Perspectives on Psychological Science

6(1) 21–37
Rebooting Psychotherapy Research ª The Author(s) 2011
Reprints and permission:
and Practice to Reduce the Burden sagepub.com/journalsPermissions.nav
DOI: 10.1177/1745691610393527

of Mental Illness http://pps.sagepub.com

Alan E. Kazdin and Stacey L. Blase

Department of Psychology, Yale University, New Haven, CT

Abstract
Psychological interventions to treat mental health issues have developed remarkably in the past few decades. Yet this progress
often neglects a central goal—namely, to reduce the burden of mental illness and related conditions. The need for psychological
services is enormous, and only a small proportion of individuals in need actually receive treatment. Individual psychotherapy, the
dominant model of treatment delivery, is not likely to be able to meet this need. Despite advances, mental health professionals are
not likely to reduce the prevalence, incidence, and burden of mental illness without a major shift in intervention research and
clinical practice. A portfolio of models of delivery will be needed. We illustrate various models of delivery to convey
opportunities provided by technology, special settings and nontraditional service providers, self-help interventions, and the media.
Decreasing the burden of mental illness also will depend on integrating prevention and treatment, developing assessment and a
national database for monitoring mental illness and its burdens, considering contextual issues that influence delivery of treatment,
and addressing potential tensions within the mental health professions. Finally, opportunities for multidisciplinary collaborations
are discussed as key considerations for reducing the burden of mental illness.

Keywords
psychological interventions, reducing the burden of mental illness

Psychological interventions to treat clinical dysfunction have interventions—namely, the goal of decreasing rates of mental
advanced remarkably in the past few decades. The progress illness and improving psychosocial functioning on a large
is evident in many ways. First, the quantity of controlled treat- scale (i.e., in society). Psychological treatments have many
ment outcome studies has proliferated. Empirical studies of purposes, but key among them is to alleviate mental illnesses
therapy for children, adolescents, and adults number well into and related sources of dysfunction. A central thesis of this
the thousands. Many journals feature therapy outcome research article is that, despite advances in research, mental health pro-
as their primary thrust so the flow of research continues. Sec- fessionals may have little success in decreasing the preva-
ond, the quality of research has continued to improve as well. lence and incidence of mental illness without a major shift
The use of randomized controlled trials (RCTs) is recognized and expansion of intervention research and clinical practice.
as the fundamental design, but many other methodological fea- The article focuses on models of treatment delivery and what
tures (e.g., the use of treatment manuals, assessment of clinical is needed to reduce the burden. By burden, we refer to the per-
significance of change, evaluation of follow-up) have set the sonal, social, and monetary costs associated with impairment.
bar high for treatment outcome studies. Third, and perhaps Within the term mental illness, we include psychiatric disor-
most salient, has been the delineation of evidence-based treat- ders and also social, cognitive, emotional, and behavioral
ments (EBTs; i.e., interventions with strong evidence on their sources of impairment or disability.
behalf). EBTs are available for many psychological dysfunc-
tions for children, adolescents, and adults (e.g., Nathan &
Gorman, 2007; Weisz & Kazdin, 2010). EBTs continue to
Corresponding Author:
emerge and reflect palpable progress from scientific research. Alan E. Kazdin, Department of Psychology, 2 Hillhouse Avenue, Yale
The remarkable progress has left in the background a key University, New Haven, CT 06520-8205
issue that is a major impetus for developing psychological E-mail: [email protected]

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22 Kazdin and Blase

We begin by highlighting the burden and cost of mental underestimate the burden of dysfunction. Nevertheless, data
illness and associated psychological sources of dysfunction. on psychiatric disorders, albeit conservative, are instructive
We then discuss why advances in current treatment are not in illustrating the scope of psychological dysfunction.
likely to have broad impact and reach most people in need. Lifetime prevalence rates reveal that mental illness (meeting
We highlight individual psychotherapy as a point of departure criteria for a psychiatric disorder) is relatively common, not
because it serves as the dominant model of treatment delivery only within the United States, but also within many countries
and is emphasized in treatment research, clinical practice, and worldwide. A series of recent surveys from the World Health
training in the mental health professions. By model of delivery, Organization assessing the global burden of mental illness
we refer to multiple characteristics of how an intervention is found a lifetime DSM-IV disorder prevalence within its 17 par-
administered, by whom, under what conditions, and in what ticipating countries of 12.0% to 47.4%, with the highest life-
contexts. Psychotherapy as a model usually is delivered to one time prevalence estimate in the United States (Kessler et al.,
person at a time (or couple, family, or in a small group) by a 2009). The same surveys reported the United States to have the
trained mental health professional at a health care or mental highest 12-month DSM-IV disorder prevalence, with a range of
health service facility or private office. Although there are 6.0% to 27.0% for all 17 countries. Summarizing the U.S. data
many variations of therapy (techniques), the model of delivery only, approximately 50% of the population meets criteria for
is more narrowly restricted among them. Yet emphasis on this one or more psychiatric disorders in their lifetimes, and approx-
one delivery model leaves enormous gaps that must be imately 25% of the population meets criteria in any given year
addressed to reduce the burden of mental illness. (Kessler & Wang, 2008).
In addition, this article highlights research on the burden of The rates of dysfunction vary as a function of culture, ethni-
mental illness and the current treatment model as steps toward city, immigrant status within a given ethnicity, geographical
elaborating changes that are needed for providing treatment. location, and socioeconomic status, among other factors (e.g.,
We illustrate several models of delivery that expand on the Alegrı́a et al., 2008). These variations and differences are
model of individual psychotherapy. The burden of mental ill- important in developing interventions. For present purposes,
ness can be reduced by expanding models of delivery. At the we merely wish to convey that psychiatric disorders are preva-
same time, reducing the burden raises other considerations lent. The estimates are likely to be conservative because they
including the integration of prevention and treatment, the need have required meeting diagnostic criteria and exclude those
for improved assessment to monitor psychological dysfunction who do not quite meet criteria but are close enough to make the
nationwide, contextual factors that influence health care, pro- distinction of meeting or not meeting the criteria minor.
fessional tensions within clinical psychology, and important
opportunities for collaborating with other disciplines.
Cost of Mental Illness
The costs of mental illness are high. Although there is no sin-
Reducing the Burden of Mental Illness and gle, agreed upon figure or set of figures of those costs, well-
Related Conditions documented examples in specific problem domains convey
The challenge for psychological interventions is to help reduce the point. For example, alcoholism and substance abuse,
the burden of mental illness and related conditions both at the which affects more than 20 million Americans and is the most
personal and societal level.1 Four interrelated considerations prevalent mental disorder in the United States, costs approx-
convey why diverse treatment delivery models are needed. imately $500 billion annually (Jason & Ferrari, 2010). The
main costs include medical and criminal justice costs, acci-
dents, and loss of earnings. For anxiety disorders, annual
Rate of Mental Illness health-care expenditures in the United States are approxi-
Consider the rate of psychological dysfunction. Not all mately $42 billion (Greenberg et al., 1999). The costs encompass
sources of psychological impairment are codified by current health-care utilization, including medical and psychiatric treat-
classification systems of psychiatric disorders (Diagnostic and ment, and decreased work productivity (see also H. Harwood,
Statistical Manual of Mental Disorders, DSM-IV-TR; Ameri- Fountain, & Livermore, 1998).
can Psychiatric Association, 2000; International Classification Reductions in annual earnings also are associated with the
of Diseases, ICD-10; World Health Organization, 2007). diagnosis of a mental illness. Individuals diagnosed with a
Impairment can result from many sources (e.g., stress, relation- DSM-IV mental disorder earn, on average, approximately
ship problems) beyond those included in diagnostic systems. $16,000 less than their control counterparts annually. This results
Also, many disorders are on a spectrum indicating continuity in a total reduction of $193.2 billion in personal earnings nation-
of dysfunction. For example, several symptoms of depression ally in 1 year (Kessler et al., 2008). A single episode of major
are required to meet criteria for a DSM diagnosis. However, depressive disorder is associated with an average of more than
just failing to meet the criteria (e.g., by a symptom or duration 5 weeks of lost productivity per worker, resulting in an annual
requirement) is still associated with dysfunction or impairment, capital loss of $36 billion to employers (Kessler et al., 2006).
commensurate with the discrepancy from meeting the criteria. Cost extends beyond the fiscal burden; personal impairment
Subthreshold dysfunction leads to prevalence rates that and subjective experience are not trivial. In one series of

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Rebooting Psychotherapy Research and Practice 23

national interviews, participants reported the number of days in populated, affluent urban areas and in cities with major
the past month in which they were unable to perform their usual universities (Health Resources and Services Administration,
daily tasks due to problems because of physical or emotional 2010; J.M. Richards & Gottfredson, 1978). Thus, mental health
health. Mental disorders were associated with more than half professionals are not distributed advantageously to reach large
of the role-disability days, and depression had one of the largest swaths of people in need (e.g., rural areas, small towns).
effects on disability of all conditions (Merikangas et al., 2007). Second, mental health professionals are unlikely to be able
Mental disorders are more impairing than common chronic to reach the vast majority in need. In the United States, there
medical disorders, with particularly greater impairment in the are approximately 700,000 mental health professionals who
domains of home, social, and close relationship functioning provide services (Hoge et al., 2007). As we mentioned, esti-
(Druss et al., 2009). These findings document the importance mates of prevalence indicate that approximately 25% of the
of the loss of productivity due to mental illness and also reflect population has at least one psychiatric disorder in a given
the widespread interpersonal difficulties. These psychosocial year. With a U.S. population exceeding 300 million; 25% is
sources of dysfunction that likewise lead to impairment, suffer- approximately 75 million people. It is not necessary for these
ing, and costs to individuals as well as to society are more dif- estimates to be precise to see that the number of individuals
ficult to capture on a national level, but they are an important who can provide treatment—at least with the current domi-
target for interventions to reduce the burden of mental illness. nant model of delivery—could not begin to reach the number
of those in need. Doubling the work force might have little
discernible impact given the number of individuals requiring
People in Need of Services services.
A vital aspect to reducing the burden of mental illness is the Third, it is not only the distribution and number but the pro-
availability of interventions for those most in need of services. file of mental health professionals. Too few mental health pro-
Recent years have seen an increase in the rate of people in need fessionals reflect the cultural and ethnic characteristics of those
receiving treatment in the United States, with 20.3% of individ- in need of care. For example, trends in ethnic minority repre-
uals suffering from a disorder receiving treatment between sentation in clinical psychology (e.g., doctoral enrollments and
1990 and 1992 and 32.9% receiving treatment between 2001 recipients and graduate department faculty) over two decades
and 2003 (no difference was found in rates of prevalence suggest that the proportions of ethnic minorities in psychology
between the two time points; Kessler et al., 2005). Even so, the do not show comparable growth relative to that of the U.S.
majority of individuals with a diagnosable mental disorder are ethnic minority population growth (e.g., see Commission on
not receiving treatment. Ethnic disparities with respect to Ethnic Minority Recruitment, Retention, and Training, 2008).
access to mental-health care among those in need are enor- Approximately 20% of doctoral degrees in psychology and cur-
mous. For example, African Americans are less likely to have rent enrollees in psychology graduate training programs are of
access to services than are European Americans (12.5 vs. minority status, and approximately 6% of psychology faculty
25.4%), and Hispanic Americans are less likely to have ade- are of minority status (African American, Asian American,
quate care than are European Americans (10.7 versus 22.7%; Hispanic American, Native American). The proportion of the
Wells, Klap, Koike, & Sherbourne, 2001). These are illustra- U.S. population that comprises minorities, projected to be
tions from a much larger literature on disparities in mental 50% by 2060, is accelerating at a higher rate than trainees in
health care delivery among individuals of minority groups their respective groups. Thus, the population of ethnic minori-
(e.g., see www.mentalhealthcommission.gov/reports/Final ties in need of mental health services will increase at a greater
Report/FullReport-04.htm). The lack of available services for rate than will the availability of ethnically matching profes-
most people and systematic disparities among those services sionals. Although treatments can be effective where there is not
have direct implications for models of treatment delivery. an ethnic match of therapist and client, in some cases that cul-
Interventions are needed that can reach many more people, but tural component influences outcome (Griner & Smith, 2006;
also with particular attention to select subpopulations. Miranda et al., 2005). Even if an ethnic match is not needed for
treatment to work, it can nevertheless present a barrier for the
potential client who is considering treatment. Ethnicity and cul-
People Providing Services ture are not the only mismatch. Other groups based on geogra-
The problem of too few people receiving services and of groups phy (e.g., individuals living in rural areas) or select populations
being particularly deprived of such services might be con- (e.g., the elderly) reflect a mismatch with a paucity of available
ceived as a ‘‘person-power problem’’ in the mental health field. resources and a plethora of need for mental health services
To oversimplify the argument, maybe more people are needed (e.g., Hinrichsen, 2010; Institute of Medicine, 2008).
to provide the usual services. Three points convey why more In light of the previous considerations, the inability to reach
providers alone may not be sufficient. First, the person- most people in need of services is not simply (or only) a person-
power problem stems in part from the geographical distribu- power issue. Many of those in need of services cannot be
tion of existing mental health professionals. The concentra- reached for a variety of reasons (e.g., access, perceived and
tion of psychologists, psychiatrists, and clinical social genuine barriers in obtaining treatment, insurance, rural areas),
workers in the United States is the greatest in highly but one of them is our own view as mental health professionals

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24 Kazdin and Blase

regarding how treatment should be delivered. Invariably, more procedures required to effect therapeutic change. Many
help is welcome. But, given the emphases of the current model familiar examples within psychoanalysis and its variants (e.g.,
of delivery, that alone is not likely to provide an increment of Jung, Kohut) and also from other views (e.g., self-theory
reduction on the burden of mental illness. of Rogers, reciprocal inhibition of Wolpe, cognitive therapy of
Beck) and shifts in orientation (e.g., positive psychology of
Seligman) illustrate the dynamic (not ‘‘psycho’’) nature of the
Individual Psychotherapy in Relation to the
field. Also, methodological advances have raised the bar for all
Burden treatment evaluation to include RCTs and increasingly more
Many interventions will be needed to reduce the burden of stringent requirements for how intervention studies must be con-
mental illness and other facets of impairment. We begin with ducted and reported (e.g., Consolidated Standards of Reporting
psychotherapy research for several reasons.2 First, there are Trials—CONSORT; Moher, Schulz, & Altman, 2001).3
many goals of psychotherapy, but salient among them is the The third component, the model of one-to-one treatment,
treatment or amelioration of psychiatric disorders; social, emo- continues to dominate even as theories about the appropriate
tional, cognitive, and behavioral problems; and stress (e.g., intervention focus (e.g., problem-solving strategies, mindful-
Dickerson & Lehman, 2006; Mahrer, 1986; Weissman, ness, and self-agency) have proliferated. The departures (e.g.,
Markowitz, & Klerman, 2000). Thus, psychotherapy is a viable treating couples, families) retain the focus on small individual
intervention for addressing significant mental health problems units. The majority of EBTs retain this model of delivering
(e.g., anxiety, depression, bipolar disorder) in addition to other treatment (Nathan & Gorman, 2007; Weisz & Kazdin, 2010).
sources of impairment (e.g., stress). Second, psychotherapy Also, the model dominates training in clinical psychology,
research has progressed remarkably. As we mentioned, social work, and psychiatry. In clinical psychology, for exam-
the emergence of EBTs is a particularly important advance. ple, accreditation of graduate programs emphasizes clinical
Generally, EBTs refer to those interventions that have carefully hours of treatment in individual therapy in graduate school fol-
controlled research on their behalf. RCTs, careful delineation lowed by an internship experience. Treatment of groups (e.g.,
of the client sample, specification of treatment, and replication 8–10) and families are counted as well, but in relation to the
of the results by an independent investigator or team are among focus of this article, delivering treatment by a mental health
the commonly used criteria. Third, psychotherapy is a domi- professional in person to small individual units are of the same
nant model of delivering psychological services. By model of ilk, namely, treatments with a very restricted reach.
delivery, we refer to how the intervention is presented or pro- Our comments are not a criticism of the model of individual
vided. In this case, we refer to the dominance of individual, therapy. One-to-one therapy will always have a place; individ-
one-to-one therapy with a client (child or adult), family, or ual crises and challenges in life are invariably at that level.
group (e.g., 8–10 clients). Psychotherapy plays a role in reduc- Also, individual therapy contributes to the overall goal of
ing the personal and social burden of mental illness. But the reducing the burden of mental illness in at least three ways.
role it does play draws stark attention to what is missing if the First, it serves a small number of individuals with effective pro-
burden of dysfunction is to be significantly reduced among cedures, and that places it firmly in the portfolio of models of
those in need. treatment delivery. Second, many of the scientific principles
It is useful to highlight briefly the model of delivery of psy- and processes (e.g., emotional memories, extinction, cognition)
chotherapy in historical context. That context conveys how the that serve as the underpinnings of individual therapy as well as
model has tacitly continued to dominate in therapy research the techniques themselves may inform other models of deliv-
and practice. Consider the enormous impact of psychoanalysis ery. Third, some therapy techniques (as noted later) might be
on the delivery of psychological treatment. For present pur- delivered in multiple ways, so the ‘‘same’’ treatment or very
poses, three facets of psychoanalysis and its variations can be close approximations may vary in their accessibility and reach.
distinguished. First is the theory or substantive foci of problem Nevertheless, additional delivery models will be needed
development (e.g., related to psychosexual stages of develop- beyond the contributions of individual therapy.
ment, superego, and variants) and of treatment (e.g., addressing
transference). Second are the methodological features used in
Developing a Portfolio of Models of
early work to support the key tenets. The anecdotal case study
(e.g., Anna O., Dora, Little Hans) was relied on heavily. Third
Delivering Interventions
was the model of delivery of treatment, namely, one-to-one Interventions that can reduce prevalence (cases with some dys-
individual patient care, all flowing from a medical-patient care function now) and incidence (new cases that emerge) are
model. Psychoanalysis was not the first one-to-one psychoso- needed to reduce the burden of mental illness. Treatment and
cial intervention (e.g., mesmerism, hypnotism), but it provided prevention work arm in arm. We emphasize treatment to con-
a prototype from which subsequent psychotherapies (and New vey key points and return to its integration with prevention later
Yorker cartoons of them) followed. in this article.
The contemporary history of psychotherapy research Consider all individuals in need of psychological services
reflects the continual development and changes in substantive (treatment) as occupying a pie chart. The goal in developing
views that explain the onset of clinical disorders and the multiple models of delivery is to ensure that segments (slices)

