From “Eminence-based” to Evidence-based mental healthcare: Time to focus on quality and accountability

For the men­tal health cri­sis of care, qual­i­ty is as much of a prob­lem as quantity.

Most peo­ple who seek men­tal health care for the first time are baf­fled by how to find a clin­i­cian. I know what many par­ents felt. When my daugh­ter, Lara, fin­ished her first semes­ter at Ober­lin, she returned home to Atlanta thin and exhaust­ed. I was excit­ed to have her back home and entire­ly clue­less about her des­per­ate strug­gle with anorex­ia. In fact, as I learned lat­er, she had been dri­ven by obses­sions about her weight and her appear­ance for over a year by that point. As was true of Amy, her per­fec­tion­ism and her shame at not being per­fect kept her from shar­ing this strug­gle. And now, in a cri­sis after a year of anguish, she was ask­ing for help. As a pro­fes­sor of psy­chi­a­try at the uni­ver­si­ty, I should have noticed her seri­ous men­tal ill­ness, and yet I missed it. At least, now that Lara was ask­ing for help, I should know where to find the best care. But the uni­ver­si­ty had no resources specif­i­cal­ly for eat­ing dis­or­ders, and I could not find a cen­ter for her treat­ment any bet­ter than Amy’s par­ents had. For­tu­nate­ly, Lara, ever the prob­lem solver, found an inten­sive out­pa­tient pro­gram with a superb ther­a­pist and began a long, suc­cess­ful road to recov­ery. But even as a pro­fes­sion­al in this space, I found it dif­fi­cult to nav­i­gate the maze of care. The first issue is that there are so many dif­fer­ent types of pro­fes­sion­als: social work­ers, mar­riage and fam­i­ly coun­selors, clin­i­cal psy­chol­o­gists, pro­fes­sion­al psy­chol­o­gists, psy­chi­a­trists —and they all call them­selves ther­a­pists. The choice real­ly mat­ters, because what you receive depends large­ly on whom you see.

This is not true for can­cer or asth­ma or heart dis­ease, but in men­tal health care, there is lit­tle con­sen­sus among the var­i­ous care providers as to how to approach even the most com­mon forms of men­tal illness.

Although I fre­quent­ly hear that we don’t have enough men­tal health providers, the num­bers don’t reveal a short­age. We have near­ly 700,000 men­tal health providers in the Unit­ed States, more than half being in the tra­di­tion­al psy­chother­a­py pro­fes­sions of social work­er, mar­riage and fam­i­ly ther­a­pist, or licensed coun­selor. The num­ber of men­tal health ther­a­pists is con­sid­er­ably greater than, for instance, the 209,000 phys­i­cal ther­a­pists or the 200,000 den­tal hygien­ists in the U.S. Psy­chi­a­trists are only about 5 per­cent of the total work­force, and child psy­chi­a­trists are rough­ly 1 per­cent. These num­bers might seem pal­try, but there are more psy­chi­a­trists than any oth­er spe­cial­ists in med­i­cine (out­side of inter­nal med­i­cine and pedi­atrics). And the rel­a­tive num­ber of psy­chi­a­trists in the U.S. is far high­er than in most of the world. Although 45 per­cent of the world’s pop­u­la­tion lives in coun­tries with few­er than one psy­chi­a­trist per 100,000 peo­ple, in the U.S. the num­ber exceeds twelve psy­chi­a­trists per 100,000.

So why is it so dif­fi­cult to get an appoint­ment to see a clin­i­cian? In absolute num­bers, the U.S. men­tal health work­force reach­es near­ly two pro­fes­sion­als per thou­sand. In fact, with 14.2 mil­lion adults with seri­ous men­tal ill­ness, we the­o­ret­i­cal­ly have rough­ly one ther­a­pist for every twen­ty peo­ple in need.

So, what’s the prob­lem? The uneven dis­tri­b­u­tion of the work­force is part of the prob­lem. The geo­graph­ic dis­par­i­ty in men­tal health ser­vices with­in the U.S. is almost as severe as the dis­par­i­ty glob­al­ly. The num­ber of psy­chi­a­trists varies from 5.2 per 100,000 peo­ple in Ida­ho to 24.7 per 100,000 in Mass­a­chu­setts. While there are near­ly three­fold more psy­chol­o­gists than psy­chi­a­trists in the U.S., they are even more uneven­ly dis­trib­uted: 7.9 per 100,000 peo­ple in Mis­sis­sip­pi ver­sus 76.0 per 100,000 in Mass­a­chu­setts. Even clin­i­cal social work­ers, who make up the largest sec­tor of the men­tal health work­force, show this kind of geo­graph­ic dis­tri­b­u­tion, from 22.0 per 100,000 in Mon­tana to 186.6 per 100,000 in Maine.

For any of us seek­ing qual­i­ty care, there are three major bar­ri­ers beyond the issues of access. First, the avail­able ther­a­py work­force often has not been trained in the treat­ments that work. Sec­ond, the care is high­ly frag­ment­ed. Dif­fer­ent forms of men­tal health care are giv­en by dif­fer­ent providers, with men­tal health and sub­stance abuse care rarely coor­di­nat­ed and behav­ioral health seg­re­gat­ed from the rest of health care. Final­ly, there is lit­tle account­abil­i­ty because men­tal health providers rarely mea­sure out­comes. You can’t improve qual­i­ty with­out measurement.

The real chal­lenge is not find­ing a ther­a­pist, it’s find­ing a ther­a­pist who knows how to pro­vide the treat­ments that work. In the ear­ly 2000s, Myr­na Weiss­man was try­ing to under­stand why so few ther­a­pists use sci­en­tif­i­cal­ly based treat­ments. She found that over 60 per­cent of pro­fes­sion­al schools of psy­chol­o­gy and master’s lev­el social work pro­grams did not include any super­vised train­ing for any sci­en­tif­i­cal­ly based therapy.

– Data includ­ed in the down­load­able PDF that accom­pa­nies the book Heal­ing; avail­able via

If these men­tal health pro­fes­sion­als are not trained to pro­vide treat­ments that are sci­en­tif­i­cal­ly proven, what are they trained to do? Few pro­grams require super­vised train­ing in any form of ther­a­py, but most expose stu­dents to psy­cho­dy­nam­ic psy­chother­a­py, which explores ear­ly conflicts.

In con­trast to evi­dence-based care, I call this “emi­nence-based care.”

– This is an adapt­ed excerpt from the new book Heal­ing: Our Path from Men­tal Ill­ness to Men­tal Health by Thomas lnsel, MD, a psy­chi­a­trist, neu­ro­sci­en­tist and nation­al leader in men­tal health research, pol­i­cy, and tech­nol­o­gy. He was the found­ing Direc­tor of the Cen­ter for Behav­ioral Neu­ro­science at Emory Uni­ver­si­ty, led the Nation­al Insti­tute of Men­tal Health (NIMH) for 13 years, advanced dig­i­tal phe­no­typ­ing at Google X, and co-found­ed Mind­strong Health and Human­est Care among oth­ers. More infor­ma­tion at

About SharpBrains

SHARPBRAINS is an independent think-tank and consulting firm providing services at the frontier of applied neuroscience, health, leadership and innovation.
SHARPBRAINS es un think-tank y consultoría independiente proporcionando servicios para la neurociencia aplicada, salud, liderazgo e innovación.

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