At the end of 2017, Alan Kazdin, Ph.D., Professor of Psychology at Yale University, will retire. He is often cited as one of the eminent psychologists of the modern era. During his storied career, Dr. Kazdin edited most major clinical psychology journals and was President of the American Psychological Association and the Association for the Advancement of Behavioral and Cognitive Therapies. He has been a trailblazer in the development of evidence-based practices in children’s mental health.
Although he is retiring, Dr. Kazdin will be continuing his research into innovative ways to close the treatment gap between those children who need mental health treatment and those who receive it. Readers may be surprised and inspired as they read Dr. Kazdin’s reflections on his own career, the field of clinical psychology, and the future of children’s mental health.
Dr. Kazdin, you are often cited as one of the most influential psychologists of the modern era. When you look back on your four-decade career, what is one thing you did that you are most proud of and that you feel had the greatest impact on improving children’s mental health?
I am most proud of the work that is not known or thought about very much. At my clinic where we do research, we treat individual families one at a time. The families bring children to us with severe aggression and antisocial behavior and horrible problems in negotiating everyday life. We have helped many children and families in a period of clinical work spanning more than 30 years. To know concretely that the children have improved and families are doing better has been the best of this work. Research is wonderful and I enjoy that part, but much of the research is written, read (maybe), and archived. I do not see that as having the impact that is so palpable from our direct work with parents and children. I think in the end, the main professional and personal question for me is have I helped anyone or made any life a little easier in a complex world? We have extensive data and more importantly direct contact with families and access to daily indices that demonstrates that families and children are doing better. Knowing this is incredibly meaningful for me and the entire clinic team.
During your career, where has the field of clinical psychology succeeded and where has it fallen short?
The field is now so diverse and specialized (e.g., neurobiology of schizophrenia, understanding marital relations, microbiome influences on psychological dysfunction) that the meaningfulness of a term like “clinical psychology” has become less clear. And perhaps that might be a place where the field has fallen short. Many areas of science and other disciplines adopt a Grand Challenges model where a process involving the input of many is used to identify what the priorities might be for the next period of time (e.g., 10 years), what resources are needed to address them, and so on. I would like to see clinical psychology have that focus. The field moves along, progress is made as measured by individual areas learning more, but it is all now so diffuse. It would be lovely to see if a ‘grand challenge’ with directions and goals might better focus many areas within the field and identify priorities that would mobilize different segments. Also, a challenge with a clear direction would allow us to evaluate progress. Without clear goals progress is much more in the eye of the beholder.
One important area of your work has been bridging the gap between treatment research and clinical practice. In a 2015 autobiographical summary of your work, you said, “In retrospect, I see my writings and efforts to bridge research and practice as naïve and I wish I could unpublish some or most of them.” Why did you say this and how can the field of children’s mental health treatment learn from your observation?
In retrospect, I vacillate between being amused and embarrassed at my naiveté. Writings on bridging the gap are extensive—if the articles and books on this topic were put together—they might “bridge the gap” between the earth and our moon. It is clear to me that these contributions lead to debate, discussion, agreement here and disagreement there, and then more articles. I have not seen any strong move that bridges the gap or makes a palpable difference. I do not see the public benefiting from any of that discussion. The public is critical here because bridging is about their clinical care.
I would like to unpublish my papers only because I believed at the time that bridging the gap was of keen interest. Now I do not think it is or even ought to be. What does bridging the gap even mean? One answer would be disseminating science findings on evidence-based treatment to clinical practice. There are scores of problems with that and sparse evidence to show the public is better off when we try to disseminate treatments from the lab to the clinic. Perhaps we need a template of some kind that states quite explicitly what we are trying to accomplish in bridging the gap and are what the points (measures, indices) along the way to see if we are succeeding. Without this latter approach, I just see more bridging papers.