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Rebooting Psychotherapy Research and Practice 25

of the pie are covered (i.e., services encompass all or most in broaden the population with access to therapeutic intervention,
need—at least in principle). One might consider slices of the but also potentially increase the likelihood that clients will
pie with the view that a given intervention or model of delivery remain in treatment. Such a model has low cost and may even
may reach one slice, but that multiple models might be needed reach population segments to which Internet-delivered models
to cover more, most, or all of the slices. The pie notion is use- may not have access.
ful, but it does not convey the multidimensional needs of the One such illustration of the potential for telephone-based
population. There are many different reasons why people do intervention is nicely demonstrated in ‘‘quitlines,’’ initially
not receive services, such as lack of access to facilities or prac- developed to provide telephone counseling for smoking
titioners, ethnic and cultural barriers, and many concrete obsta- cessation through the U.S. National Cancer Institute. Tobacco
cles (e.g., transportation, babysitting). No single model of users who call a quitline receive an empirically validated, stan-
delivery can be assured to circumvent all of the obstacles asso- dardized, and manualized intervention incorporating various
ciated with a given subgroup or slice of the population pie. services such as materials by mail, prerecorded messages,
Among the many characteristics that might delineate models real-time phone counseling or a return phone call from a coun-
of delivery, the ability to reach many individuals in need of ser- selor, access to quitting medication, or some combination
vices reflects the type of changes that are needed if treatment is thereof (Lichtenstein, Zhu, & Tedeschi, 2010). Quitlines have
to significantly reduce the burden of mental illness. We illustrate demonstrated tremendous reach, as they are currently offered
models of delivery of psychosocial interventions to convey some in all 50 states and Washington, DC and have also been adopted
of the many options that might comprise the portfolio. and sponsored at the national level of various countries in
Europe, Oceania, Asia, and South and North America.
Although the content and structure vary across quitlines, the
Technologies initial call typically lasts less than an hour, orients the client
The Internet. Unlike individual therapy, the use of various to the program, and establishes a quit date. Subsequent calls
technologies to deliver treatment has the ability to reach a large of 10 to 15 min are scheduled following the quit date over a
proportion of the population in need of services. Among the period of 1 or more months with a frequency based on a relapse
technological options, there is a rapidly growing literature on curve (Zhu & Pierce, 1995). A staff with bachelor’s- or master’s-
the use of the Internet (e.g., Barak, Hen, Boniel-Nissim, & level training typically delivers the counseling services, although
Shapira, 2008; Dimeff, Paves, Skutch, & Woodcock, 2011; computers drive much of the quitline counseling. An estimated
Ybarra & Eaton, 2005). The ability to reach a large segment 1% of smokers in the United States utilize quitline services each
of the population in need is nicely illustrated in an application year (Cummins, Bailey, Campbell, Koon-Kirby, & Zhu, 2007),
to cigarette smoking, which is often a target of psychological and some states with increased marketing reach as many as 4%
interventions. to 5% of their smoking populations in a single year (Swartz
A series of Web-based intervention studies for smoking Woods & Haskins, 2007). Quitlines have even demonstrated a
cessation conducted in English and Spanish have shown signif- special ability to reach underserved populations, as African
icant smoking termination rates through a standard smoking American smokers are more likely than any other ethnic group
cessation guide and mood management course (Muñoz et al., to utilize these services and Asian immigrant smokers are as
2006). An individualized, password-protected Web site pro- likely as European American smokers to utilize them (Maher
vided access to the smoking cessation intervention to consent- et al., 2007; Zhu, Wong, Stevens, Nakashima, & Gamst,
ing eligible individuals and was used to obtain assessment data 2010). This program highlights the advantages of models utilizing
throughout the intervention. The intervention reached more telephone-based intervention, namely, the potential to overcome
than 4,000 smokers from 74 countries and was carefully eval- various logistical barriers to treatment that exist for in-person
uated (e.g., RCT, follow-up assessments). Studies of this pro- individual psychotherapy. This and the brief, standardized,
gram illustrate the potential for use of Web-based semianonymous nature of phone counseling administered by
interventions and the ability to reach people in their homes. paraprofessionals greatly increases the accessibility and reach
Once developed, such Internet-based administrations can be of the intervention.
relatively inexpensive to implement and easy to maintain. Smartphones. Due to advances in technology, cellular phones
Telephone. As with the Internet, the telephone can be used to are no longer simply mobile telephones for the sole purpose of
deliver mental health interventions for both individuals and making calls. Updates in these devices (e.g., GPS) provide new
groups (see Mohr, Vella, Hart, Heckman, & Simon, 2008). Typi- opportunities for methods of intervention and assessment (e.g.,
cally, ‘‘telemental psychotherapy,’’ as this is sometimes called, location of client engaged in homework assignments to over-
involves administration of full sessions of therapy through come fear of open spaces; Boschen, 2009a, 2009b). The most
scheduled weekly phone calls. This is much like the model of commonly studied form of mobile phone intervention employs
in-person psychotherapy, but because no face-to-face contact the use of short message service (SMS) or text messaging. One
is necessary, it allows for remote administration of services. example of implementing an SMS-based intervention is nicely
Interestingly, telephone-administered psychotherapies have illustrated in an aftercare treatment of bulimia nervosa. Patients
lower rates of attrition than traditional individual psychotherapy received weekly text messages for the 6 months following their
(Mohr et al., 2008). Thus, phone-based treatment may not only release from inpatient psychotherapy. These messages provided

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26 Kazdin and Blase

feedback on their self-reported bulimic symptoms and consisted present. An example of the potential to reach some such
of both standardized messages and individualized feedback individuals is nicely illustrated in an intervention for cigarette
(Bauer, Percevic, Okon, Meermann, & Kordy, 2003). Such an smoking administered in a physician’s office during a routine
intervention has the advantages of low cost and effort, interactiv- office visit. One intervention currently in use focuses on what
ity, individualization, anonymity, and widespread reach. physicians say to their patients during routine office visits.
The increased use of multifunction smartphones provides Physician visits are relatively brief (median ¼ 12–15 min) in
additional prospects for methods of therapeutic intervention. the United States. During the visit, advice from the physician
These devices grant easy access to third-party applications that or nurse can have a small but reliable effect on smoking. The
provide promising intervention opportunities. Although research physician says something like the following to patients who are
exploring the use of such applications has only just begun, the cigarette smokers: ‘‘I think it important for you to quit tobacco
implications for greater reach are remarkable. One example is use now,’’ or ‘‘As your clinician, I want you to know that quit-
the use of dialectical behavior therapy (DBT) for borderline per- ting tobacco is the most important thing you can do to protect
sonality (see Dimeff et al., 2011). A smartphone application your health.’’ The comments lead to approximately a 2.5%
called the DBT Field Coach provides a resource to clients, incremental increase in smoking abstinence rates in compari-
including specific skills and instructions, a log where individuals son with no intervention, as seen in meta-analyses of multiple
can track their use of skills throughout the day, access to RCTs (e.g., Rice & Stead, 2008; Stead, Bergson, & Lancaster,
uploaded supportive video and audio messages from their clini- 2008). As a result of this effect, internal medicine practice
cian and members of their support network, individualized moti- guidelines now recommend that physicians provide specific
vational images when encouragement is needed, and a variety of advice to stop smoking. The example is instructive because it
means for enduring a crisis to prevent exacerbation of the situa- also conveys the importance of ‘‘weak’’ treatments. The inter-
tion, such as games and music to distract from intense emotional vention results in a small increase in the percentage of individ-
urges. Although this particular example of technology is used as uals who became abstinent. Small effects on a large scale
an adjunct to the traditional individual therapy model, it nicely (affecting many people) provide an important complement to
illustrates various resources that can be provided through mobile other models of delivery.
phone applications. Future research exploring the use of such This example might raise concerns that many cigarette
devices may expand delivery to rely less or not at all on a pro- smokers may not attend routine physical exams or may not
fessional therapist. admit to smoking and therefore not receive the message. Yet
Another example that nicely illustrates the use of smartphone the task is not to have one intervention reach everyone. We do
applications in therapy is an application known as Mobile not possess the psychological equivalent of fluoridation that
Therapy (Morris et al., 2010). The application prompts users can be poured into a stream from which mental health flows.
to report their mood levels throughout the day by indicating their Rather, we only wish to illustrate interventions that have the
mood on a touchscreen ‘‘mood map’’ and to report their levels on ability to reach individuals who might not seek intervention
single-dimension mood scales for happiness, sadness, anxiety, or not have readily available access to care. Numerous other
and anger. The application subsequently provides mobile thera- special settings may be identified and used for the goal of
peutic exercises based in cognitive-behavioral techniques (such reducing the burden (i.e., schools, community centers, welfare
as breathing visualization, physical relaxation, and cognitive offices, family settings, to name a few).
reappraisal exercises) as needed to cope with their stress and
mood. A 1-month field study of the application demonstrated
users’ increased self-awareness and stress-coping abilities
Opportunities for Nonprofessionals
through the use of the therapeutic concepts. The focus on everyday settings underscores opportunities for
These examples illustrate only a minute fraction of the nontraditional providers to administer interventions that can
opportunities that advances in networking and technology will improve mental health. This is not an effort to substitute
provide for future therapeutic intervention. The constant high-school students, fellow parents, or work colleagues for
updates and improvements in technology make it increasingly professional therapists. Rather, in developing a portfolio of
accessible to the public and provide new methods for collecting interventions, there are multiple opportunities to intervene both
information and administering treatment. Most critical to the for prevention and treatment and these can reach many people
goal of reducing the burden of mental illness is the ability to in need. For example, in one intervention aimed at reducing
reach those in need. Interventions that incorporate technology rates of sexually transmitted diseases (STDs) among African
will reach far greater numbers of people than traditional psy- American adult males, a lay health adviser administered a
chotherapy and grant access to segments of the population that single-session sex-education program that reduced rates of
have been relatively inaccessible and neglected. unprotected sex and number of sexual partners and increased
condom use. This intervention resulted in reduced rates of
STDs in participants (Crosby, DiClemente, Charnigo, Snow,
Use of Special Settings & Troutman, 2009). This program was brief, reached a portion
Another model of delivering treatment takes advantage of spe- of the population with traditionally little access to therapeutic
cial settings where those individuals in need are already intervention, and was administered in a clinic-based setting.

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Rebooting Psychotherapy Research and Practice 27

Parents have played a role in treatment administration to and mood difficulties, eating disorders, addictive behaviors,
other parents and families as well as their own children (Hoag- personality disorders, and severe psychopathologies, the model
wood et al., 2010). For example, a parent-based intervention of self-help is an excellent addition to the portfolio of models of
focused on reducing binge drinking in first-year college students treatment delivery. Self-help has the potential to reach individ-
(Turrisi, Jaccard, Taki, Dunnam, & Grimes, 2001). Parents were uals in need and reduce many barriers (e.g., geographic and
given a 35-page intervention handbook to read, which contained financial barriers) associated with more traditional therapist-
all of the necessary instructions for implementing the delivered interventions.
communication-based intervention with their precollege adoles-
cents. Unlike the traditional psychotherapy model, this example
highlights relatively low cost and effort and ease of administra-
Media
tion within a home setting without the direct involvement of The media (i.e., radio, television) can be an effective way to
professionals and with very little training. implement widespread intervention with great capability to
reach large segments of the population. Entertainment educa-
tion is a prominent example of how to exert social change on
Self-Help critical issues including family planning, adult literacy, HIV/
Self-help is a set intervention in which the individual takes con- AIDS prevention, sexual abstinence for adolescents, parenting,
trol and implements an intervention on his or her own. There and promoting a sustainable environment and mitigating
are variations that reflect a continuum of external support, climate change (Charles, 2009; Singhal, Cody, Rogers, &
including complete independence; group support; and minimal Sabido, 2003; Singhal & Rogers, 1999). The process begins
to full-time aid from volunteer, semiprofessional or profes- by studying individuals within a given culture (e.g., surveys,
sional help (T.M. Harwood & L’Abate, 2010). Self-help inter- focus groups) and developing characters for an extended radio
ventions use various media (i.e., audio recordings, books, or television drama series (depending on the medium available
video, the Internet) to address numerous mental health con- to the community) that reflect local culture and people in their
cerns. For example, an Internet-based self-help treatment for daily lives. The characters take on different roles, deal with
panic disorder, consisting of five modules over 5 to 8 weeks, daily challenges of life within the culture, and model social
was associated with reductions in panic frequency and distress change on the critical issues.
during panic attacks (J.C. Richards & Alvarenga, 2002). This The goal is to achieve concrete change within individuals,
particular self-help intervention was solely self-directed and communities, and societies. For example, one of the early
included psychoeducation regarding anxiety disorder and cop- applications in Mexico focused on family planning and efforts
ing skills. Once established, an intervention like this can reach to reduce fertility rates (Singhal & Rogers, 1999). Family life,
many individuals and at a low cost. marital relations, and the daily drama and stressors were con-
In general, self-help interventions comprise an immense veyed in detail as the televised series unfolded. The fictional
literature encompassing numerous approaches at various degrees family gained control over their lives and benefitted from fam-
of involvement by professionals. For example, an entire self- ily planning—all in realistic episodes. In terms of impact, sales
help treatment genre is based on writing. Distance writing, in the of contraceptives in the community rose dramatically, and
form of open-ended journal entries; autobiography; and expres- there was a 34% drop in birthrates over a 5-year period. Similar
sive, programmed, or dictionary-assisted writing, allows for the results were obtained in Kenya. More generally, the model has
exchange of information between professionals and participants been used throughout the world on other social issues and has
so that help can be given without seeing one another face-to- produced widely engaging shows. Ratings of shows are high,
face. A second example of the diverse approaches to self-help viewers or listeners become involved with the characters, and
is that of group self-help. There are many options for group there is genuine change on the targeted social behavior, rather
self-help interventions, as evident in support groups consisting than just increased awareness. An effort with a focus on large-
of people facing a similar challenge and attempting to overcome scale mental health problems, handling stress, substance use, or
their shared adversities (Davison, Pennebaker, & Dickerson, depression could be targeted to various groups and geographi-
2000). Group self-help interventions also can vary in degree of cal regions and could have widespread reach, especially as this
involvement of trained professionals, and some are even led strategy has been successful on TV as well as radio.
by a fellow group member.
Countless self-help books, known as bibliotherapy, have
been written for a wide range of mental health problems. Also,
General Comments
there are various Web-based self-help and informational Our illustrations are not intended to be comprehensive. We have
resources for diverse problems, some of which may even incor- taken off-the-shelf, currently available interventions—not all of
porate online support groups.4 Many self-help treatments are which have strong evidence on their behalf. Most of these are not
now evidence-based interventions with comparable effects routinely included in reviews or evaluations of EBTs. Also, the
(effect sizes) to those obtained with individual therapy (T.M. models of delivery usually are omitted from graduate training in
Harwood & L’Abate, 2010). With so many self-help resources psychology, psychiatry, or social work and are not easily avail-
available for a wide variety of conditions, including anxiety able to individuals in need of services. Our goal in mentioning

