Psychotherapy branding and marketing

I just read a mildly disturbing article in the New York Times called "What Brand Is Your Therapist?"   The author Lori Gottlieb was a full-time journalist who took six years to retrain as a psychotherapist — her website, but not the article, says she has a master's degree in clinical psychology.  Yet she found herself virtually unemployed after several months and in search of marketing consultants to attract clients.  The thrust of the article is that such marketing involves branding, i.e., defining a niche that promises quick, painless, easily grasped results, and then promoting oneself online and elsewhere using that brand. Gottlieb is clearly uncomfortable about the trade-offs inherent in branding and marketing psychotherapy services.  Traditional psychotherapy is often painstaking, uncomfortable, and lengthy, and thus hard to sell.  In contrast, one-time phone consultations and executive coaching are brief, feel-good interventions that lend themselves to snappy, positive catchphrases that sell better.  Such services may be "fast-food therapy — something that feels good but isn’t as good for you; something palatable without a lot of substance."  Moreover, she notes that many sales techniques clash with the tenets of traditional psychodynamic therapy.  Sharing personal details makes one more approachable and "human," at the cost of complicating and possibly precluding transference work.  Active use of social media such as Facebook and Twitter can attract potential clients and publicize one's "brand," but may also blur relationship boundaries essential for effective psychotherapy.  Gottlieb lays out the dilemmas well in her article, but her practice website illustrates the practical conclusion: Lots of "selling" of various services, few of which are recognizable as psychotherapy.

Of course, I am writing this on my psychiatry blog, which is linked to my own practice website.  I too have grappled with similar trade-offs.  I launched my website over five years ago, and started the blog about a year later.  Several months ago I heeded marketing advice I found online:  I re-wrote my website in the first-person and added photographs.  I expanded the sections on my hospital committee work and past research.  I included more practical information about my practice.

Like Gottlieb, I had mixed feelings about doing this.  On the one hand, helping potential patients make more informed choices sounds innocuous enough.  I want suffering people to be able to find me and to know what I can help with.  I want the process of engaging in psychotherapy to be as transparent as possible.  I explain what I do, and even list my fees on my website (most of my peers don't).

On the other hand, I'm concerned that branding and marketing commodifies a personal healing relationship.  It offers to treat psychological issues in little bite-sized pieces, misleadingly suggesting that therapy to resolve one's indecision about marrying, say, can be completely separate and distinct from therapy to deal with career indecision.  It conflates psychotherapy with counseling and coaching, all of which are useful but different things.  Mainly it risks dumbing down psychotherapy.  Psychotherapy is often complex if done carefully, and in my opinion it can't be conducted as well over the phone, by email, while sitting by the pool with Skype running on one's laptop, or in a guaranteed four-session package.

I haven't availed myself of the whole branding arsenal, since I strive to maintain a psychotherapy practice worthy of the name.  If I ever write a book, offer coaching services, or engage in public speaking, those activities will be clearly distinct from my role as a psychotherapy-oriented psychiatrist.  Moreover, patients and would-be patients seem to agree that informational websites are useful, but that too much branding and self-promotion by a psychotherapist is a turn-off.  That makes good sense, and encourages me to take another look at my own website — I may turn it down a little.  What do you think?

Movie review: "Escape Fire: The Fight to Rescue American Healthcare"

The independent documentary Escape Fire: The Fight to Rescue American Healthcare by Matthew Heineman and Susan Froemke is a thoughtful indictment of the status quo.  Instead of focusing on political polarization, the pros and cons of Obamacare for instance, the film mainly documents the absurdity and waste of what we have now.  Instead of a system to promote health, Americans have a "disease management system" that spends almost twice as much as any other country — and nearly as much on prescription medicines as the rest of the world combined — yet we are 50th in life expectancy, and almost 75% of healthcare costs are spent on preventable diseases that are the major causes of disability and death in our society.  Economic incentives maintain this status quo.  High-tech interventions are reimbursed generously, yet reimbursement for face-to-face primary care often does not even cover the cost to deliver it.  As a result, fewer new physicians enter primary care, and doctor visits become shorter and shorter.  Meanwhile, unnecessary medical and surgical procedures are prevalent despite their risks, and cost thousands of lives each year. Escape Fire uses a firefighting metaphor to make its main point.  In forest fires, sometimes a smaller fire is set in order to deprive the main fire of fuel, creating a firebreak.  Such firebreaks can allow firefighters to escape the area — thus an "escape fire."  The filmmakers use this metaphor to say that the status quo in health care isn't working, and that we may need counter-intuitive and non-traditional solutions to save the system.  I confess that I find this metaphor somewhat ill-chosen: The remedies suggested in the film do not "fight fire with fire."  And there is no escaping our need to address health care.

