled workers or technically trained people, whose time is best used ‘efficiently’ for the advantage of ‘society.’

Manualized Treatments

Strategies to further scientifically manage mental healthcare and deskill therapists have steadily increased in recent decades. When managed care accelerated the drive to increase profits and cut healthcare costs, the evidence-based practice movement, a group of researchers and clinicians, emerged to rationalize these measures. Rather than demanding that treatment length be determined by patient needs in lieu of artificially capping sessions to save money, mental health researchers felt compelled to accept the constraints of a privately-rationed health system and developed brief, sometimes single-session therapies. Many of these often well-meaning, scientists justified setting their sights lower by invoking patients’ preferences for a quicker fix than psychoanalysis.

The development of these time-limited therapies signaled to insurance companies that brief therapy is not only good enough, but scientifically proven. The evidence-based practice movement has proven lucrative for insurers. In the past several decades, despite growing treatment demand, the mean number of psychotherapy visits has declined, in large part because insurance companies are unwilling to reimburse for longer term therapy services.

One of these evidence-based practice pioneers was Aaron Beck, the developer of cognitive behavioral therapy. In the 1960s Beck began developing a manualized treatment for the study of his recently developed cognitive therapy for depression and conducted the first multi-site randomized controlled trial of psychotherapy in the mid-1970s. Since then, brief, symptom-focused, manualized psychotherapy treatments have become the dominant form of therapy offered by clinicians.

Manuals view the role of therapists as adhering to a set of protocolized techniques and interventions—much like a surgeon operating on a patient—rather than viewing the therapeutic relationship itself as the intervention. Indeed, beyond significantly reducing the duration of services, manualized therapy can often take a medicalized form, rather than a humanistic engagement with patients’ problems in living. Just as mental health services are now atomized into their constitutive elements, patients learn to view themselves as composed of a collection of symptoms they must manage, rather than whole people navigating an alienating world.

To be sure, manualized protocols play an important role in mental healthcare. Standardizing practice for the sake of study in randomized controlled trials makes it possible to evaluate whether clinical techniques merely work due to placebo effects or due to hypothesized mechanisms of therapeutic change. To help those who suffer from psychological distress, clinicians can leverage scientific research to inform their diagnostic decision-making and treatment planning. Moreover, a welcome number of relationship-focused manualized therapies (such as transference-focused therapy, mentalization-based treatment, and Child-Parent Psychotherapy) have jettisoned the mind-body dualism of older manualized treatments. Nevertheless, manualized treatments are granted an outsized place in the provision of care and graduate training. Though scientific discoveries of average group effects will never be the advertised panacea for complex and individually specific human problems, graduate training programs increasingly emphasize teaching manualized psychotherapy treatments at the exclusion of all other forms of clinical practice. Predictably, insurance companies often refuse to pay for more open-ended, relational psychotherapy.

In terms of its effect on workers, manualizing therapy has the effect of reducing therapists’ control over their work, rendering them instruments in a process rather than co-creators of it with their patients. New data suggest that reducing therapists’ autonomy is associated with therapist burnout, reduced engagement by patients, and worse treatment. Stripping therapists of skill and autonomy has only reduced the quality of mental healthcare, undercutting attempts by even the most well-meaning researchers to improve therapy with science.

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.

As Gordon Lafer succinctly puts it in his 2017 book The One Percent Solution: How Corporations are Remaking America One State at a Time: “Licensing requirements limit the supply of skilled labor and enable licensed tradespeople to command higher wages.” This is why, as Lafer goes on to describe, the American Legislative Exchange Council—one of the most powerful corporate lobbies in the country—has attempted to gut professional licensure and certification requirements for the past ten years.

Researchers and health systems are very explicit about the need to fill in the gaps in service demands not provided by a market-driven health system and their desire to devalue (and eventually replace) licensed psychologists and psychiatrists who train for years to acquire degrees and licensure requirements. Arguing for the cost-effectiveness of training lay people, public health scholars Drs. Prabhjot Singh and Dave Chokshi argue, “Employment of CHWs [community health workers] creates meaningful job growth for people with lower educational attainment…From the perspective of a health system, CHWs may be a bargain, with mean annual pay of about $37,000 in 2012.”

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.

Even when community health workers are not volunteering their time, they are not sufficiently compensated or supported. Studies of community health workers show they are often inadequately trained, distressed, overburdened, and underpaid for their demanding work. Based on evidence from across a host of randomized controlled trials, lay counselors offer relatively minimal improvements for patients compared to usual care. The comparative effectiveness of community health workers and licensed mental health professionals remains an open question, though data suggest that years of training are related to quality of care. After undertaking an ambitious systematic review of community mental health workers, public health scholars noted that task-shifting cannot be an “outright solution” to shortages of mental health specialists. They concluded that rather than hiring cheap and unskilled labor, governments should publicly invest in mental healthcare.