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28 Kazdin and Blase

diverse models of delivery is to prompt a slightly different way in treatment will meet that goal and consider what more might
of thinking about psychosocial interventions. The focus is not on be needed to have an impact. A portfolio of intervention mod-
one ideal model of delivery, but on dovetailing multiple models els is emphasized for sensitivity to the diverse individuals in
of delivery, each incorporating various characteristics that will need and the contexts, settings, and circumstances required to
allow them to reach many individuals in many different ways reach them. Even so, it would be naive to imply that the field
and ultimately to reduce the burden of mental illness. merely needs to get a bigger bag of intervention delivery tricks
We have noted that most EBTs are based on the delivery of to solve the national (and international) burden of mental ill-
individual therapy. This model of delivery is not very helpful in ness. There are additional and complementary considerations
reaching the many individuals in need. However, developing we highlight as well.
EBTs may potentially contribute to the goal of reducing the
burden of mental illness. The scientific principles underlying
various individual psychotherapies as well as the techniques
Prevention
that derive from them can then be extended in a programmatic We have focused on treatment and specifically psychother-
way to move from intensive, costly, and individual case appli- apy because of the enormous attention these receive in
cation to versions that are more population based. research, practice, and clinical training. Prevention is pivotal,
An excellent example is the Positive Parenting Program and here too the same points can be made—namely, that a
(Triple-P), a parenting program developed in Australia to treat portfolio of preventive interventions with various models of
disruptive behavior in preschool children (Sanders, 2008; delivery is needed. There are some ways in which prevention
Sanders & Murphy-Brennan, 2010). Early studies demon- is further along conceptually, insofar as the portfolio of inter-
strated efficacy in applications with individual families. Over ventions (e.g., targeted, universal), the timing of interven-
a period spanning 25 years, efforts were made to develop brief tions (e.g., prenatal, preschool), intervention settings (e.g.,
and cost-effective versions of the program, ways of delivering home, schools), and selection of samples (e.g., risk factors)
treatment through groups, and flexible delivery through tele- recognize the need for multiple interventions delivered in
phone consultation and the media. The range of interventions multiple venues and contexts. What we add to this is the inte-
available from this one ‘‘treatment’’ encompasses versions of gration with treatment and the portfolio concept of identify-
the program that can be intensively provided to individual fam- ing preventive interventions that vary in their reach and other
ilies or provided as preventive interventions via media widely characteristics (e.g., cost, effort). Reducing the burden of
available (e.g., DVD, online). The transition involves more mental illness will depend on avoiding onset or limiting
than just varying how treatment is presented because new tasks severity of onset and, by doing so, reducing incidence and the
and challenges emerge as treatment moves to the community need for treatment. The portfolio idea would be beneficial for
from the treatment setting. conceptualizing the task of prevention because it begins with
We raise this example as a successful case of starting with who ought to be reached in the population, what interventions
an individual therapy model and using the treatment to develop are likely to accomplish that for various groups, and what the
multiple models of delivery. The challenges of moving a given effects are.
treatment from an individualized version to something avail- The treatment and prevention agenda are shared, comple-
able to more people on a large scale will vary as a function mentary, and essential to integrate. The treatment question
of the clinical problem, treatment, and age of the clients. Even underlying this article is ‘‘What models of intervention deliv-
so, there may be some standard challenges or an approximate ery will help reach the population of individuals in need?’’
template as a guide to help move treatment through different The prevention question is ‘‘What interventions or experi-
models that vary in their reach. ences can be provided for persons who are or might be at risk
Among the major challenges is identifying how an interven- that can avert the onset or severity of some condition?’’
tion achieves change. Although there are many EBTs available, Decreasing prevalence and incidence are important for more
there is little understanding of the mechanisms of change than just the goal of reducing the burden of mental illness. The-
(i.e., precisely how they work; Kazdin, 2007). Understanding ory and principles that underlie current interventions as well as
mechanisms of action may be extremely important when trying the techniques that derive from them might have variations
to develop different models of delivery of a given treatment applicable to both prevention and treatment. Many of the deliv-
that vary in intensity, mode, and agent of delivery. Knowing ery methods (e.g., use of the Internet, parent-to-parent delivery)
what the essential ingredients are as well as how they work may be shared as well.
(mechanisms) will ensure that these critical facets are not In short, we omitted prevention to focus our argument on the
unwittingly sacrificed as the treatment is scaled up, monitored task of developing a portfolio of treatment delivery models. To
less closely, and abbreviated. reduce the burden of mental illness, we must expand our con-
ceptualization of interventions and models of delivery. How-
ever, that thesis is equally applicable to prevention and
Critical Issues Central to the Portfolio treatment. We focused on treatment because of the advances
If a central goal of psychological interventions is to reduce the in evidence-based psychotherapies and their still restrictive
burden of mental illness, we question whether current advances model of delivery.

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Rebooting Psychotherapy Research and Practice 29

Assessment interventions, outcome measures remain important. However,

measures might also focus on characteristics of the treatment
The goal of reducing the burden of mental illness begins with
delivery model. Characteristics of treatment—such as what
better assessment to monitor mental illness and impairment
groups in need can be reached and when (developmentally) and
nationally (i.e., some measure of the mental health of the
where (setting) the intervention can be delivered—become
nation). This would provide ongoing information for tracking
important. The arbiter of the value of a treatment is not neces-
changes in mental illness and its burden over time across
sarily in its effect size on outcome measures but where that
cohorts and across possible social influences that might affect
intervention fits in a broader portfolio to help reduce the burden
that baseline. There is a need for a national database on mental
of mental illness.
illness that allows comparisons over time—a point others have
Measuring characteristics of treatment that relate to delivery
well articulated (e.g., Bickman, 2008; Chorpita, Bernstein,
is not at all new. Cost of interventions and cost–benefit
Daleiden, & The Research Network on Youth Mental Health,
analyses are examples of measures that reflect on the utility
2008). There are many models that are in place to monitor men-
of interventions (e.g., M.G. Newman, 2000; Yates, 1995).
tal health changes over time. As a prominent case in point, the
Although these measures are not routinely used in treatment
National Comorbidity Study, which samples the mental health
studies, they have been used on multiple occasions (e.g.,
status of thousands of adults and youths, provides data on inci-
Gabbard, Lazar, Hornberger, & Spiegel, 1997; Krupnick &
dence and prevalence and encompasses several countries in
Pincus, 1992). Cost is one important measure for building a
conjunction with the World Health Organization (www.hcp.
portfolio of interventions. Other dimensions also relate to the
med.harvard.edu/ncs/). Another example is the Monitoring the
reach of interventions, such as ‘‘therapeutic effort’’ (dose,
Future Study, which assesses behaviors, attitudes, and values of
degree of restrictions placed on the client, and cost of repeated
school students (http://monitoringthefuture.org/). The project
episodes of the disorder; F.L. Newman & Howard, 1986). The
began in 1975 and has provided data on drug, alcohol, and
categories or dimensions need to be devised along with opera-
cigarette use nationwide and involves approximately 50,000
tional definitions that permit some classification or characteri-
students (8th, 10th, and 12th grade) annually. Finally, the Insti-
zation. The goal is to develop interventions that overlap along
tute for Health Metrics and Evaluation (University of Washing-
some dimensions but purposely do not overlap in other ways.
ton) focuses specifically on evaluating data on health indicators
Consequently, characteristics of interventions (e.g., how they
including prevalence of major diseases and effectiveness of
can be used, their scale of application, when during develop-
health programs (Murray & Frenk, 2008). Mental health and
ment they might be applied) are no less important than the
major psychological sources of impairment would be a natural
usual outcome measures.
extension of this latter effort, given that mechanisms for rigor-
ous evaluation are already in place. In short, there are prece-
dents and methodologies for obtaining the requisite data.
Contextual Influences on Reducing the Burden
A national database is a fundamental step for decreasing the
burden of mental illness because it provides a baseline to better of Mental Illness
establish the extent of the burden and whether there are changes There are many influences that contribute to, determine the
over time. We have emphasized psychosocial interventions to effects of, and limit the delivery of mental health services.
reduce the burden of mental illness. However, there is no single There are enormous barriers for persons in need that interfere
modality of intervention or discipline that has claim to the with receiving services. Some of these are perceived; others are
range of factors that might have such impact. Interventions, real. Their net effects are similar. Many of the barriers involve
natural and human made, from climate, pollution, and natural health care policy, law, legislation, limits of insurance and
disasters are known to have deleterious impact on physical and third-party payment, competing interests of different stake-
mental health (e.g., Berglund, Lindvall, & Schwela, 1999; holders in health care, and politics. These are important to
Bouchard et al., 2009; Reacher et al., 2004; Satcher, Friel, & acknowledge for at least two reasons. First, collaborations will
Bell, 2007). With a goal of reducing the burden of mental be needed with many organizations and interest groups to
illness at a national level, understanding factors that might effect changes in policy and legislation that can influence
contribute could also mobilize multiple disciplines (e.g., educa- accessibility to mental health services. As an obvious and his-
tion, sociology, social policy). A national database would provide torically important case in point, recent health-care legislation
opportunities to generate and test hypotheses about influences in the United States extends health coverage to tens of millions
(e.g., economic, social) that might be understood and possibly of uninsured persons, reduces health care costs for many with
harnessed to improve mental health. and without insurance, and ends insurance practices considered
Assessment issues emerge at a more concrete level in by many to be discriminatory.5 Such legislation can alter the
developing a portfolio of interventions. Outcome assessments reach and availability of services, as well as the nature of these
in psychosocial intervention focus on the domain of interest. services (e.g., psychological services in the context of commu-
Treatments for depression, for example, include multiple mea- nity-based health-care teams). Thus, we recognize the health-
sures of depression and perhaps related domains as well (e.g., care delivery system is dynamic and an important influence
stress, physical symptoms). In developing a portfolio of in conceptualizing what services will be provided to whom.

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30 Kazdin and Blase

Second, the contextual influences that drive mental health change, and merely developing new models of delivery alone
services are not necessarily immutable or givens, but they will not be sufficient to ensure they will be taught in training
might well be influenced by developing novel models of ser- programs, allowed by licensing boards to count as relevant
vice delivery. The development of multiple models of delivery experience, and then delivered in practice.
that vary in cost, disseminability, and ability to be delivered for A second potential source of tension in advocating a portfo-
large-scale application might well influence contextual factors lio of models is the question of who would be involved in
(e.g., policy, law, reimbursement) that seem outside of the administrating interventions. Some of the interventions would
control of any one discipline. For example, early intervention focus on preventing onset of dysfunction among at-risk groups.
delivered by lay persons or via large-scale Internet applications For example, an intervention might be conducted at home or at
might change the nature of insurance coverage, reimbursement, school long before any treatment was needed. But consider
and the costs of delivering more intensive services. Insurance interventions where treatment is needed, because this better
companies might well be willing to cover more intensive conveys the professional issues. It is heresy within psychology
psychological intervention services for those individuals who to mention that one does not need to have a PhD to deliver
have not responded to more readily available and less costly effective or evidence-based individually tailored treatments.
evidence-based interventions. Indeed, it would be difficult to support empirically that PhD-
The possibility that better, different, and more diverse inter- trained individuals are more effective than those with less train-
vention models might reduce barriers to treatment is specula- ing. At best, experience and possessing a doctoral degree would
tive. It is better to acknowledge that psychologists and other be moderators of treatment—that is, they might influence out-
mental health professionals do not control or are not likely to comes in some situations. Even if there were strong evidence
have great impact on key policy influences related to providing that a PhD improved outcomes, it would still mean there prob-
services. That does not gainsay the areas over which mental ably is no difference as a function of academic degree in many
health professionals do have control. The intervention research other circumstances. With a broad portfolio of interventions,
agenda could be modified to focus more on a portfolio of inter- there are opportunities for peers, lay people (parents), the
ventions that could reach more people and seek to reduce men- media, teachers, bachelor’s- and master’s-degree-level individ-
tal illness and its burden. Mental health professionals could uals, and self-help to play a role in reducing the burden of men-
readily influence implementation of preventive and treatment tal illness. Actually, these are not ‘‘opportunities’’—a large set
services if there were more to implement and more ways to of them is likely to be essential to reduce the burden of mental
deliver those services. illness. Thus, an impediment to reducing the burden of mental
illness might be assumptions and restrictions on the range of
individuals who are allowed to provide services in one form
Potential Tensions Within Mental Health
or another.
Professional Training A third potential source of tension stemming from the advo-
Each of the mental health professions has a model of clinical cacy of a portfolio of models regards jobs and reimbursement
training that combines academic and practical experiences. for clinical services. Currently, strong advocacy and lobbying
Training and requirements for clinical work may actually inter- efforts focus heavily on obtaining reimbursement for PhD-level
fere with developing and implementing a portfolio of models of practitioners engaged in the traditional model of providing ser-
delivering treatment. This can be illustrated by commenting on vices (www.apapracticecentral.org/advocacy/index.aspx). It is
three issues within clinical psychology: accreditation, deter- natural for a profession to set standards for training (e.g.,
mining who is allowed to deliver services, and reimbursement accreditation, core curriculum), protect its name (e.g., use of
and jobs. First, within clinical psychology, accreditation of ‘‘psychologist’’), and worry about restricted and unrestricted
graduate training programs influences greatly the model of trade practices (e.g., who is allowed to provide, charge, and
treatment delivery. Individual therapy and its closely related be reimbursed for mental health services). Our article does not
variations (family, group, couples therapy) are required. This lobby for eliminating any particular practice; however, it does
model of delivery reflects what ‘‘counts’’ as legitimate training draw attention to the need for more options for service delivery,
and permits one to acquire a license to practice in states and given the large majority of unserved individuals in need. We
provinces within the United States and Canada. Thus, currently begin with the goal of reducing the burden of mental illness
within the profession of psychology, a portfolio of models of based on psychosocial interventions (i.e., those interventions
delivery is not quite in keeping with requirements of training to which research is or might be devoted). This point of depar-
by tradition and by required courses, although there are no pro- ture opens many options, but it also sacrifices protective prac-
hibitions against novel treatments. tices that focus on the question of who gets to deliver treatment.
We mention clinical training merely to acknowledge a Rather, the goal begins with how delivery of services can be
potential barrier in expanding models of treatment delivery. optimized to reduce the burden and what innovations in ser-
Any broad intervention portfolio taken up by researchers may vices would be needed. One would hope that there is no clash
need to be reflected in clinical training. Otherwise, interven- between reducing the burden of mental illness and retaining
tions would be developed that ultimately would not be used individual therapy as a model of treatment delivery as delivered
in practice. Accreditation requirements are very slow to by doctoral-level individuals who have accredited clinical

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Rebooting Psychotherapy Research and Practice 31

training. Perhaps there are new roles and opportunities for problems, different onsets and durations, courses, and
doctoral-level trained clinicians (e.g., supervising and monitor- amenability to a given type of intervention that varies in cost,
ing a network of others who vary in training) that would still ease of administration, ease of delivery on the scale needed,
give the highest priority to reducing the burden of mental ill- resources to provide these interventions, and likely effective-
ness. Psychology can play a major role in providing a portfolio ness, to mention some of the factors. These factors could be
of interventions given the theory and research about human modeled to help guide the field in where to place the emphasis
behavior from which to draw, even if the actual delivery of the not only in delivering but also in developing interventions.
full range of interventions has many agents of administration. There are several areas in which math modeling plays a crit-
ical role in solving complex problems. For example, in opera-
tions research, math and statistics are used to achieve goals
Collaborating With Other Disciplines: Brief while maximizing the desired outcome and minimizing loss
Illustrations or risk. Probability theory, game theory, graph theory, decision
Reducing the burden of mental illness involves challenges well analysis, queueing theory, and more are brought to bear to
beyond developing a broad portfolio of treatment delivery achieve some goal (e.g., Hiller & Leiberman, 2005). Early
models. The goal will require collaborating with other disci- applications solved problems of deploying weapons in war and
plines, in part because of the complexity of the influences to focused on decision making for complex but very practical
be considered in providing services under many different con- problems. Operations research extends the point here about
ditions (e.g., economic) and contexts (e.g., cultural). Collabora- drawing on math but also statistics and many related modeling
tion in the sciences has increased (Cacioppo, 2007; Kliegl, tools used in other disciplines to solve policy and complex
2008) and now collaborative work or team science exerts application problems. Providing better mental health services
greater impact than work of individual investigators (Wuchty, is not only or even primarily a math or operations research
Jones, & Uzzi, 2007). Similarly, collaborations to reduce the problem, but there could be great benefit in drawing on these
burden of mental illness are likely to increase the impact of any and related areas in deciding priorities for developing and
single profession. Of course mental health professionals (e.g., deploying interventions.
in psychology, psychiatry, social work) already collaborate
with each other to provide treatment services. Yet the colla- Technology
borations we are referring to encompass other disciplines and
strategies that are beyond standard practice. Consider briefly We highlighted the use of technology in the development of a
a few disciplines and approaches and how they might portfolio of treatment delivery models. Arguably technology
contribute. could have the greatest impact on psychological interventions
in the coming years. Psychotherapy research already draws
on technology, especially the delivery of direct services over
Mathematical Modeling the Internet for many clinical problems (e.g., anxiety, stress,
With current treatments and an expanded portfolio of delivery pain, phobias) for the treatment of adults (e.g., Barak et al.,
models, one might ask, ‘‘What is the best way to allocate 2008; Ritterband et al., 2003; Rochlin, Zack, & Speyer,
resources to reach those individuals and groups in greatest need 2004). However advanced many of these seem, this area is
or to have the greatest reduction in the burden of mental ill- probably at a very early stage because of the development of
ness?’’ Math can be quite helpful in modeling the challenge and the technology itself.
potential solutions. The point can be illustrated in the context of Three critical uses of technology are important to mention in
controlling epidemics, responding to a bioterrorist attack (e.g., relation to improving clinical services and their reach. First,
smallpox), and deploying vaccines to keep illness to a mini- technology can deliver interventions and reach places beyond
mum (e.g., Hughes, Garnett, & Koutsky, 2002; E.H. Kaplan, the reach of brick and mortar services. Even though some of
Craft, & Wein, 2002; Magal & Ruan, 2008). Critical variables these treatments are still intensive (e.g., requiring a trained thera-
such as how contagious the disease is and for what duration, pist), not all of them are. Second, and especially relevant to the
how many contacts individuals have, what groups are at great- portfolio, technology might well permit treatment with less, lit-
est risk for contracting or spreading the disease, how long it tle, or no therapist contact. Clients can access materials that can
takes for the vaccine to take effect, and other such variables can promote therapeutic change with little or no therapist assistance.
be modeled in relation to how to minimize death and to eradi- Finally, technology will permit refined assessment and feedback
cate the disease. both to patients and clinical services. Electronic devices to
In relation to psychological treatment, there are three major record functioning in everyday life are already in use in such
intervention challenges to consider: preventing onset of psy- areas as the study of sleep, mood, social interaction, and speech
chiatric disorder, treating acute disorder (e.g., trauma from a (e.g., Hasler, Mehl, Bootzin, & Vazire, 2008; Pentland, 2008).
catastrophic experience), and treating chronic and episodic dis- Better assessment can greatly enhance interventions in targeting
orders (Ulmer, Bruno, & Burke, 2010). The methods for inter- both when and to whom an intervention is provided.
vening with better mental health services will vary as a function Technology can be exploited much further, and collabora-
of these challenges and more specifically the types of clinical tion with leaders in technology applications could benefit the