The film spends much time on the military, in part as a microcosm of the problems facing our larger society.  Soldiers' use of prescription drugs has tripled in the past five years.  A large section of Escape Fire, including fascinating footage inside a C-17 Medevac plane as it crosses the Atlantic, follows Sergeant Robert Yates returning from Afghanistan.  Severely injured in a battle that killed most of his platoon, he suffers chronic pain and PTSD.  Sgt. Yates was given a shopping bag full of pills, but later replaces them with stress- and pain-management techniques he learns as part of an innovative Army program.

Although the film never mentions psychiatry as a medical specialty, mental health issues loom large in both military and civilian health care.  Again and again, patients are depicted in primary care offices reviewing their antidepressant medications, or breaking down in tears.  The current system, devoted to disease management, offers poor care to such patients.  They need time, not reimbursed procedures.  As medical journalist Shannon Brownlee notes on camera: "Health care should have a lot more care in it."

The film proposes several escape fires, i.e., solutions, to rescue American health care.  In 2005 Safeway began to provide financial incentives for employees who engage in healthier behavior, and thereby lowered its health care costs by more than 40%.  (That's how the film puts it.  Actually, from 2005 to 2009 Safeway's health care costs remained flat for the 30,000 employees enrolled in the program, while most companies' costs rose by 40% over the same period.)  This was the one example of a monied interest realigning financial incentives to promote health.  The film would have been stronger with more such examples — I hope there are some.

The military provides a solution of a different type.  Often innovation gains a foothold there before achieving acceptance in civilian society.  Just as America's armed forces were on the vanguard of racial integration and later gender equality, perhaps they can lead the way on health care too.  The Army Surgeon General established a Pain Management Task Force to look at alternatives to narcotics, and now the Army is using acupuncture and meditation to decrease narcotic use in the wounded.  Sgt. Yates, the self-proclaimed "redneck hillbilly" who didn't believe in Eastern Medicine, "decided to give it a shot," and it worked.

I found the profile of Dr. Erin Martin the least hopeful in the near term.  Initially shown as a primary care doctor in a low-fee clinic, Dr. Martin had high ideals, but was demoralized by too many patients and too little time.  She was dissatisfied and frustrated by a system that made her job nearly impossible.  Her escape fire was literally to escape: She quit the clinic, became a fellow in Dr. Andrew Weil’s Integrative Medicine program, and found a practice that supported her patient, humane approach.  The film endorses this as the escape fire for primary care — but of course those clinic patients still need a doctor.

Dr. Martin's path is similar to the one I took myself.  Early in my career I worked for two years in a public mental health clinic.  The patients were in great need, but the system was frustrating and the work demoralizing.  Providing comprehensive, humane mental health care in such a system is an uphill battle at best, and in some respects nearly impossible.  I have much admiration for those who work in such settings.  However, like Dr. Martin, I chose to leave and practice in a way that makes more sense to me.  While the makers of Escape Fire would likely endorse my choice, public mental health clinics still need doctors too.  Moreover, it will be a long time before the American health care system rewards Dr. Martin and others who aim to avoid commodity care.  Indeed, the system is accelerating in the opposite direction.  Those of us who build this particular escape fire in essence work outside the larger system.

As I wrote at the outset, Escape Fire is a thoughtful indictment of the status quo.  The film has been reviewed positively, and it strikes a nice balance between worrisome facts and emotional interest, ending on a hopeful note.  We should have no illusions about easy solutions though.  Healthier lifestyle choices are hard to pursue when fast food is cheap and tasty; a shift to preventative care from disease management would represent a fundamental sea change and a realignment of billions of health care dollars.  For a start, at least, we can agree that American health care is burning, and that new solutions are desperately needed.