From Analyst to Algorithm

Another prong in the fourth industrial revolution in mental healthcare, per Dr. Simon’s warning, is the development of digital health technologies. These technological developments further the process of making therapists obsolete, or at the very least accelerate the pace at which mental health workers have become mere appendages to machines. Over the past several years venture capital has invested hundreds of millions of dollars in direct-to-consumer digital mental health technologies that offer self-directed meditation and mindfulness exercises, text-based therapeutic strategies, and telehealth coaching offered by non-professionals.

The most successful of these technologies offer structured programs that mirror the format of psychotherapy treatment. Headspace, a smartphone application that offers session-by-session meditation training, is valued at $250 million. Calm, Headspace’s rival, is another smartphone application that offers audio-guided meditation. Calm raised $150 million in startup capital and reached a valuation of $2.2 billion this year. Though most of the technologies that have received an influx of venture capital are not subject to scientific review, Calm and Headspace have employed teams of scientists to evaluate their efficacy to ensure their sustainability. Intent on cornering the mental health market, they are well aware that they need to survive scientific and regulatory scrutiny. Here, and time again, scientists are the handmaiden to capitalist entrepreneurs who architect large-scale transformations to the provision of mental healthcare.

Some digital technologies attempt to recreate well-established manualized treatments that are amenable to digitization, such as cognitive behavioral therapy. Though still in their nascent stages, apps that replace therapists with artificial intelligence to conduct psychotherapy are beginning to crop up. Youper, a mental health chatbot, raised a considerable amount of seed funding this year. The tech firm plans to continue developing its therapist-bots as it solicits more and more venture capital.

More common, however, are digital technologies that require licensed mental health professionals to guide patients through modular, app-based programs. Pear Therapeutics, having raised $139 million in start-up capital, markets itself as a pioneer in digital health therapeutics. The tech firm developed an app-based program called reSET, which is the first prescription digital therapeutic to receive authorization from the Federal Drug Administration to offer cognitive behavioral therapy to patients suffering from substance use disorders. The company is clear that the technology would merely serve as an adjunct to a provider-directed contingency management system. Contingency management is a mental health treatment in which clinicians offer substance users rewards (food and money) to reinforce users’ abstinence. In other words, the app guides patients through a module-based course on thoughts and feelings while therapists dole out prizes to their patients.

It is only a matter of time before an impressive pedigree is no longer a barrier to getting hired as a rarified dog trainer. Indeed, Lyra Health, a highly successful tech firm that offers mental health service plans to employers such as Uber and Ebay touts its non-licensed professional, telebased mental health coaching services as an asset. So far it’s paid off. Lyra is currently valued at $1.1 billion and is continuing to grow as it partners with Human Resources departments of firms offering short-term therapy to their employees. Recognizing that the recent presidential election may have affected worker productivity, Lyra released an “Election Toolkit” that offers employees self-guided worksheets such as “How to Avoid Post-Election Cynicism.” The dominance of tech firms such as Lyra in an employer-provided health insurance market in the midst of an economic recession hardly tempers this cynicism.

The Future is Now

As Dr. Simon warned in 2018, the fourth industrial revolution has finally reached mental healthcare. The increased division of labor, the deskilling of therapists, and the rise of digital technologies are a logical consequence of psychotherapy manualization. When what is curative is viewed as something that is outside of the people engaged in the clinical practice, it makes sense that what matters more is how closely someone adheres to a relatively automated process and less how much training and clinical experience they’ve received. The incentive is then to try to hire clinicians for cheap, and as recent transformations portend, to replace clinicians altogether with highly sophisticated software programs. Despite mounting evidence that the effectiveness of therapeutic technique and the therapeutic relationship are fundamentally intertwined, there has been a concerted and successful push to strip therapy from therapists.

Unable to obscure the deep-seated failures of the healthcare system, industry leaders have proposed “new and innovative” solutions to tackle the mental healthcare crisis—the gap in demand for services with their supply. Though many of these innovations only exacerbate conditions—or at best, keep the worst problems at bay—industry leaders have leveraged the minor successes of these transformations and invoked scientific authority to promote their expansion. Expanding the mental health workforce that can offer therapy (from psychiatrists to social workers to community health workers) has minimally increased access to care, though the underlying dynamics of inadequate insurance coverage are still more pressing. Manualized treatments standardize care and offer scientists methods to evaluate therapeutic effectiveness. Dashing insurers’ hopes, however, manuals can at best serve as blueprints for therapists working in real-world settings with complex patients. In terms of technological innovations, the craze for mindfulness smartphone applications is relatively innocuous so long as one recognizes that these programs facilitate a “practical adjustment to existing conditions” rather than a “radical medium of enlightenment.” On the other hand, the proliferation of mental health technologies that replace therapists with chatbots is a more troubling development in the provision of mental healthcare.

The vast majority of people who seek treatment or deliver it will suffer from this revolution. These changes have proletarianized therapists without their knowing it and reduced the quality of mental health services. The degradation of the talking cure from a deep introspective practice facilitated by well-trained clinicians to an automatized process conducted by machinists or machines will continue to persist as long as healthcare is driven by the profit motive. Psychotherapy is now a practice that divides providers and patients into isolated fragments in order to habituate them to a world of alienation and exchange. Universalizing healthcare can help begin to mend these split-off parts.

Briana Last is just mopping things up.