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32 Kazdin and Blase

development of a portfolio of models of delivery. The creativity another example, several years ago, a review of fatty acid
of video games may increasingly be applied to treatment or pre- supplements for psychotic disorders suggested that the research
ventive regimens and be made readily available. Similarly, a was promising (Joy, Mumby-Croft, & Joy, 2003). More
library of virtual evidence-based interventions for psychological recently, a randomized and placebo controlled trial suggests
conditions is hardly a conceptual or technological leap. The ini- therapeutic effects of fatty acid supplements on psychoses
tial reaction is that technology will never substitute for a ‘‘real’’ (Amminger et al., 2010).
person. An aficionado of robotics might argue that, but the better The roles of diet and nutrition in mental health remain to be
point is that technology is not competing with a real person. It is developed. Any dietary component that could be harnessed and
directed toward the goal of reducing the burden of mental illness, shown to prevent, treat, or attenuate acute or chronic psychia-
and in this regard it can make a contribution to a portfolio of tric symptoms would be a valuable addition to the portfolio of
delivery models that is without peer. treatments. We are not suggesting that diet is the answer or that
Technology for intervention delivery and assessment will the new New Yorker therapy cartoon should be a drive-through
advance and will contribute enormously to mental and physical fast-food place to treat serious psychopathology. We are sug-
health. Smartphones are currently being used in everyday life, gesting that if the focus is on reducing the burden of mental ill-
but as technology moves to increasingly brilliant phones, ness and associated conditions, there are several partners in this
assessment and intervention possibilities increase. As for enterprise. Nutrition might well be one. The arbiter is evidence
assessment, subjective experience and biological indices of and allegiance to the goal rather than allegiance to a profession
psychological states (e.g., via breath, blood flow, electrophy- or a restricted model of treatment delivery.
siology, smells) could be fed back to some clinic but also could
be fed back to the device with the client and activate some
intervention. Perhaps a virtual teddy bear to hug in times of
Epidemiology and Public Health
crises would reduce impairment ever so slightly. ‘‘Ever so These two linked disciplines are obvious partners because they
slightly’’ can make a difference in determining whether an indi- focus on the distribution of dysfunction (e.g., disease), the fac-
vidual goes off the deep end or wades in the shallow water until tors involved in risk and prevention, and population-based
a crisis passes. interventions. Reducing the burden of illness and disease is
central to the goals, and drawing on that orientation will be
pivotal to work in the mental health professions. As an example
Diet and Nutrition of a public-health approach, the Office of Disease Prevention
The credibility of the role of diet in the etiology and treatment and Health Promotion has delineated a national goal: Healthy
of psychological and psychiatric dysfunction has suffered from People 2020 (www.healthypeople.gov/). This initiative sets
faddish diets, quick cures for desperate parents and clients, and, national objectives for promoting health and preventing dis-
at best, checkered evidence. It is still the case that diet ‘‘cures’’ ease. Every 10 years, the initiative draws on what has been
are readily available on the Web (e.g., for attention-deficit/ learned from research regarding health and uses that as a basis
hyperactivity disorder, autism, and dyslexia) despite the for setting priorities. The public sector and various stakeholders
absence of evidence and multiple empirical diet challenges that are involved to craft the policy and to promote health. Major
show little or no impact. With that background, one must tread agencies also illustrate the public-health approach. Prominent
carefully. Yet diet and nutrition continue to involve increas- among these is the Centers for Disease Control, which takes
ingly sophisticated lines of empirical research (e.g., alternative a population approach to prevent illness and to improve the
medicine, cellular microbiology of nutrition). Also, mechan- quality of life (www.cdc.gov/). Among the key features of epi-
isms of action of critical influences (e.g., conversion of diet demiology and public health and the specific examples men-
to minerals to neurotransmitters; cell trafficking and transport) tioned briefly here are interest in evaluating health and
and the ability to assess these mechanisms in a more fine- disease, the factors that predict onset and can be used to iden-
grained fashion have changed the nature of research. It is very tify groups at risk, the development and testing of intervention
plausible that diet, nutrition, vitamins, and minerals affect crit- strategies, and encouragement to move to policy or widespread
ical psychological processes and can be harnessed to influence adoption where possible. They also recognize the disparities in
mental health and illness (see B.J. Kaplan, Crawford, Field, & health-care delivery and those who are not served.
Simpson, 2007). A public-health approach is central to a portfolio of inter-
From the standpoint of this article, the ability of diet to reach ventions. The field needs population-based interventions that
a large segment of people would make this an excellent addi- can reduce the burden of mental illness through prevention as
tion to a portfolio of models of delivery. Of course, one would well as treatment. However, population-based interventions
want strong evidence that nutrition and mental health were con- alone will not be sufficient; many individuals in need will be
nected in relation to risk factors, etiology, and treatment. There missed, many who do receive the intervention may not respond,
are many intriguing leads already. For example, pesticides in and many who respond may not respond well enough. Also,
one’s diet (e.g., especially on fresh and frozen fruit) have been public-health approaches often consist of providing informa-
implicated in the onset of attention-deficit/hyperactivity disor- tion to the public. Psychological science can add to this
der (Bouchard, Bellinger, Wright, & Weisskopf, 2010). As approach by drawing on theory and research (e.g., message

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Rebooting Psychotherapy Research and Practice 33

framing, social norming, focusing illusion) that might be to reach individuals in need, even if the number of mental
applied to optimize changes in attitudes, behaviors, decision health professionals doubles. Developing EBTs and placing
making, and subjective experience. these in the hands of practitioners remain laudable accomplish-
A public-health perspective sensitizes the field to an ments and goals, respectively. Although we as researchers and
approach to interventions that warrants more influence on what clinicians ought to perfect our individual treatments, under-
is done in psychology. At the extreme, a very costly interven- stand how they work, and disseminate them, much more atten-
tion could be identified (e.g., individual, weekly, in-person psy- tion is needed to those models of delivery that can reach the
chotherapy) that can only be applied on a small scale to a very majority of people in need; that will require a portfolio of mod-
select few of the many in need. In a portfolio of intervention els of delivery.
models, there is a need and place for that intense focus. How- The goal of developing a portfolio of models of delivery
ever, the mental health professions must also identify interven- expands on the traditional and current research agenda. Much
tions that are effective and could be provided on a greater scale of research in the context of therapy has compared treatment
to larger groups (e.g., communities, large patient groups). against treatment as usual or has compared different treatments
There are examples in which public-health (population) per- to see which one is better or best. Indeed, the federal Compara-
spectives are being encouraged to address family interventions tive Effectiveness Research agenda highlights and underscores
for parenting and domestic violence (e.g., Sanders, 2008; Sher this as a current priority (www.hhs.gov/recovery/programs/cer/
& Halford, 2008). Advances in technology, mentioned earlier, index.html). When two (or more) interventions have identical
also provide a window to increasingly larger extensions of psy- or nearly identical goals and are very similar in their character-
chological interventions to the public at large. Collaborations istics (e.g., to whom they can be applied, for a given cost, on a
with public health at the outset of intervention development given scale), invariably there is the question of which one is
could enhance development of the portfolio of interventions. better. If they are equally effective, there is the question of
whether one has some other advantage (e.g., fewer side
General Comments effects).
The research agenda implied by the development of a port-
We have highlighted a few of the many disciplines and areas folio of delivery models shifts the current focus a bit. Evidence
with which we might collaborate in the effort to reduce the bur- that an intervention is having an effect is still needed. However,
den of mental illness. There are many other disciplines (e.g., eco- interventions that vary widely in their reach, focus, costs,
nomics, business) and topics (e.g., exercise, meditation) that effects, and other dimensions are crucial. Separate components
could have been included. Our illustrations are to advocate for of a portfolio that will not be directly comparable are needed.
partnerships rather than to limit who those partners might be. Each is useful in relation to the overall goal (reducing inci-
Reducing the burden of mental illness can profit from many dence or prevalence), but they will focus on different windows
basic and applied areas of psychological research. Intervention of opportunity to effect change and will be targeted to different
research is the work most immediately directed to the goal, yet people, in different settings, and so on. Direct head-to-head
intervention research alone will not accomplish the goal of comparisons will not be as relevant if there are different interim
reducing the burden of mental illness. For example, producing goals needed to achieve the longer term goal of reducing the
‘‘new and improved’’ EBTs may do little if still administered as burden of mental illness.
individual therapy in ways that systematically exclude most of The evaluation of some intervention research may change
the population in need and especially those most in need. Part- slightly. For example, EBTs often seek large mean effect sizes
nering with other areas can help shape the agenda and provide (ES; e.g., d > .80 a la Cohen, 1988). With a broader portfolio of
theory, research, and methodological tools that can guide models of delivery, strong ESs are not always the first consid-
development of models and how they can be deployed to reach eration. An intervention with a larger ES is not invariably better
those in need. than one with a smaller one. An intervention with a weak but
reliable effect that can reach large numbers with little cost
would be worth having and could only be bumped out of place
Conclusions (think of the Olympic sport of curling) by another intervention
This article began with the view that psychosocial interventions with a greater ES that addressed the same population, cost, and
directed toward mental illness and health should primarily so on. Also, it is quite possible, even in this context, that both
focus on the reduction of mental illness and the impairment treatments are kept as viable options because they reach a
associated with social, cognitive, emotional, and behavioral slightly different group among those in need.
functioning. The prevalence of dysfunction is relatively high, In addition to the research agenda, conceptual work is
and most people who might benefit from services for their dys- needed to address the broad focus on reducing the burden of
function do not receive care. Additional resources in terms of mental illness. The task is to consider how interventions might
person power might help. However, the dominant model of relate to each other, how they might be sequenced in a step-like
treatment delivery in clinical practice focuses on in-person fashion, to whom they are applied, and when. For example,
treatment provided to individuals or relatively small units reducing the burden of depression requires consideration of dif-
(groups, family, and couples). The model constrains the ability ferent ages of onset, different types of depression, and different

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34 Kazdin and Blase

durations of depression. It would be helpful to develop broader Declaration of Conflicting Interests

concepts for where to begin here. If the goal were to reduce the The authors declared that they had no conflicts of interest with respect
burden of unipolar depression, one consideration would be to to their authorship or the publication of this article.
determine the windows of opportunity that might be used
across the developmental spectrum for preventing onset and Notes
reducing impairment of those who are currently depressed. For-
1. We use the term mental illness rather than a new term (e.g., burden of
mal consideration of the battleground and where first, best
psychological dysfunction) to connect to the broader literatures in
efforts are likely to have impact would be an important step.
which the burden of mental and physical disability has been evalu-
By formal consideration, we refer to drawing on specific models
ated. Also, our discussion focuses on the burden of mental illness
(e.g., math modeling, operations research, strategic planning)
within the United States, although of course the burden is worldwide.
that help guide the agenda.
2. Psychotherapy is defined broadly in this article to include systema-
Mental health professionals might continue to refine indivi-
tic efforts to apply psychosocial intervention to reduce distress or
dually delivered therapies, perhaps especially if they generate
maladaptive behavior or enhance adaptive functioning. Psychoso-
techniques or principles that can be applied in different ways.
cial intervention, in contrast to medical or biological intervention
Yet it is necessary to make progress in new ways with a focus
(e.g., medication, surgery), focuses on such means of change as
on the goal of decreasing mental health problems. Mental ill-
interpersonal interaction and systematic experiences (e.g., new
ness is an enormous burden. Anyone with a family member
ways of behaving through practice, role-playing, homework
who suffers from mental illness knows all too poignantly the
assignments, advice) designed to produce change. The therapist
personal costs, the suffering and pathos of those who experi-
provides conditions to alleviate that person’s distress and to
ence the dysfunction, and the toll of the necessary care for a
improve functioning in everyday life (e.g., Garfield, 1980; Mahrer,
loved one directly suffering. From a societal perspective, pub-
1986). The interaction is designed to alter the feelings, thoughts,
lic and private agencies at every level know the burden of eco-
attitudes, or actions of the person who has sought or has been
nomic costs. Most people with mental illness are not being
brought to treatment.
served. The challenge is determining what is being done in
3. CONSORT encompasses multiple procedures to improve the qual-
applied intervention work to reduce mental illness and extend
ity of reporting of empirical tests (www.consort-statement.org/).
care to those in need. Current models of delivery need to be
Examples include detailed information about participant inclusion
expanded to reduce the burden. Continued proliferation of
criteria, recruitment, screening, and attrition; how the intervention
treatments delivered in a way that cannot reach most people
was administered; and unplanned changes from the protocol. The
in need ought to reconsidered. The goal of this article was to
standards have been adopted by hundreds of professional journals
draw attention to a neglected, albeit central goal of psychoso-
from many disciplines and countries (see www.consort-statement.
cial intervention research—namely, the goal of reducing the
org/about-consort/supporters/consort-endorsers—journals/).
burden of mental illness. The research, practice, and training
4. Understandably, there is professional skepticism about self-help
agenda ought to integrate this goal of intervention work with
books and materials, given an unrelenting tsunami of such products
the needs of the national and international community.
based on opinion, clinical (but not empirical) evidence, and both
common and uncommon sense. It is true that the majority of
Editor’s Note self-help materials in the local bookstore have not been evaluated
If you are interested in commenting on Kazdin and Blase, you can empirically. In fairness, it is appropriate to note as well that the vast
submit a 200-word abstract to the Perspectives portal at http:// majority of psychotherapies in use have no supporting evidence for
mc.manuscriptcentral.com/pps by February 14. their effectiveness (see Kazdin, 2000).
Please submit the ‘‘type’’ as ‘‘commentary.’’ You will have to sub- 5. The enacted laws are referred to as the Patient Protection and
mit the abstract both as ‘‘abstract’’ in Step 1 and ‘‘main document’’ Affordable Care Act (P.L. 111-148) and the Health Care and Edu-
in Step 6. Editors will read the abstracts and invite a few authors to cation Reconciliation Act of 2010 (P.L. 111-152; see http://
write full comments. These will be published together in a subse- frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname¼111_cong_
quent issue along with a reply by the authors. Criteria for selection
bills&docid¼f:h3590eas.txt.pdf; http://frwebgate.access.gpo.gov/
include likely influence of the comment/critique, interest to a broad
cgi-bin/getdoc.cgi?dbname¼111_cong_bills&docid¼f:h4872enr.
readership, and importance of the issues raised. Also, the Editors
will select a set of proposals that offer a diversity of viewpoints, txt.pdf)
rather than multiple examples of a single perspective. For those pro-
posals that are not selected for publication, the authors will have an References
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 Perspectives on Psychological Science

Reactions to the Call to Reboot 6(5) 475–477

© The Author(s) 2011
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DOI: 10.1177/1745691611418242

Introduction to Special Section of http://pps.sagepub.com

Comments on Kazdin and Blase (2011)

Bethany A.Teachman1 and Teresa A.Treat2

1
Department of Psychology, University of Virginia, Charlottesville, and 2Department of Psychology,
University of Iowa, Iowa City

Keywords
mental illness, intervention, psychotherapy, dissemination, service delivery

The field of clinical science has made great progress in devel- national database that can be used to establish a baseline and
oping evidence-based treatments, but we have failed to reach reference point for examining change in the burden of mental
our fundamental goal of reducing the prevalence of mental ill- illness over time, as well as the key predictors and moderators
ness in society and its devastating effects on psychosocial of burden reduction. Although they acknowledge that a shift
functioning on a large scale (Baker, McFall, & Shoham, 2008). toward a broad portfolio of delivery models will be controver-
We can often help a given individual who is struggling with sial and raise new challenges for traditional mental health pro-
mental illness, but how are we to stem the tide of human viders, they also argue that the only way to effect widespread
suffering? change is to connect with other disciplines outside of standard
In “Rebooting Psychotherapy Research and Practice to practice (e.g., in epidemiology, nutrition, math modeling, tech-
Reduce the Burden of Mental Illness,” Alan Kazdin and Stacey nology development, etc.) and to dramatically alter what we
Blase (2011b) argued that individual psychotherapy, the domi- construe as being under the exclusive purview of therapists.
nant method used to deliver treatment, cannot possibly meet This call to action would demand change in our research,
society’s overwhelming mental health needs. The rates of men- service delivery, grant funding and training models. Recogniz-
tal illness are too high; approximately half of all Americans will ing that calling for such a dramatic shift in the field would elicit
meet diagnostic criteria for at least one psychiatric disorder dur- strong responses, Perspectives on Psychological Science put
ing their lifetime (Kessler & Wang, 2008), yet over half of these out an open call for comments on Kazdin and Blase’s proposal.
individuals will not receive treatment (Kessler et al., 2005). The caliber and diversity of the 26 submissions made it quite
Given the variability in the reasons people do not receive pro- challenging to select only 6 to include in this issue. (Additional
fessional help (e.g., lack of access to a trained clinician, stigma, comments can be submitted and viewed in the online version of
cultural obstacles, limited resources), a one-size-fits-all model the original article at http://pps.sagepub.com/content/6/1/21.
of treatment delivery is not now, nor will it ever be, effective. full; click on “Read all comments” under the Reader Responses
Kazdin and Blase thus advocate for development of a portfolio sidebar, then click “Full Text.”) Submissions were rated for
of treatment delivery methods, including harnessing available likely impact, intellectual rigor, originality, and overall quality.
technologies, such as web- and phone-based interventions, pro- The final selection of comments offers a diverse set of perspec-
viding treatment in everyday settings (rather than exclusively in tives on how we can most effectively shift toward reducing the
the therapist’s office), using nontraditional providers of inter- global burden of mental illness.
ventions, promoting self-help approaches, and using the media Varda Shoham and Thomas Insel (2011, this issue) provide
to communicate prevention and intervention messages to large a unique perspective on the Kazdin and Blase article, writing
segments of the population. in their roles as the Director (Insel) and Special Assistant to
Kazdin and Blase call for radical reform in how we think the Director, Division of Adult Translational Research and
about delivering prevention and intervention approaches.
They note that it will be critical to identify the mechanisms of
Corresponding Author:
change underlying successful interventions to determine how Bethany A. Teachman, Department of Psychology, University of Virginia, P.O.
they can be abbreviated for broader dissemination without los- Box 400400, Charlottesville,VA 22904-4400
ing their essential ingredients. Also, they outline the need for a E-mail: [email protected]