The commodification of psychiatry

Several recent articles, blogs, and even my participation in HealthTap (discussed in my last two posts) have led me to think about how psychiatry, and mental health treatment generally, are increasingly viewed as commodities.  In the language of economics, a commodity is a physical good, such as food, grain, or metal, which is interchangeable with any other product of the same type.  Commodities are carefully specified, e.g., "Wheat, No.1 Hard Red Winter, ordinary protein, FOB Gulf of Mexico," but the supplier is immaterial.  Everything one needs to know about a commodity is in the specification.  Based on that alone, a smart buyer seeks the lowest price. Much has been written lately about the psychiatric "med check," a 10 to 20 minute encounter every few months for patients who take psychiatric medications.  A New York Times profile of one such high-volume practice generated notoriety for this approach, well deserved in my view.  Even the profiled doctor had reservations, but succumbed to the lure of higher income as compared to the traditional model of one patient per hour.

Although psychiatric medication management can be done well, the "med check" is often critiqued as an assembly-line approach that treats collections of symptoms, not people.  The assembly-line metaphor highlights the commodification of both parties.  On an assembly-line, each "part" moving down the line can be treated as any other. Likewise, each worker is interchangeable with any other having the same qualifications.  In commodity psychiatry, any fully specified "Major depression, single episode, moderate severity" can be treated as any other.  Mental health workers of a given specification (psychiatrist, nurse, counselor) are interchangeable as well.  The only thing left is to let the marketplace (or government) set the price of this commodity transaction.

While commodity treatment is easiest to recognize in the stereotypical "med check," it is rampant in the rest of the field as well.  Suicidal patients should immediately be sent to the ER, yes?  Because all patients who declare themselves suicidal are the same, just like "Wheat, No.1 Hard Red Winter, ordinary protein, FOB Gulf of Mexico."  Well, no.  In supervising residents and talking with colleagues, I'm amazed how often patients cool their heels, and spend thousands of dollars, in three-day inpatient stays triggered by a threat of suicide.  I claim no magical gift for curing depression or suicidal urges, and I've had my share of patients who scream, "I'm heading for the Golden Gate Bridge right now!"  Nonetheless, I can't recall the last time I hospitalized anyone for suicide risk, and I've never had a patient die by suicide.  Why?  Because it means something when someone threatens suicide, and that meaning varies from person to person.  "Suicidality" isn't a commodity specification, and it should not be treated as such.

Nor is psychotherapy immune from commodification.  "You have social anxiety?  We offer a 16 session cognitive-behavioral treatment for that." As though people who are anxious in social situations are interchangeable — and as though any practitioner who conducts a brand-name 16 session intervention is the same as any other who offers that brand.  The specification is all that matters, the supplier is immaterial.  Perhaps the ultimate example of therapy as commodity is when there is no therapist at all, as in this recent article about a smartphone app designed to decrease social anxiety.  Here, however, the app really is a commodity: Every copy of the app works the same, and it treats all users exactly the same as well.

With an ever-expanding diagnostic manual, and with a pharmaceutical, electronic, or scripted cure for every ill, psychiatry speeds toward a future where it no longer matters who has symptoms, it only matters what the symptoms are.  Likewise, practitioners are interchangeable and thus should be chosen for the lowest cost, just as a buyer spends the least possible on a certain grade of wheat.  It makes no sense to pay for an expensive psychiatrist or psychologist to perform psychotherapy, when psychotherapy is a commodity that can be supplied by people who charge less, or perhaps by a computer program, website, or smartphone app.

To be sure, there are areas of medicine well-served by rote protocol.  Thankfully, no one stops to "customize" CPR during a cardiac arrest.  But in most health care scenarios, treating patients as commodities is dubious.  And in the subtle realm of emotional health it's tragic.  As I wrote in my post about nomothetic versus idiographic thinking in psychiatry, western medicine derives its considerable power from lumping patients into a disease category, and then applying statistically proven treatment to members of that category.  For example, in psychiatry we are not forced to approach a new case of bipolar disorder in complete ignorance; among other things, we know lithium is apt to relieve the signs and symptoms.  But if we stop there, at the nomothetic level of knowledge, we are treating the bipolar disorder, not the patient.  The "supplier," the person suffering the disorder, is immaterial.  We are doing commodity psychiatry.

The alternative is not to abandon the hard-won knowledge of western medicine and nomothetic research.  It is to acknowledge that every person sharing a diagnostic category is unique — that no individual experiences major depression or bipolar disorder in quite the same way as anyone else.  Understanding and enhancing each patient's unique experiential reality is the essence of psychiatric practice, and mental health care generally.  Since these nuanced goals cannot be accomplished without considering the "supplier" — the person with the disorder, as well as the person offering care — the commodity model will forever shortchange psychiatrists and their patients.