Needless to say, I am not against bridging. My dentist talks about it all the time and I believe her when she says bridging is important and saves mouths. I am less persuaded when psychologists (including me) talk about it.
It is estimated that less than 20% of children who need mental health treatment receive it. In addition, of those who receive mental health treatment, only a third receives minimally adequate treatment as defined by existing treatment guidelines. What should society (funders, policy makers, researchers, consumers) be doing to address the gap between children who need mental health treatment and those who receive it?
Here is a case where I feel progress is quite possible. Three ideas come to mind that would encompass each of the players in child mental health. First, a Grand Challenge approach would be a valuable starting point. This would prioritize goals and mobilize very different constituents to achieve them. Second, there are government programs that take on “doable” goals, provide resources for all the states to implement intervention programs to solve clinical problems, and monitor the extent to which the goals are achieved. One program, for example, is called “Winnable Battles” by the Center for Disease Prevention and Control. The program selects important national goals (e.g., reduce cigarette smoking, suicide), mobilizes resources for states and cities to oversee implementation of policies and interventions that could have impact, and monitors progress to ensure the goals are approached or achieved.
Third, we have models of delivering treatment that depart drastically from the usual individual therapy, by a mental health professional, in an office. With terms that are unfamiliar within psychology (e.g., task shifting, disruptive innovations, best-buy interventions), there are ways of improving mental and physical health that achieve the same goals as psychotherapy. The key of such models is that they can be scaled up to reach many people in need and can be targeted to reach people especially unlikely to receive care (e.g., individuals from ethnic minorities, children, single mothers, older adults, victims of violence).
What role will technology – the Internet, apps, smart phones- play in addressing the treatment gap?
Technology can play an enormous role in addressing the treatment gap. Consider the ways that assessment and treatment impact both mental and physical health. Assessment includes monitoring of states (affect, cognition, behavior, physiology) in real time related to the clinical focus. This is already well underway with various “apps,” but much more has been developed that is not in use such as clothing that monitors multiple channels of functioning. Treatment includes an enormous array of self-help programs, apps, and treatments that require little or no therapist intervention. For example, social robots (robots that interact with humans) will play a role; they already do in the care and treatment of the elderly. Technology facilitates the integration of assessment and treatment so that assessment is in real time as the person negotiates his or her life and is programmed to send therapeutic interventions as needed based on moment-to-moment states of the individual. Instead of going to a treatment, technology allows treatment to be brought to the client in real time. Already, there is a plethora of outcome evidence on technological applications showing treatment can be effective with clinical dysfunctions and just as effective as in person one-on-one therapy.
What changes in healthcare delivery and financing are most likely to affect the treatment gap?
Initial arguments for change often begin with more funding is needed. That has been a horrible place to begin because when more funds are provided, they usually go into the current system, which is a proven way of not reaching people in need. Adding more money to business as usual is pernicious in my view because the only thing worse than not helping is not helping but giving the illusion that one is.
When cost is raised as an issue, behind it is the assumption “If we do everything the way we are now.” But, we do not want to continue business as usual because it is of little help in reducing the burdens of mental illness. A large-scale project in England showed that scaling up mental health services (to treat clinical depression) was cost effective by getting more people back into the work force. Indeed, providing treatment on a large scale saved money (i.e., cost less than providing federal services and increased revenue from taxes). More money would be great to have for services but only if they were connected to better models of delivering those services.
Health care delivery is very much controlled by service models and professional restrictions. For example, state licensing often restricts who can practice and provide treatment and these restrictions are intended to protect the public. But public protections hold back services. We now know that lay counselors and lay persons can be just as effective as highly trained mental health professionals. Yet in the US, it is very difficult to have lay counselors provide psychological services for clinical disorders. Evidence suggests using lay counselors could address all sorts of barriers (e.g., local access to treatment, more therapists who matched the ethnicity of the clients; treatment in areas of the cities and rural parts of the country where services are not available). One change would be to reconsider the range of individuals that could provide services. Yes, lay counselors still need to be trained but that has been shown to be quite possible and on a large scale.