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476 Teachman and Treat

Treatment Development (Shoham) of the National Institute of regulation, or adherence to treatment. To date, such methods
Mental Health (NIMH). They argue that reducing the burden have been used only to modify nonclinical behavior in research
of mental illness requires more consistently and carefully con- contexts. Shalev and Bargh suggest that variants of these tech-
sidering for whom simplified intervention and prevention niques potentially could be individualized, presented via con-
approaches will be sufficient and for whom more extensive temporary technological devices, and deployed widely at low
approaches will be needed. To achieve this goal of determin- cost to set the stage for clinically relevant change.
ing what type and level of intervention are needed for a given Brian Yates (2011, this issue) makes the case that we must
individual, they outline the importance of Attribute by Treat- do more to investigate different modes of delivering treat-
ment Interaction (ATI) research, which examines how a given ments, so that we can reduce costs and reach more people. He
individual characteristic (e.g., baseline symptom severity, age advocates for funding to evaluate different delivery methods
of illness onset) interacts with the treatment conditions to pre- (rather than just different treatments) and challenges research-
dict treatment response. They review stories of success and ers to make delivery costs more explicit in their calculations of
failure in ATI research, highlighting initiatives from NIMH cost effectiveness. Yates cites numerous examples of delivery
that can help support ATI research to advance more personal- systems that have the potential to reduce resource use and
ized prevention and intervention work. costs, yet still pass on most (if not all) of a given treatment’s
Marc Atkins and Stacey Frazier (2011, this issue) suggest effectiveness, including Internet-based interventions, auto-
that the time is ripe for adoption of a multilevel model of care mated phone interventions, and video-based interventions. He
that subsumes universal prevention strategies, targeted efforts argues that we know a lot about the ingredients (treatment
with high-risk populations, and more individualized manage- approaches) needed to help people who are suffering, but we
ment of persons with intensive needs. Comprehensive integra- need to study the “spoon” (delivery method) that passes these
tion of prevention and intervention services across these three ingredients along to the hungry client: “Just as therapy is no
levels ideally would extend the reach of mental health services longer an art but a science based on research evidence gath-
while decreasing the number of individuals needing more ered in clinical settings, so too can be its delivery” (p. 498).
costly and time-intensive individualized treatment. Atkins and Denise Sloan, Brian Marx, and Terence Keane describe a
Frazier stress that the success of this public health approach plethora of recent service-delivery innovations launched by
would necessitate investing to a much greater degree in the the Veterans Health Administration (VA) to enhance the men-
training and support of nontraditional providers in nontradi- tal health care provided to the almost 2 million veterans in this
tional settings (e.g., laypersons in natural community settings, country (2011, this issue). First, the VA is leveraging techno-
personnel in social-services agencies). They note how their logical resources such as the Internet, smartphones, and video-
proposal is consistent with the goals of recently enacted conferencing to expand the reach and availability of potentially
health-care reform in this country, as well as recommendations anonymous services. Second, the VA is investing in the train-
from the World Health Organization. ing and support of laypersons for the provision of mental
Bruce Chorpita and colleagues (2011, this issue) argue that health care, including VA chaplains, VA police, and peers.
the field has overemphasized knowledge production to the detri- Third, the VA has committed to systemwide dissemination and
ment of knowledge management. In particular, they argue that implementation of evidence-based treatments for mental-
whereas the focus on developing new evidence-based treatments health problems, necessitating the development and evalua-
has led to many positive advances in clinical care, it has also cre- tion of large-scale training, consultation, and monitoring
ated an untenable situation. There are so many separate treat- strategies. The VA’s efforts provide excellent models for the
ment manuals that there is no way that a given psychologist can comprehensive dissemination and implementation of such
possibly learn even a fraction of them, or know how to combine treatments on a nationwide scale.
them for clients with comorbidity. Instead, Chorpita and col- Finally, the special section concludes with an incisive reply
leagues propose a shift in emphasis to focus on knowledge man- from Kazdin and Blase (2011a, this issue). As evidenced both
agement: novel approaches to develop, administer, and organize by their provocative, original article and by the strong response
interventions. They outline a variety of strategies that can be it has already elicited in the field, change is afoot in interven-
used to aggregate our existing knowledge, such as discerning the tion science. These commentaries flesh out many of Kazdin
essential “practice elements” to treat a given set of symptoms by and Blase’s suggestions and highlight the diverse means by
looking at which clinical procedures are commonly associated which these issues are being tackled. Kazdin and Blase pro-
with good treatment outcomes across clinical trials. vide an exciting forum for conceptualizing, implementing, and
Idit Shalev and John Bargh (2011, this issue) share an inno- disseminating strategies aimed at reducing the burden of men-
vative proposal to leverage priming strategies developed by tal illness. The current special section continues this important
experimental social psychologists for the modification of non- conversation.
conscious processes that perpetuate maladaptive behavior.
They describe how a variety of simple visual or physical expe- Declaration of Conflicting Interests
riences (e.g., inducing feelings of physical warmth) could be The author(s)declared no potential conflicts of interest with respect
used to promote feelings of social warmth, goals of emotion to the research, authorship, and/or publication of this article.

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Introduction to Special Section 477

Funding Kazdin, A.E., & Blase, S. L. (2011b). Rebooting psychotherapy

The author(s) received no financial support for the research, author- research and practice to reduce the burden of mental illness. Per-
ship, and/or publication of this article. spectives on Psychological Science, 6, 21–37.
Kessler, R. C., Demler, O., Frank, R. G., Olfson, M., Pincus, H. A.,
References Walters, E. E., . . . Zaslavsky, A. M. (2005). Prevalence and treat-
Atkins, M., & Frazier, S. (2011). Expanding the toolkit or chang- ment of mental disorders, 1990 to 2003. New England Journal of
ing the paradigm: Are we ready for a public health approach Medicine, 352, 2515–2523.
to mental health? Perspectives on Psychological Science, 6, Kessler, R. C., & Wang, P. S. (2008). The descriptive epidemiology
483–487. of commonly occurring mental disorders in the United States.
Baker, T. B., McFall, R. M., & Shoham, V. (2008). Current status and Annual Review of Public Health, 29, 115–129.
future prospects of clinical psychology: Toward a scientifically Shalev, I., & Bargh, J. (2011). Use of priming-based interventions to
principled approach to mental and behavioral health care. Psy- facilitate psychological health. Commentary on Kazdin and Blase
chological Science in the Public Interest, 9, 67–103. (2011). Perspectives on Psychological Science, 6, 488–492.
Chorpita, B., Rotheram-Borus, M. J., Daleiden, E., Bernstein, A., Shoham, V., & Insel, T. R. (2011). Rebooting for whom? Portfolios,
Cromley, T., Swendeman, D., & Regan, J. (2011). The old solu- technology, and personalized intervention. Perspectives on Psy-
tions are the new problem: How do we better use what we already chological Science, 6, 478–482.
know about reducing the burden of mental illness? Perspectives Sloan, D. M., Marks, B. P., & Keane, T. M. (2011). Reducing the burden
on Psychological Science, 6, 493–497. of mental illness in military veterans: Commentary on Kazdin and
Kazdin, A. E., & Blase, S. L. (2011a). Interventions and models Blase (2011). Perspectives on Psychological Science, 6, 503–506.
of their delivery to reduce the burden of mental illness: Reply Yates, B. (2011). Delivery systems can determine therapy costs and
to commentaries. Perspectives on Psychological Science, 6, effectiveness, more than type of therapy. Perspectives on Psycho-
507–510. logical Science, 6, 498–502.

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 Perspectives on Psychological Science

Rebooting for Whom? Portfolios, 6(5) 478–482

© The Author(s) 2011
Reprints and permission:
Technology, and Personalized Intervention sagepub.com/journalsPermissions.nav
DOI: 10.1177/1745691611418526
http://pps.sagepub.com

Varda Shoham1,2 and Thomas R. Insel2

1
University of Arizona, Tucson, and 2National Institute of Mental Health, Bethesda, MD

Abstract
We share Kazdin and Blase’s (2011) sense of urgency about finding better ways to reduce the burden of mental illness.
Although effective psychosocial treatments exist, they do not often reach the patients who need them most. Kazdin and Blase’s
portfolio approach aims to cast a wider net through increased use of technology, media, self-help, nonprofessional providers, and
collaborations with other disciplines. It is unclear, however, whether reaching more people would suffice to reduce the burden
of mental illness, much less offset the small effect sizes of simplified, scaled-down interventions such a portfolio approach would
likely entail. We focus here on an underdeveloped theme in Kazdin and Blase’s essay—that bending the curve of mental illness
will require better knowledge of for whom simplified intervention and prevention strategies will suffice and for whom more
intensive intervention is necessary. Such “for whom” questions deserve a central place on the national research agenda as we
move toward individualized or personalized health care. In the absence of such knowledge, we risk treatment decisions guided
by accessibility to resources rather than patient needs—the very problem Kazdin and Blase aim to solve.

Keywords
treatment, mental illness, personalized intervention

We share Kazdin and Blase’s (2011) sense of urgency about treatment does not necessarily mean less burden, especially if
finding better ways to reduce the burden of mental illness. the treatment is insufficient or inappropriate.
Although effective psychosocial treatments exist, they often In this commentary, we focus mainly on an underdeveloped
do not reach the patients who need them most. Kazdin and theme in Kazdin & Blase’s essay—that bending the curve of
Blase’s portfolio approach aims to cast a wider net of empiri- mental illness will require better knowledge of for whom sim-
cally supported interventions through increased use of tech- plified intervention and prevention strategies will suffice and
nology, media, self-help, nonprofessional providers, and for whom more intensive intervention is necessary. In our
collaborations with other disciplines. The authors’ off-the- view such “for whom” questions deserve a more central place
shelf examples provide an intriguing glimpse of what this on the national research agenda as we move toward individu-
could look like and usefully bridge the artificial boundary alized or personalized health care. In the absence of such
between prevention and treatment. Because efficacious treat- knowledge, we risk treatment decisions guided by accessibil-
ments will usually require simplification for portfolio dissemi- ity to resources rather than patient needs—the very problem
nation, we especially appreciate Kazdin and Blase’s cautionary Kazdin and Blase aim to solve.
note about the importance of understanding how these treat-
ments work. Without such knowledge, an abbreviated (though
more accessible) intervention could unwittingly sacrifice Which Treatments for Whom?
essential mechanisms of change. As the cornerstone of personalized intervention, research on
Although reaching more people is a laudable aim, it is not prospective treatment moderators (what works for whom) nec-
clear whether this by itself will reduce the burden of mental ill- essarily cuts across a wide range of case and treatment charac-
ness, much less offset the small effect sizes of simplified, scaled- teristics. The basic question in this Attribute × Treatment
down interventions such a portfolio approach would likely Interaction (ATI) paradigm is which cases characteristics
entail. It is interesting that the same National Comorbidity Study
the authors cite for burden statistics demonstrated a 50%
Corresponding Author:
increase in treatment between 1991 and 2001 without any Varda Shoham, Department of Psychology, University of Arizona, 1503 E.
decrease in prevalence or morbidity (Kessler, Berglunk, Borges, University Boulevard, Tucson, AZ 85721
Nock, &Wang, 2005; Kessler et al., 2005). Apparently, more E-mail: [email protected]

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Rebooting for Whom? 479

moderate (interact with) which treatment conditions to predict patient’s trauma history are associated with better response to
clinical outcomes. Because the most conspicuous case-level a variant of cognitive behavior therapy than to antidepressants
moderators—psychiatric diagnosis—have not proved terribly (Nemeroff et al., 2003). Similarly, looking beyond the patient,
useful for guiding psychosocial intervention, the search for the quality of family or couple communication appears to
meaningful moderators has recently expanded to include such moderate the success of family- and couple-focused treat-
diverse factors as current and historical problem severity, cog- ments (Miklowitz et al., 2009; Shoham, Rohrbaugh, Stickle, &
nitive processes, and characteristics of the family social envi- Jacob, 1998).
ronment. There is equal or greater diversity on the treatment Despite these advances, we are still a long way from having
side, in which Kazdin and Blase’s big-menu portfolio approach a sufficient body of evidence to guide psychosocial variants of
now ups the ante on answering “for whom” questions to guide personalized medicine based on treatment-matching algo-
selection of interventions. And this is not to mention an even- rithms. Part of the problem is that current evidence based on
more pressing ATI question where serious mental illness is statistical significance often lacks clinical significance. Our
concerned—namely, for whom will combined psychosocial search for moderators is still very much in a discovery phase,
intervention and pharmacotherapy be more beneficial than and the clinical value of any discoveries will ultimately need
either modality alone (Nemeroff et al., 2003). to be tested in clinical trials with patients stratified on putative
Psychosocial ATI research is not new, dating back at least moderator variables.
to Cronbach and Snow (1977), and its history has included Where can we expect to discover the most promising mod-
both excitement and disappointments. For example, the hope erators? The horizon includes several promising developments
engendered by early ATI findings in psychotherapy research we think are worth mentioning. One is the Research Domain
(e.g., Beutler, 1991; Shoham-Salomon & Hannah, 1991) was Criteria (RDoC) project at the National Institute of Mental
dampened by the high-profile failure of Project Match Health (NIMH; Insel & Cuthbert, 2009; Sanislow et al., 2011),
Research Group (1997) to find significant moderators of alco- which is attempting to ground the patient attribute (A) side of
holism treatments. Factors limiting the yield of ATI research the ATI equation in underlying neurobiological dimensions of
include investigation of post hoc, hard-to-replicate modera- psychopathology. Given the high variability in pathophysiol-
tors; moderators unrelated to theory-derived, hypothesized ogy among patients diagnosed with the same disorder (as
mechanisms of change; underpowered tests of moderation; determined by the Diagnostic and Statistical Manual of
comparisons among similar or overlapping treatments (as in Mental Disorders), variability in treatment response among
Project MATCH), which limits moderator detection; and patients similarly classified is not surprising. The science-
unbalanced measurement of A and T variables, in which based, bottom-up RDoC approach to mental disorders aims to
researchers assess case attributes (As) in precise detail while establish validity in ways that may ultimately align better with
documenting treatments (and treatment fidelity) only grossly. treatment response.
Shulman (1981) noted years ago this tendency to measure As Other promising developments are methodological. For
with micrometers and Ts with divining rods. example, new applications of so-called adaptive randomized
Despite this checkered history, recent years have seen a designs can illuminate the most efficient and effective sequenc-
burgeoning interest in treatment moderators, and preliminary ing of several interventions rather than just one—as when non-
findings highlight the importance of pursuing this line of responders to a first-line intervention receive more intensive
research more vigorously than we have so far. Thus, regarding treatment in a stepped-care framework (Collins, Dziak, & Li,
cognitive treatments for depression, there is good evidence 2009; Collins, Murphy, & Srecher, 2005). These adaptive
that optimal treatment selection depends on factors such as age designs are also well suited for testing treatment moderators,
of illness onset (Jarrett et al., 2001), current and historical including for whom starting with a “light” version of a given
symptom severity (Bockting et al., 2005; Fournier et al., 2011), treatment might ultimately prove iatrogenic or counterproduc-
and patient preference for pharmacological or psychosocial tive. One could approach this question either sequentially, as
intervention (Kocsis et al., 2009). Similarly, in the schizophre- in adaptive design research, or simultaneously, by considering
nia domain, a patient’s age at treatment initiation appears to moderators of pared-down interventions in the population
moderate the effects of cognitive rehabilitation (CR) interven- more broadly.
tions, such that younger patients (< 40) benefit more than A related innovation is the Kraemer, Wilson, Firburn, and
older patients from receiving CR (McGurk & Mueser, 2008; Agras (2002) approach to creating moderator profiles.
Wykes et al., 2009). Whereas traditional ATI research employing group factorial
A more promising class of potential treatment moderators designs typically stumbles on the prospect of multiple inter-
relates to theory-derived mechanisms of problem formation or acting moderators—Cronbach’s (1975, p. 119) “hall of mirrors
problem maintenance. For example, there is evidence that that extends to infinity”—the Kraemer et al. method allows for
baseline levels of maladaptive cognitions hypothesized to testing multiple moderators and identifying the strongest ones
maintain depressive symptoms serve to moderate the success via a probability index of replication (prep) instead of the tradi-
of cognitive-behavior therapies relative to control conditions tional significance level. Thus, a prep ≤ .90 indicates that there
(Hollon et al., 2005) and that theory-relevant aspects of a is at least a 90% chance to replicate the moderator’s effect

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480 Shoham and Insel

with a new sample from the same population, provided that the Imagine what just a fraction of that accomplishment could
effect size of the moderator is at least as strong as the effect mean for mental health.
size of the treatment. This then leads to hypothesis-testing A promising line of prevention research involves early
studies in which prospective, empirically based moderators stage intervention with major mental illnesses such as schizo-
serve as stratification variables. phrenia and bipolar disorder. For example, a combination of
In a notable application of this moderator-profile approach, features now allows detecting the prodrome of schizophrenia
Vittengl, Clark, and Jarrett (2010) investigated which respond- with more than 80% accuracy in adolescents who have not yet
ers require continuation-phase cognitive therapy (CT) to become psychotic (Cannon et al., 2008). Further along in the
achieve stable remission of depressive symptoms and which prevention spectrum, characteristics of the family environ-
could sustain positive treatment outcomes without further ment moderate how adolescents with early-stage bipolar dis-
intervention. Based on examining a range of plausible and par- order respond to psychosocial interventions combined with
tially overlapping moderators in a hypothesis-generation medication; here a family-focused approach appears to be
framework, Vittengl et al. found that a profile including most beneficial—and perhaps essential—for families showing
younger current age and younger age of onset in combination high “expressed emotion” (criticism, hostility, and emotional
with high social inhibition and emotional detachment served overinvolvement) in relation to the patient (Miklowitz et al.,
to discriminate the criterion groups. They are now seeking to 2009).
replicate this profile result in a prospective, hypothesis-testing This approach of personalized and preemptive interven-
design that could solidify an empirical basis for providing tions is a major focus of the NIMH Strategic Plan (www
continuation CT. The investigators speculate that continuation .nimh.nih.gov/about/strategic-planning-reports/index.shtml).
CT may be “too little, too late” for some older patients, Beyond studies of the prodrome of schizophrenia and bipolar
which brings us to the crucial role of “for whom” research in disorder, we have launched a broad effort on biomarkers that
prevention. could serve as moderators or predictors of response. One such
study, EMBARC (which stands for Establishing Moderators/
Mediators for a Biosignature of Antidepressant Response in
Prevention for Whom? Clinical Care), is combining genomics, imaging, quantitative
Kazdin and Blase note that “the portfolio idea would be ben- EEG, and cognitive measures to develop a profile or biosigna-
eficial for conceptualizing the task of prevention because it ture of antidepressant response. In another effort, the Study to
begins with who ought to be reached in the population, what Assess Risk and Resilience in Soldiers, we are looking for pre-
interventions are likely to accomplish that for various groups, dictors of posttraumatic stress disorder and depression in sol-
and what the effects are” (p. 28). This important point deserves diers. And in another, we are following younger siblings of
further development: On one hand, the potential payoffs from children with autism to identify the earliest signs of this disor-
well-targeted preventive intervention could be enormous. On der. We hope that the identification of such risk factors will
the other hand, without better understanding of who benefits translate into treatment moderators, thus leading to better tar-
from which prevention strategies, we risk shooting in the dark geted interventions.
and hitting targets indiscriminately, which could be costly and
even iatrogenic. Most important, we need to understand risk
and resilience at an individual level. Despite some good leads Technology for Whom?
on risk factors from both the nature (genetics) and nurture Technology-assisted treatments are surely here to stay, but
(experience) sides of the mental illness equation, we do not yet these too need better targeting to be efficient. Such interven-
have biomarkers or psychological attributes with high predict- tions, sometimes referred to as e-Health (Baker, McFall, &
ability for any individual. Shoham, 2008), are highly replicable and portable and thus
Like physical illnesses, most mental disorders have a clear easy to disseminate. Computer-based e-Health interventions
developmental trajectory. It is disconcerting in this respect that have the additional virtue of permitting exposure to diverse
treatment for mental disorders begins on average 11 years realistic contexts achieved via virtual reality capabilities
after problem onset (Wang et al., 2005). The field of medicine (Bordnick et al., 2008), and they have the potential to reduce
has rarely reduced the burden of any illness when initial inter- utilization of more expensive health care options (Boberg
vention takes place so long after onset. Observable symptoms et al., 1995). Because e-Health interventions allow for some
of mental illness, possibly reflecting underlying biological tailoring based on a variety of patient characteristics (Strecher
processes, may have a relatively long latency period. Add to et al., 2005), we were surprised that Kazdin and Blase do not
this the long delay for treatment, and prospects for reducing emphasize this.
the burden of mental illness appear even more daunting. At the Although technology could prove a game changer, it may
risk of medicine envy, it is worth noting that early detection of also have some unintended consequences. As commentators
specific risk factors coupled with “for whom” risk factor like Abraham Verghese (2011) have pointed out, the com-
reduction interventions has enabled cardiology to realize a plaints we hear from patients, family, and friends are rarely
60% reduction in mortality from coronary artery disease. about the dearth of technology but about its excesses, turning

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Rebooting for Whom? 481

patients into “i-patients.” In the “which treatments for whom” Boberg, E. W., Gustafson, D. H., Hawkins, R. P., Peressini, T., Chan,
framework of ATI research, we know virtually nothing about C., & Bricker, E. (1995). Development, acceptance and use pat-
the treatments for which, or the patients for whom, a human terns of a computer-based education and social support system
relationship or therapeutic alliance is essential to productive for people living with AIDS/HIV infection. Computers in Human
behavior change. Without such knowledge, even in a best-case Behavior, 11, 289–312.
scenario, e-Health will to some extent require shooting in the Bockting, C. L. H., Schene, A. H., Spinhoven, P., Koeter, M. W. J.,
dark. A worst-case scenario is that e-Health interventions could Wouters, L. F., Huyser, J., & Kamphuis, J. H. (2005). Preventing
“spend out” some of our most effective techniques, rendering relapse/recurrence in recurrent depression with cognitive therapy:
them less amenable to subsequent, face-to-face intervention. A randomized controlled trial. Journal of Consulting and Clinical
It bears repeating that technology-based intervention portfo- Psychology, 73, 647–657.
lios imply simplifying and abbreviating treatments that were Bordnick, P. S., Traylor, A., Copp, H. L., Graap, K. M., Carter, B.,
empirically, even experimentally, supported in their original for- Ferrer, M., & Walton, A. P. (2008). Assessing reactivity to virtual
mat. Yet, by Kazdin’s (2007) own account, the field does not reality alcohol based cues. Addictive Behaviors, 33, 743–756.
know much (and certainly not enough) about how multicompo- Cannon, T. D., Cadenhead, K., Corhblatt, B., Woods, S. W., Adding-
nent or even simple psychosocial interventions actually work. ton, J., Walker, E., . . . Heinssen, R. (2008). Prediction of psycho-
Apart from the problem of abbreviated (if more accessible) sis in youth at high clinical risk: A multisite longitudinal study in
interventions sacrificing essential mechanisms of change, we North America. Archives of General Psychiatry, 65, 28–37.
worry that pared-down portfolio interventions gaining prema- Collins, L. A., Dziak, J. J., & Li, R. (2009). Design of experiments
ture adoption in community settings will yield effects no larger with multiple independent variables: A resource management
than those for “treatment as usual,” which are very small. The perspective on complete and reduced factorial designs. Psycho-
e-Health picture may well improve as additional efficacy and logical Methods, 14, 202–224.
effectiveness data accumulate, but in our view the “which treat- Collins, L. A., Murphy, S. A., & Srecher, V. (2005). The multiphase
ment for whom” question will not soon go away. optimization strategy (MOST) and the sequential multiple assign-
On balance, Kazdin and Blase do the field an important ment randomized trail (SMART): New methods for more potent
service by highlighting the diverse ways in which technology e-Health interventions. American Journal of Preventive Medi-
could enhance the world of psychotherapy. We are hopeful cine, 32, S112–S118
that the increased access and increased flexibility of this Cronbach, L. J. (1975). Beyond the two disciplines of scientific psy-
approach will deliver improved outcomes. At the same time, chology. American Psychologist, 30, 116–126.
we would caution that technology is a tool, not an answer: Cronbach, L. J., & Snow, R. E. (1977). Aptitude and instructional
With a better understanding of how and for whom technology- methods: A handbook for research on interactions. New York,
assisted treatments work (see Amir, Taylor, & Donohue, in NY: Irvington.
press, for a promising example of this), mental health profes- Fournier, J. C., DeRubeis, R. J., Hollon, S. D., Dimidjian, S., Amsterdam,
sionals should be in a better position to personalize psychoso- J. D., Shelton, R. C., & Fawcett, J. (2011). Antidepressant drug effects
cial intervention and ultimately reduce the burden of mental and depression severity: A patient-level meta-analysis. Journal of the
illness. American Medical Association, 301, 47–53.
Hollon, S. D., DeRubeis, R. J., Shelton, R. C., Amsterdam, J. D.,
Declaration of Conflicting Interests Salomon, R. M., O’Reardon, J. P., . . . Gallop, R. (2005). Pre-
The author(s)declared no potential conflicts of interest with respect vention of relapse following cognitive therapy vs. medication in
to the research, authorship, and/or publication of this article. moderate to severe depression. Archives of General Psychiatry,
62, 417–422.
Funding Insel, T. R., & Cuthbert, B. N. (2009). Endophenotypes: Bridging
The author(s) received no financial support for the research, author- genomic complexity and disorder heterogeneity. Biological Psy-
ship, and/or publication of this article. chiatry, 66, 988–989.
Jarrett, R. B., Kraft, D., Doyle, J., Foster, B. M., Eaves, G. G., &
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 Perspectives on Psychological Science

Expanding the Toolkit or Changing the 6(5) 483­–487

© The Author(s) 2011
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DOI: 10.1177/1745691611416996

Health Approach to Mental Health? http://pps.sagepub.com

Marc S. Atkins and Stacy L. Frazier

University of Illinois at Chicago

Abstract
Kazdin and Blase aptly describe the enormous mental health burden facing our nation and suggest several ways to reform the
workforce, setting, and content of services to address this long-standing unmet need. We propose that current health care
reform legislation and associated advances in service delivery provide a unique and timely opportunity for a paradigm shift
in mental health research, practice, and training to support services that are comprehensive, readily accessible, and relevant
to a broad range of mental health needs and capacities. Using the recent public health initiative to contain the H1N1 virus
for comparison, and informed by a long-standing and extensive literature documenting the need for a public health model for
mental health, we describe the rationale for a three-tiered public mental health model, illustrated with examples from ongoing
research, to minimize universal risk for mental health difficulties via capacity building in natural settings; reduce onset and
severity of symptoms by prioritizing high-risk groups via screening and services for targeted populations; and reduce psychiatric
impairment among individuals with more intensive needs via individual, family, and group interventions. New priorities for
clinical science to support a public health approach are proposed.

Keywords
public health, policy, treatment

In March 2009, the World Health Organization (WHO) worldwide epidemic. Notably, necessary reactive measures
received reports of deaths in Mexico from a new strain of (e.g., isolate those already infected) were combined with vol-
influenza virus, labeled H1N1 but known generically as swine untary proactive measures (e.g., promote proper hygiene) to
flu. By June, the virus had spread to several countries, includ- limit the spread of infection. In contrast, consider the response
ing the United States, which reported incidences in all states (or lack thereof) of the mental health community to the enor-
and territories. Public health officials braced for the worst. mous mental health burden facing our nation, aptly described
Facing the possibility of a worldwide epidemic, the WHO by Kazdin and Blase and widely acknowledged for decades as
declared a pandemic alert and initiated a public health response highlighted in the historic Surgeon General’s report of mental
with three interrelated goals: an intensive intervention to iso- health published at the turn of the millennium. As Dr. Satcher
late and treat infected patients with antiviral drug therapy, a notes in his preface, “Even more than other areas of health and
targeted intervention for at-risk populations (e.g., elderly, medicine, the mental health field is plagued by disparities in
pregnant woman, young children) for immediate distribution the availability of and access to its services . . . viewed readily
of the newly developed vaccine, and a universal public health through the lenses of racial and cultural diversity, age, . . .
campaign to limit the spread of infection through proper gender . . . (and) a person’s financial status” (U.S. Public
hygiene (e.g., hand-washing, coughing into one’s elbow). Health Service, 2000).
With these efforts, nearly 80 million people in 77 countries We commend Kazdin and Blase for raising the urgency of
received the vaccine and a worldwide epidemic was averted. these issues among the clinical science community, but we
Although not without problems (World Health Organization, are concerned that their recommendations, though often
2011), this was the largest and most successful public health
response to an emerging crisis in over 40 years.
Corresponding Author:
As we reviewed the Kazdin and Blase article, we reflected Marc S. Atkins, University of Illinois at Chicago, Institute for Juvenile
on lessons learned from the international public health com- Research (MC 747), 1747 W. Roosevelt Rd., Chicago, IL 60608
munity's coordination of a multilevel intervention to avert a E-mail: [email protected]
484 Atkins and Frazier

innovative, may serve to increase the toolkit rather than approach to mental health, including specific examples from
transform the paradigm. Similarly, although we greatly our own work, as much to show the urgent need for additional
appreciate their call for the integration of prevention and research as to illustrate opportunities for change.
intervention, we suggest, as others have before, that the
problems are so long standing, so vast, and so unresponsive
to current methods and models that a new comprehensive Universal
approach that utilizes levers of change at multiple levels is We have elsewhere proposed a model for mental health pro-
required. In particular, there will be no resolution of the motion at the universal level that enhances the natural synergy
nation’s unmet mental health needs without recognition of between community settings and mental health (Cappella,
the social determinants of health (Wilkinson & Marmot, Frazier, Atkins, Schoenwald, & Glisson, 2008; Frazier,
2003) and the synergy that is created by distinct but comple- Cappella, & Atkins, 2007). Shifting prevention to natural set-
mentary efforts along the continuum from prevention to tings (e.g., schools, park districts, community centers) makes
intervention. sense for two primary reasons. First, mental health promotion
We also note that, in another way, the timing of the Kazdin already lies at the heart of most natural settings, whose goals,
and Blase article could not be more propitious given current routines, and activities are inherently designed to foster skills
innovations in health care and recently enacted health care building, positive relationships, and healthy functioning. Sec-
reform legislation. As reviewed by Frank (2011), the Patient ond, there is an extensive empirical literature to suggest that
Protection and Affordable Care Act includes three primary frontline staff often struggle to provide high-quality services
levers of change: parity for mental health services as fully or meet the extensive needs of youth or families in their care
integrated with other health services, specific provisions for (e.g., Larson & Walker, 2010; Pianta, Belsky, Houts, &
funding mental health promotion and prevention services, and Morrison, 2007). Borrowing from an organizational perspec-
the inclusion of community mental health centers in the defini- tive, we propose that supporting a natural setting means
tion of a “health home” (cf. Alakeson, Frank, & Katz, 2010). strengthening organizational capacity to achieve its mission
In addition, the WHO recently issued a fact sheet on mental and goals by supporting staff to effectively implement its core
health that could become a driver of mental health policy, technology (i.e., deliver high-quality service) so that consum-
research, and practice and, we suggest, promote a reordering ers of that service derive the most benefit out of their participa-
of priorities for clinical science (World Health Organization, tion in that setting. By example, we have been pursuing a
2010). Most notably, WHO emphasizes “intersectoral strate- program of research in collaboration with the Chicago Park
gies” that deemphasize mental disorders to focus on “main- District that examines the capacity of recreational after-school
streaming mental health promotion into policies and and summer programs to promote children’s mental health in
programmes in government and business sectors.” Nationally urban, poor communities (Frazier et al., 2007).
and internationally, the balance is tipping in favor of a para- To illustrate, extensive empirical data suggest that after-
digm shift towards comprehensive models to alleviate mental school programs can play a critical role in children’s psycho-
health suffering, social development, especially for children living in
The compelling case for a public health framework—and a communities of concentrated urban poverty (Durlak, Mahoney,
three-tiered approach in particular—to address the persistent Bohnert, & Parente, 2010). Despite their potential, however,
barriers to accessible and effective mental health services has program impact is often compromised by the extensive mental
been made before: in the Surgeon General’s (2000) report, health needs of children and the pervasive poverty in which
with further detail and emphasis in the recent Institute of Med- they live. Hence, we are pursuing two concurrent pathways.
icine's report on prevention of youth mental health disorders First, we are examining the feasibility and impact of commu-
(Institute of Medicine, 2009), and most recently and succinctly nity mental health agency consultation to recreation staff
by Stiffman, Stelk, Evans, and Atkins (2010). All of these around academic enrichment, coaching behaviors, activity
reports recognize that a shift towards the efficient and effec- engagement, and behavior management (Frazier, Chacko, Van
tive implementation of a coordinated and comprehensive Gessel, Boyle, & Pelham, in press). Second, we are working
three-tiered approach to mental health will involve many chal- with lead administrators to examine and expand their organi-
lenges, including a reallocation of resources (e.g., Kelleher, zational capacity to offer systematic training, professional
2010), a retooling of the workforce (Schoenwald, Ringeisen, development, and comprehensive support to their recreation
Hoagwood, Evans, & Atkins, 2010), and a broader reconcep- leaders and physical instructors. Both efforts converge around
tualization of mental health promotion that includes healthy the goal of improving service delivery and outcomes for youth
functioning across domains (e.g., cognitive, social, physical) participating in out-of-school-time programs.
and settings (e.g., home, school, work; M. Atkins, Hoagwood,
Kutash, & Seidman, 2010). Our goal in this commentary is not
to reiterate these already well-articulated justifications for a Targeted
public health approach to mental health. Instead, we hope to As is true for any public health problem, universal interven-
extend this vision by describing components of a three-tiered tions are necessary but not sufficient to address the enormous
A Public Health Approach to Mental Health 485