We hear a lot about how ‘stigma’ prevents people from accessing mental health services. Should we devote more resources to reducing stigma?
There are many barriers to treatment and stigma and self-stigma (views one has about oneself and one’s condition) are among the greatest. Obviously, it is important to understand the development and amelioration of stigma. At the same time, I believe it is misguided or an untested hypothesis to suggest that combatting stigma will have any palpable impact on receiving treatment. Most people in need of psychological treatment receive nothing. If we eliminated stigma tomorrow that would not redress a plethora of issues related to access to treatment (in one’s neighborhood or at least nearby), cost of providing and receiving services, the number of professionals who could provide treatment and so on.
In my view, we ought to look for ways to side step barriers, i.e., make them less relevant. For example, stigma comes up when one talks about “mental problems,” seeking “treatment,” being “abnormal,” and other such terms. Many interventions (e.g., use of the media, taxes, exercise) have been shown to have impact on mental disorders and addictions, but they are outside the domain of treatment, and much less likely to raise stigma as a barrier. There are other such options that can surmount many of the barriers. Yes, we want to understand and eliminate barriers but that is not the direct path to providing more care to more people.
Clearly, retirement isn’t what it used to be, because you still have a very active research enterprise. Tell us about the research you are doing now and why it is important.
I have devoted much of my work to developing treatments. I and many other colleagues have had this focus and now there is a long list of evidence-based treatments. The treatments are not reaching many people because of the “treatment gap”, i.e., the difference in the number of people who need services and who receive them. Putting evidence-based treatments in the hands of clinicians is laudable but will not help the treatment gap. Indeed, if every therapist tomorrow were to use the most well supported treatment from research, that would not reduce the burdens very much. Most people simply do not have access to treatment given the dominant model of treatment delivery, individual psychotherapy.
My work now is on trying to change how treatment is delivered. There are so many options that are ready now, have been tested, and could be used but are not. The question for me is what can I do to help achieve change? Of course, I will fail—there is not much interest in providing services to those in need—but I only need to move the ball forward, to mobilize others with similar interests, to convey the goal to students, and to point out when I can that our current commitment to mental health services reflects the moral low ground.
You have a book being published in March 2018. Could you tell us the focus of this book and why it will be important for those seeking to address the treatment gap?
Thank you for asking. The book title is, Innovations in Psychosocial Interventions and Their Delivery: Leveraging Cutting-Edge Science to Improve the World’s Mental Health (Oxford University Press, March 2018)
The overall goal of the book is to detail ways of reducing the burdens of mental illness to individuals, families, and society at large. The book details the scope of the problem of mental illness, what currently is being done, why treatment is not reaching people in need, and what can be done differently. Multiple models, well outside of the mental health professions (psychology, psychiatry, social work) could have an enormous impact right now. The book conveys new ways of delivering treatment as well as new ways of developing and investigating treatments so that they are much more likely to reach people in need.
Do you have any additional thoughts about how to improve children’s mental health treatment now and in the future?
To improve children’s mental will require the involvement of multiple parties and better organization of their efforts. Science is helpful but quite insufficient on its own. The message of what we can accomplish needs to be communicated. The mental health professions are not doing this well. The public needs to be mobilized better. Perhaps we could bring together groups interested in specific disorders and find common ground. Finally, we need to see what models currently in use could make a difference. The Centers for Disease Control’s Winnable Battles, which I mentioned previously, is a proven model, already in use, already with promising leads, and just one of many options we could extend right now to children.
Because so much can be done and so little is done, we need to focus on the “will” of citizens, legislators, and policymakers. This is way outside any expertise I have but for the first time, I am getting a better, more realistic and more mature view of what is needed.
Thank you for asking me to comment on these critical issues. The full blog post can be found on the Children’s Mental Health Network.