mental health burden facing our nation. They will produce impairment. In turn, our nation's limited pool of mental health
far less impact by themselves than if they are implemented as providers would be at liberty to serve the smaller subset of
part of a comprehensive model, with unique but synergistic individuals whose intensive mental health needs warrant more
efforts at each level of intervention. When implemented suc- extensive treatment. For example, returning to the after-school
cessfully, universal interventions would reduce the risk for and school-based work noted earlier, we anticipate the need
mental health problems and limit the numbers of individuals for more intensive services in classrooms and homes, as new
who enter this level of need. It follows, then, that targeted findings indicate personal characteristics and settings that are
interventions would prioritize care for high-risk groups via unresponsive to the service model. Indeed, it is at this level of
indicated outreach, screenings, and services. Examples of the pyramid—this end of the continuum from prevention to
high-risk groups might include children of parents with men- intervention—that Kazdin and Blase’s innovative recommen-
tal illness, families living in poverty, or individuals exhibit- dations for new psychotherapy tools are most relevant and
ing subclinical symptoms or early evidence of impaired most ripe for close empirical examination.
functioning. Targeted interventions can be integrated into It is also worth noting that trends would predict that the
both community and clinical settings, as illustrated in our highest rates of unmet mental health need at this tier still
earlier example. However, perhaps unlike natural settings would emerge from targeted groups at highest risk, thereby
that are designed for entire communities, targeted interven- justifying the need to allocate resources for early intervention.
tions may be more readily incorporated into settings such as Hence, to meet the needs at this most intensive level, we need
primary-care offices, emergency rooms, and social service to follow a variety of paths that extend beyond the most tradi-
agencies inherently committed to identifying and reducing tional clinical research and practice models, as Kazdin and
risky behaviors via health screenings, community outreach, Blase note quite clearly.
psycho-educational activities, and early intervention. However, early efforts to move efficacious treatments from
The consultation of mental health providers to after-school university-based clinical trials into community care settings
staff noted above is one example of integrating universal and revealed the extensive challenges associated with implementa-
targeted interventions. As another example of a targeted inter- tion. As highlighted with some frequency in the literature (e.g.,
vention with universal components, we are studying a Medic- Weiss, Doss, & Hawley, 2005), the long-standing science-to-
aid fee-for-service, school-based mental health model for service gap in large part emanates from the fact that most
urban, low-income children and families that is guided by evidence-based treatments have been developed with samples
empirical evidence for schooling as critical for children's of patients and providers whose characteristics fail to repre-
social and emotional adjustment and by evidence for the sent those in routine care settings.
direct and indirect benefits of academic achievement for chil- Fortunately, the last decade has given rise to several new
dren's mental health (Cappella et al., 2008). In a series of areas of research, each helping to close the research to practice
iterative studies, we have identified teacher-referred children gap. For example, transportability studies emphasize training,
in early elementary grades exhibiting disruptive behaviors supervision, fidelity, and feedback mechanisms to examine
that impair classroom functioning and interfere with aca- what it will take to achieve outcomes that approach those
demic progress. Community mental health providers, parent reported in efficacy studies (Schoenwald & Hoagwood, 2001).
advocates, and peer-identified teacher key opinion leaders Alternatively, Hoagwood and colleagues proposed the clinic–
(M. S. Atkins et al., 2008) together receive training and super- community intervention development model, which includes
vision in the implementation of evidence-based tools for the eight steps that begin with intervention development and end
key empirical classroom and home predictors of children's with dissemination and sustainability. Unique to this model is
learning. This ongoing work links universal (classroom-wide) its emphasis on starting and ending in community settings
and targeted (services for high need youth) levels to redefine with the providers and consumers for whom the interventions
mental health goals, mobilize natural and indigenous are intended (Hoagwood, Burns, & Weisz, 2002). Most
resources, and capitalize on the inherent capacity of natural recently, Chorpita and colleagues introduced a “common ele-
settings to promote children’s healthy development (M. ments” approach to service delivery, responding to the limited
Atkins et al., 2006, 2011). time and opportunity in community settings for clinician
training and supervision in evidence-based interventions
(Chorpita, Deleiden, & Weisz, 2005). They identified 30 core
Intensive intervention components that have high impact and broad rel-
As noted by Kazdin and Blase, current rates of mental illness evance (e.g., differential attention, relaxation training social
diagnoses in our country exceed the availability of mental problem-solving), and packaged them in a website designed
health providers, resulting in an enormous mental health bur- specifically for community-based service providers (Chorpita,
den. The infusion of resources at universal and targeted levels Becker, & Deleiden, 2007). This approach is currently being
of intervention is designed to reduce the prevalence of mental implemented nationally with ongoing evaluation and appears
health disorders, thus reducing the number of individuals to have great promise to bring evidenced-based practice to
exhibiting clinical symptoms or more severe functional scale.
486 Atkins and Frazier

Final Thoughts and predictors of learning in urban schools (National Institute of

Mental Health R01MH073749). Bethesda, MD: National Insti-
The long-standing mental health burden facing our nation is tute of Mental Health.
too vast and too impervious to change to be resolved by the Atkins, M., Hoagwood, K., Kutash, K., & Seidman, E. (2010).
fragmented approach that exists today. We thank Kazdin and Towards the integration of education and mental health in
Blase for highlighting the enormity and urgency of the prob- schools. Administration and Policy in Mental Health and Mental
lem for the clinical science community, though we suggest Health Services Research, 37, 40–47.
that a primary focus on revising psychotherapy, however inno- Atkins, M. S., Frazier, S. L., Leathers, S. J., Graczyk, P. A., Talbott, E.,
vative, addresses a relatively small proportion of the problem. Jakobsons, L., . . . Bell, C. C. (2008). Teacher key opinion lead-
As we have described, there is strong consensus that only a ers and mental health consultation in low-income urban schools.
comprehensive and integrated public health model can ade- Journal of Consulting and Clinical Psychology, 75, 905–908.
quately address the pervasive societal problems that underlie Cappella, E., Frazier, S., Atkins, M., Schoenwald, S., & Glisson, C.
our country’s mental health needs. Recent innovations in (2008). Enhancing schools’ capacity to support children in pov-
health care reform and newly enacted legislation provide a erty: An ecological model of school-based mental health services.
unique and timely opportunity to advance comprehensive Administration and Policy in Mental Health and Mental Health
models of mental health practice. Services Research, 35, 395–409.
The ongoing programs of research we have presented are Chorpita, B., Becker, K., & Deleiden, E. (2007). Understanding the
attempting to meet the need for new models of mental health common elements of evidence-based practice: Misconceptions
service delivery. We offer them to augment the recommenda- and clinical examples. Journal of the American Academy of Child
tions by Kazdin and Blase, to address the limitations of tradi- & Adolescent Psychiatry, 46, 647–652.
tional psychotherapy, and to counter the tendency of our field Chorpita, B., Deleiden, E., & Weisz, J. (2005). Identifying and selecting
to Balkanize prevention and intervention. Our field continues the common elements of evidence based interventions: A distillation
to allocate the most time and resources to the intensive tier of and matching model. Mental Health Services Research, 7, 5–20.
intervention (i.e., evidence-based treatments), whereas a pub- Durlak, J. A., Mahoney, J. L., Bohnert, A. M., & Parente, M. E.
lic health approach suggests that we would have more success (2010). Developing and improving after school programs to
if comparable effort were allocated to coordinated care. We enhance youth’s personal growth and adjustment: A special issue
acknowledge that none of the models or examples is without of AJCP. American Journal of Community Psychology, 45, 285–
limitation or immune from criticism and all are in need of fur- 293.
ther research and development. In fact, that is our very point in Frank, R. (2011, April). Reforming the problem of disparities: Health
highlighting them for this commentary. The clinical science care system change and improved behavioral health. Plenary
community has much to offer in clinical acumen and research presentation at From Disparities Research to Disparities Inter-
expertise. In addition, interdisciplinary research with basic ventions: Lessons Learned and Opportunities for the Future of
science, social science, and clinical allies will strengthen and Behavioral Health Services conference. Arlington, VA.
speed the development of effective strategies to alleviate our Frazier, S. L., Cappella, E., & Atkins, M. S. (2007). After school pro-
nation's mental health burden. To that end, we urge the clinical grams for children in urban poverty: Preventing problems and
science community to heed the long-standing call for a public promoting opportunities. Administration and Policy in Mental
health approach to mental health service delivery and, in par- Health and Mental Health Services Research, 34, 389–399.
ticular, to prioritize a more equitable distribution of resources Frazier, S. L., Chacko, A., Van Gessel, C., O’Boyle, C., & Pelham, W.
across the continuum from prevention to intervention. E. (in press). The summer treatment program meets the south side
of Chicago: Bridging science and service in urban after-school
Declaration of Conflicting Interests programs. Child and Adolescent Mental Health.
The author declared no potential conflicts of interest with respect to Hoagwood, K., Burns, B.J., & Weisz, J.R. (2002). A profitable conjunc-
the authorship or the publication of this article. tion: From science to service in children’s mental health. In B.J.
Burns & K. Hoagwood (Eds.), Community treatment for youth:
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 Perspectives on Psychological Science

Use of Priming-Based Interventions 6(5) 488–492

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DOI: 10.1177/1745691611416993

Commentary on Kazdin and Blase (2011) http://pps.sagepub.com

Idit Shalev and John A. Bargh

Yale University, New Haven, CT

Abstract
Whereas traditional psychological interventions have been conceptualized in terms of deliberate readiness for change (Prochaska
& DiClemente, 1983), emerging findings from social psychology suggest that regulation of behavior can operate independently
of conscious selection and guidance (Bargh & Morsella, 2010). This evidence has come from studies using priming techniques
based on activation of relevant mental representations by external environmental stimuli (Bargh & Chartrand, 2000). Research on
automatic interpersonal processes has shown that feeling of social warmth (Bargh & Shalev, 2011; Williams & Bargh, 2008a) and
the regulation of maladaptive emotions (Williams, Bargh, Nocera, & Gray, 2009), for example, can be induced nonconsciously by
physical sensations, visual images or semantic concepts. Interventions based on the procedure of priming could be administered
by multiple providers and communication devises to regulate emotional states, increase adherence to treatment instructions, or
activate mind-sets that facilitate adaptive functioning. Integrating the methodology of priming and clinical intervention could both
contribute to treatment delivery and enrich our understanding of change processes. We conclude that the use of supplementary
priming-based interventions to facilitate and disseminate psychological change should be encouraged.

Keywords
priming, psychological intervention, embodiment, self regulation, implicit processes, automaticity, emotion regulation, change

Kazdin and Blase (2011) argue that a major shift and expansion (Prochaska & DiClemente, 1983). Because of this belief, sys-
of intervention research and clinical practice is needed to tematic costly efforts are invested in individual treatment
decrease the prevalence and incidence of mental illness. The delivery, and individual-based interventions are not available
goal of decreasing rates of mental illness and improving psycho- for all those in need of services (Kazdin & Blase, 2011).
social functioning on a large scale (i.e., in society) begins with Despite little understanding of the mechanisms of change (i.e.,
challenging basic assumptions as to which components underlie precisely how they work; Kazdin, 2000, 2007), many tradi-
psychological intervention. We ask what school of thought could tional therapies (e.g., psychodynamic therapy) as well as
also be used to ameliorate psychological health problems. Much evidence-based approaches (e.g., cognitive therapy) are
of our evidence has come from studies of automaticity using focused on capturing nonconscious maladaptive patterns and
priming techniques, which refer to the passive, subtle, and unob- challenging them through the use of strategies for arousal of
trusive activation of relevant mental representations by external awareness (e.g., emphasis on insight; Messer & McWilliams,
environmental stimuli, including exposure to semantic concepts, 2007; challenging automatic thoughts; Beck, 1997). Though
short messages, visual images, and physical sensations (Bargh & most behavioral interventions highlight mechanisms other
Chartrand, 2000). To integrate the notions of automaticity and than awareness (e.g., exposure; Foa & Kozak, 1986; behav-
clinical intervention, we discuss basic assumptions underlying ioral activation; Lewinsohn, 1975; behavior modification;
priming-based intervention as compared with traditional inter- Kazdin, 1980), these techniques mostly involve conscious
ventions and demonstrate uses of priming-based procedures to volitional engagement on the part of the patient.
activate and facilitate psychological change. In traditional personality psychology, techniques based on
arousal of awareness were supported by the idea that a conscious,
Nonconscious Source of
Psychological Change Corresponding Author:
Idit Shalev, Institute of Social and Policy Studies,Yale University, New Haven,
Traditional psychological interventions have been conceptual- CT, 06520, USA
ized in terms of the client’s deliberate readiness for change E-mail: [email protected] or [email protected]

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Priming-Based Intervention 489

agentic self is posited to be the ultimate controller of individual and hence could activate one another or be used strategically
human behavior (Bargh, Gollwitzer, & Oettingen, 2010). There- for psychological intervention.
fore, change will only be resulted by volitional engagement to One example for translating this associative mechanism
defeat automatic responses. Similarly, traditional social psy- into potential population-based intervention is the close asso-
chology research on self-regulation suggests that success or ciation of physical and psychological warmth (and coldness).
positive outcomes only occur through the application of con- This association was first demonstrated by Harry Harlow
scious control, with the blame for negative outcomes laid at the (1958), who showed how physical warmth could be effec-
feet of automatic influences (e.g., Mischel & Ayduk, 2004). For tively substituted (in monkeys) for absent maternal warmth,
example, for individuals who are trying to lose weight, auto- leading to significantly greater social warmth capacities for
matic impulses are seen as the cause for the overconsumption of the monkey later in adulthood. It was further supported by
fattening foods, whereas controlled, conscious processes are social neuroscience research implicating insular cortex in the
believed to be necessary to prevent these impulses from unduly processing of both physical temperature (e.g., Craig, Chen,
affecting behavior (Baumeister, Heatherton, & Tice, 1994). Bandy, & Reiman, 2000; Sung et al., 2007) and the psychoso-
Social psychologists have produced numerous demonstra- cial version of warmth information: feelings of trust (e.g., San-
tions of nonconscious processes attaining the same outcomes fey, Rilling, Aronson, Nystrom, & Cohen, 2003; Todorov,
as their conscious counterparts across a variety of research Baron, & Oosterhof, 2008), empathy, and prosociality (Eisen-
domains (Aarts & Dijksterhuis, 2003; Bargh, Gollwitzer, Lee- berger, Lieberman, & Williams, 2003; Kang, Williams, Clark,
Chai, Barndollar, & Troetschel, 2001; Bargh & Huang, 2009; Gray, & Bargh, 2010; Kross, Egner, Downey, Ochsner, &
Bargh & Morsella, 2010; Dijksterhuis & van Knippenberg, Hirsch, 2007). Similarly, recent research on embodied cogni-
1998), suggesting that both conscious and nonconscious pro- tion has shown these feelings of social warmth or coldness can
cesses play an important role in behavior change (Bargh et al., be induced by experiences of physical warmth or coldness and
2010). Whereas conscious processes are generally costly, vice versa (Bargh & Shalev, 2011; IJzerman & Semin, 2009;
intentional, controllable, and effortful, and the individual is Williams & Bargh, 2008a; Zhong & Leonardelli, 2008).
aware of engaging in them, nonconscious automatic processes In a recent set of studies, we tested the use of this associa-
are characterized by their unintentional, relatively effortless tion for emotion regulation intervention. Remarkably, we have
(i.e., efficient; minimal attentional resources required) nature, found that people already implicitly use this automatic asso-
and they operate outside of awareness (see Bargh, 1994; Bargh ciation between physical and social warmth to regulate their
& Williams, 2007). Use of subliminal primes has the advan- emotional states through the frequency, duration, and pre-
tage of assuring authenticity of the patients’ responses, because ferred water temperature of the showers and baths that they
strategic self-presentational modifications of responses are take. Applications of physical warmth temporarily reduced or
highly unlikely when the process occurs without awareness even eliminated feelings of loneliness and exclusion without the
(Levy, 2009). individual’s explicit awareness of the physical–psychological
relation. Furthermore, socially excluded participants who
were primed with physical warmth showed a significant
What Mechanism Underlies decrease in their need for affiliation and a desire for emotion-
Priming-Based Interventions? improving activities in comparison with a group of excluded
Priming-based interventions are based on the perception that participants who were primed with physical coldness or a con-
relevant stimuli (primes) automatically activate a goal repre- trol group (Bargh & Shalev, 2011).
sentation. The goal will then be pursued even though there is This example demonstrates that primed experiences of
no conscious awareness of the primes, the active intention physical warmth could be a boon to a population-based inter-
toward the goal, or the active guidance of goal-directed vention of syndromes associated with emotion regulation
thought and behavior (Bargh & Gollwitzer, 1994; Bargh & (e.g., borderline personality disorder; see Glenn & Klonsky,
Huang, 2009). The association between the external primes 2009; Linehan, 1993). Physical warmth primes can facilitate
and the concept or the mental representation could be created bonding and interpersonal trust in the health provider that is
naturally over development. For example, concepts concern- the bread and butter of every psychological intervention
ing the physical world (e.g., physical distance, size, and physi- (Bowlby, 1969, 1988; Gelso, 2011; Gelso & Samstag, 2008;
cal temperature) form early in childhood as they are based on Orlinsky, Ronnestad, & Willutski, 2004). This therapeutic
direct concrete experiences. These concepts do not require bonding establishes a secure base from which the therapist
mental capacities of memory retrieval and comparison that do influences the client through various psychological interven-
not develop until years later (Clark, 1973; Mandler, 1992). tions (e.g., suggestion, encouragement of open communica-
When these abstract concepts are later developed they tend to tion, modeling, reward manipulation, exposure and cognitive
be “built upon” (and thus strongly associated with) these phys- restructuring). Moreover, these findings also demonstrate that
ical concepts to the extent they are analogous (i.e., share key change can be produced without conscious awareness on the
features; Asch, 1946; Kelley, 1950; Lakoff & Johnson, 1980; part of the patient and by simple techniques other than the tra-
Williams & Bargh, 2008a; Williams, Huang, & Bargh, 2009) ditional individual model for treatment delivery.

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490 Shalev and Bargh

Which Psychological Problems Could be words, such as learned and confused, on a computer screen at
Targeted by Primes? subliminal speeds—fast enough to prevent conscious percep-
tion, but slow enough to allow encoding (Levy, 1996). A variety
Kazdin and Blase (2011) argue that the challenge for psycho- of social phenomena (e.g., stereotypes, stigmatized mental
logical interventions is to help reduce the burden of mental health groups, attitudes toward minorities) could be activated by
illness and related conditions both at the personal and societal environmental contexts (i.e., primes) of physical impairment.
level. By promoting adaptive behaviors and mental-health- For example, Stapel and Lindenberg (2011) recently found that
related responses such as easing stress or irritability, feeling disordered contexts (such as litter or a broken-up sidewalk,
better about oneself, feeling secure, feeling motivated, feeling abandoned bicycle and a dirty train) promoted stereotyping and
affiliated and the like, positive primes may push some signifi- discrimination toward minorities. Future research will examine
cant number of individuals into a slightly more positive and if these conditions could be challenged by physical cues of
less stressed realm and for many that would have impact on cleanliness or environmental organization.
determining whether symptoms or disorders were associated Priming-based interventions could enrich existing proce-
with impairment. dures for different conditions. A wide array of maladaptive
Following this view, studies based on the nonconscious, habitual behaviors (e.g., smoking, procrastination) could be
automatic perspective have demonstrated not only that mal- targeted by primes that activate avoidance or aversion reac-
adaptive behavioral outcomes (e.g., overeating) can be driven tions. Similarly, treatment of anxiety and mood difficulties,
by incidental exposure to contextual cues (i.e., priming) asso- eating disorders, addictive behaviors, or learning disabilities
ciated with that behavior (televised food ads; Harris, Bargh, & are all affected by environmental influences. Use of health-
Brownell, 2009). Primes can also promote prosocial/mental related primes could reduce emotion contagion within
health related responses and activate aids to self-regulation depressed couples or family accommodation to symptoms by
such as reappraisal processes (Mauss, Cook, Cheng, & Gross, consistent reminders of cues associated with functional behav-
2007; Williams, Bargh, et al., 2009) or emotional distance ior patterns.
(Williams & Bargh, 2008b). For example, in one set of experi- Individual differences also need to be examined to address
mental studies, nonconscious reappraisal priming was found differences in response to environmental conditions (Aarts,
to be significantly more effective than people’s spontaneous Wegner, & Dijksterhuis, 2006). These studies could examine
regulatory efforts, with the nonconscious emotion regulation the interrelations between specific deficits (e.g., attentional
condition demonstrating less reactivity than the conscious bias) and response to contextual cues. For example, theories of
reappraisal group (Williams, Bargh, et al., 2009). In another depression (Abramson, Seligman, & Teasdale, 1978; Beck,
set of studies, priming of physical distance by merely having 1967) suggest that differences between dysphoric and nondys-
the participant plot an assigned set of points on a Cartesian phoric patients result from cognitive schemata that are trig-
coordinate plane activated representations of physical distance gered by self-referential processes (e.g., Bargh & Tota, 1988).
and influenced feelings of emotional and interpersonal dis- Consistent with this assumption, dysphoric compared with
tance (Williams & Bargh, 2008b). In the most recent set of nondysphoric patients were found to be lower in sense of
studies, temperature primes reduced perceived loneliness and authorship (the feeling that observed effects are caused by
sense of social exclusion (Bargh & Shalev, 2011). one’s own actions) after priming of the self concept in an
It is possible that a variety of conditions associated with ambiguous situation. However, priming the potential effects of
emotion regulation and interpersonal relations (e.g., self- an action just prior to their occurrence increased the sense of
control, impulsivity, or interpersonal violence) could be amelio- authorship in all participants (Aarts et al., 2006). This study
rated by physical temperature interventions. Physical primes, demonstrates the differences between normal and clinical
especially those revolving around issues of trust and empathy, populations in response to the prime, indicating that people
may also be of great value to the treatment of young children’s who are unable to (implicitly) self-regulate their behavior
attachment and other emotional problems, because as the non- through the prime may be candidates for additional effective
conscious emotion regulation research shows, nonconscious interventions. Priming-based intervention combined with
interventions are of particular value to those who are unable to other techniques may facilitate the treatment effects for clini-
regulate through the traditional, conscious means. cal population.
Primes can also promote adaptive functioning of specific
groups (e.g., preverbal children, elderly). For example, priming
was used in one set of studies for improvement of adaptive How to Incorporate Priming-Based
functioning among the elderly. When old and young partici- Interventions Into Daily Life?
pants were first primed with either positive or negative elderly Experimental studies have demonstrated the utility of
stereotypic words, memory performance in the older (but not priming-based interventions in laboratory setting and field
younger) participants was improved by the positive stereotypic experiments (Bargh & Shalev, 2011; Levy, 2009). The findings
associations and was hindered by the negative stereotypic asso- demonstrate that people implicitly use natural sources to self-
ciations. These effects resulted from flashing age-stereotype regulate their emotional states without conscious awareness of

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Priming-Based Intervention 491

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of contextual cues in broader, everyday settings and on a sus- practical guide to priming and automaticity research. In H. T.
tained basis. To address this goal, natural environmental condi- Reis & C. M. Judd (Eds.), Handbook of research methods in
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text messaging, visual images). Similarly, computers screen between situations and behavior. In W.D. Spaulding (Ed.), Inte-
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Clearly, the use of mundane physical experiences, easily tion and pursuit of behavioral goals. Journal of Personality and
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Declaration of Conflicting Interests (pp. 429–445). New York, NY: Guilford Press.
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respect to their authorship or the publication of this article. control: How and why people fail at self-regulation. San Diego,
CA: Academic Press.
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 Perspectives on Psychological Science

The Old Solutions Are the New Problem: 6(5) 493–497

© The Author(s) 2011
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Mental Illness?

Bruce F. Chorpita1, Mary Jane Rotheram-Borus1,

Eric L. Daleiden2, Adam Bernstein1,Taya Cromley1,
Dallas Swendeman1, and Jennifer Regan1
1
Department of Psychology, University of California, Los Angeles, and 2PracticeWise, LLC, Wilsonville, OR

Abstract
Kazdin and Blase (2011) propose that traditional models of delivering therapy require more resources than are available to
address the scope of mental illness. We argue that finding new platforms and avenues for our existing treatments is a good
start but that it is not enough. We contend that the field also needs to develop formal strategies to reorganize its increasing
abundance of knowledge to address the scarcity of resources for its application. If we can better utilize our existing knowledge,
treatment delivery and service resource allocation can become more efficient and effective. If the field continues with its almost
singular emphasis on knowledge proliferation (e.g., developing new treatments), as opposed to knowledge management (e.g.,
developing new ways to design, apply, and organize existing treatments), the problem outlined by Kazdin and Blase cannot be
solved.

Keywords
methodology, treatment

Kazdin and Blase (2011) assert that unless we make some large to comprehend and apply optimally by any psychologist.
major changes, our profession cannot meet the demand for In our recent efforts to examine how to choose a set of
mental health services in the U.S. or globally. They offer the evidence-based treatments (EBTs) that best fit an organiza-
idea of a portfolio of models, and we agree entirely that tion’s service population (Chorpita, Bernstein, & Daleiden, in
increasing the range of how existing treatments can be applied press), we discovered that simply selecting a set of no more
will help reduce the overall burden of mental health suffering. than a dozen treatments from among all EBTs for children
However, within the current zeitgeist, this could well mean yields over 67 sextillion possibilities. To put this number in
that we will see 10 different versions of each protocol, each some perspective, if one were to write each unique set of 12 or
requiring 10 efficacy trials and 10 more effectiveness trials— fewer treatments on a single sheet of ordinary paper, the result-
essentially taking us from thousands of treatments to hundreds ing pile would reach to the sun and back. Over 20 million
of thousands. This is certainly not what Kazdin and Blase times. Each of these sets has a unique composition and thus a
intend, but we believe that without deliberate intervention, it is potentially unique impact on the service population. Selecting
likely to be how the field responds. an ideal array of treatments from among the promising possi-
bilities is no longer a simple problem and it is approaching
unsolvability. Although we know much about what works, we
We Need More and Better Ways to can no longer apply that knowledge efficiently.
Organize and Move Knowledge
We see this as a knowledge management problem. That is,
continued proliferation of knowledge about treatment will
Corresponding Author:
not help unless we get much, much better at summarizing, Bruce F. Chorpita, Department of Psychology, University of California,
synthesizing, integrating, and delivering what we already have Los Angeles, Box 951563, Los Angeles, CA 90095
(Graham et al., 2006). The existing knowledge base is now too E-mail: [email protected]

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494 Chorpita et al.

Any system seeking to provide quality care informed by in press) and in our multidisciplinary collaboration with the
research must select treatments to put into its service array. National Child Traumatic Stress Network (e.g., Layne et al., in
Given that providing evidence-based, quality care to those in press). The point of this work is that the patterns in the whole
need has become a public health priority (U.S. Department of may reveal more than just the sum of the parts—for example,
Health and Human Services, 2007) and that there are numer- the supportive evidence for a single treatment protocol may be
ous ongoing efforts to implement EBTs at the state and national bolstered by the findings from procedurally related treatments.
level (Chambers, Ringeisen, & Hickman, 2005), the number We can imagine possibilities where the actions of therapists
of systems facing this challenge is only increasing. It is time to are guided not always by a single manual but at times by the
consider whether our policies to implement EBTs and our entire relevant treatment literature.
rules for how we define them are really compatible. By aggregating across treatments to look for common ele-
ments, we seek to outline the robust or important features of an
EBT and to distinguish those features that are nonessential
We Need Options Other Than Treatment “nuance.” What features are important for efficacy is ulti-
Manuals to Transfer Knowledge mately an experimental question, and until we have that
Over the past 20 years, the field has emphasized efficacy and knowledge in place and can then deliver it in real time to
internal validity over external validity, feasibility, and accept- inform treatment prescription, data aggregation methods such
ability in order to identify what works. Following the princi- as the distillation and matching model are the intermediate
ples of good research design (Kazdin, 2003), the field required step. Kazdin (e.g., 2008a, 2008b) has repeatedly cautioned
primarily that treatments be well-specified, typically in the that an ontology of change mechanisms will take more than
form of a book or manual (e.g., Chambless & Hollon, 1998). our lifetimes to establish. Waiting to discern what we do
This development was an extraordinary and innovative leap not know should not stop us from reconsidering what we
forward. But like nearly all innovations, it has had unforeseen already do.
consequences as well, which we must now face squarely. Many strategies can be used to aggregate knowledge; iden-
Our knowledge has been packaged in units that cannot eas- tifying practice elements is only one of them. Identifying com-
ily be combined. Is each manual, tested within its own research mon processes is another (Collins, Phields, Duncan, & Science
program, really a world unto itself? If so, then we have hun- Application Team, 2007; Ingram, Flannery, Elkavich, &
dreds, perhaps thousands, of silos of expert knowledge, with Rotheram-Borus, 2008; Rotheram-Borus, Ingram, Swende-
little means to organize or combine them. Despite many years man, & Flannery, 2009). Processes refer to such things as the
of brilliant innovation in treatment development and research, degree of structure, activities directed at setting a tone for the
a child with two different problem clusters (e.g., separation group, or the role of the facilitator as active or not. Another
anxiety and depressed mood) will at best receive a sequence of approach in both clinical and health promotion trials is to
two separate EBTs built by two different experts. In this day identify standardized functions (Hawe, Shiell, & Riley, 2004),
and age, there is still no way for a child to receive care in the such as providing education, improving detection, building
community that formally combines the collective scientific social networks and support, or facilitating accumulation of
expertise on what to do for both conditions, even though we instrumental goods. In other words, treatments can be orga-
now have very good ideas for how to treat each. Although nized more around aims than strategies to achieve those aims.
transdiagnostic treatment models are at last emerging (e.g., Complex interventions may have limited impact because we
Allen, McHugh, & Barlow, 2008), for the most part, the prod- too literally advocate for replication with fidelity of activities
ucts of our research are still getting in the way of utilizing the and scripts. There may be multiple strategies to achieve health
knowledge behind them. knowledge, all of which are acceptable, especially in allowing
In our own work, we have sought to aggregate knowledge cultural tailoring, if the function of increasing health knowl-
in the form of practice elements (discrete clinical procedures), edge is served. Thus, in our existing compendia of EBTs,
noting which ones are commonly associated with successful almost any dimension can be aggregated and mined: how
outcomes for which symptoms in clinical trials (e.g., distilla- treatments are arranged, the style with which they are deliv-
tion and matching model; Chorpita & Daleiden, 2009). This ered, the manner in which they are supervised, or the functions
work has involved coding all available treatments protocols they serve. Each analysis reveals patterns that summarize fea-
for their common procedures and operations (e.g., use of a tures of the best treatments.
reward program, relaxation training, cognitive restructuring) So what will these patterns tell us? At one end of the spec-
and identifying how those operations are associated with cli- trum, they can point to intact EBTs. For example, the treat-
ent or context features (e.g., diagnosis, age, setting). This pro- ment that shares the most features in common with all of the
cess produces profiles or frequency distributions showing 45 EBTs relevant to a 12-year-old girl with anxiety could be a
which procedures are most commonly associated with suc- reasonable choice, because it is not only evidence-based
cessful treatments for which clinical presentations. within its own replication series but it is also backed by over
Similar efforts to aggregate practice elements across inde- 30 neighboring randomized trials of highly similar treatments.
pendent treatments are underway in social work (Barth et al., The same cannot be said for an anxiety treatment whose

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Old Solutions Are the New Problem 495

features suggest it is more of an outlier within that group—it out again at the point of service by practitioners with local
may have to stand alone on its own clinical trials. expertise who are embedded in the local context. Let thera-
Further along the continuum, aggregate patterns can tell us pists add their own jokes, games, or metaphors, and let
how to build new, perhaps those that are more flexible and researchers outline the core change strategies that should be
more broadly applicable, that borrow the most commonly used preserved within those operations. If we do not know the core
procedures of treatments for various disorders. We have devel- strategies, let knowledge aggregation point to promising can-
oped and recently tested one such protocol that targets four didates to be tested in focal or dismantling research designs.
disorders (anxiety, depression, conduct problems, and trau- Having researchers and clinicians codesign treatments in this
matic stress) using a combination of the components drawn way is consistent with the recently stated ideals of the American
from existing evidence-based approaches and coordinated by Psychological Association in the statements regarding evidence-
a set of guiding algorithms (MATCH-ADTC; Chorpita & based practices (APA Presidential Task Force, 2006). However,
Weisz, 2009). We do not really see this as a new treatment—it despite these ideals, the landscape of clinical practice still
is better characterized as a new arrangement of the old treat- appears to be mostly characterized by a false dichotomy of
ments—an attempt to do more with what we already have. evidence-based practice or clinical judgment. We need more
At the furthest end of the spectrum of independent versus formal models and exemplars for evidence-based practice and
flexibly aggregated treatments, we see the possibility for real- clinical judgment together. Of course, we do not know how
time design of treatments based solely on libraries of compo- much treatment design should occur a priori in the lab versus in
nent procedures and libraries of the algorithms for combining real time in the field. Thus, we also need a new research agenda
and ordering those procedures. We have recently designed and to study which codesign proportions work best (although we
implemented such a direct service prototype in children’s already have some idea that a heavy proportion of investigator-
mental health, focusing on the selection and delivery of prac- specified design does not; e.g., Addis & Krasnow, 2000; Born-
tice elements using guiding algorithms and in the context of trager, Chorpita, Higa, & Weisz, 2009).
feedback on progress and practice history (Chorpita &
Daleiden, 2010). Ultimately, we see possibilities for multide-
veloper treatment content libraries that can be delivered flexi- Treatments Will Have to Work Together
bly across multiple media and service platforms. We have many treatments that work but only a limited under-
standing of how they work together. Kazdin and Blase describe
the image of a pie, with slices representing people covered by
We Need to Codesign EBTs different treatments. Whether treatment is ultimately delivered
To meaningfully achieve the goal that Kazdin and Blase out- as therapist-selected practice elements, discrete manualized
line—a portfolio of models—we may also need to move away programs, or in some combination, we have not put enough
from a paradigm in which laboratory experts solely design thought into how to assemble arrays of treatments within ser-
treatments. Treatment may ultimately involve codesign: vice systems or how to gauge their collective impact on a
important initial parameters and procedures built in the lab and community.
real-time adjustments and local adaptation made in the field by How many EBTs are required to serve a given population?
clinicians. This will yield treatments that involve shared The real answer depends on the local epidemiology; however,
expertise—leveraging two knowledge bases. A priori, the our analyses suggests that even learning all of them would
investigator contributes the essentials as to what aspects of generally not be enough to ensure that everyone with mental
treatment should be included or how certain procedures should health needs receives evidence-based care—far from it (Chor-
be performed at the time of service delivery. In real time, the pita et al., in press). Simply making new treatments is not
clinician then adds the local expertise to adapt process, con- likely to solve this problem and only exacerbates the problem
tent, or logic based on the thousands of context variables that of selecting the best set. To that end, we have developed an
the laboratory developer cannot anticipate. Many EBTs now analytic method for simultaneously combining local popula-
overspecify procedural details—sometimes right down to tion data and treatment outcome data to point to best-fitting
what games to play or which characters to use to illustrate a solutions (Chorpita et al., in press). This methodology applies
point (cf. Schoenwald, Garland, Southam-Gerow, Chorpita, & mathematical modeling to enhance resource allocation and
Chapman, 2011). Identifying the nonessential details in EBTs help a service system achieve the greatest reduction in the bur-
will move those treatments closer to Kazdin and Blase’s con- den of mental illness, much as Kazdin and Blase suggested.
cept of a portfolio of models. This tool can be considered a knowledge management appli-
So how do we know which details are nonessential? It very ance, and we need more like it to address our new problems.
well may be those that do not show up in most treatments
when we aggregate across all of them relevant to a particular
set of client characteristics—yet another reason to pursue Knowledge Must Flow in Many Directions
knowledge aggregation. By stripping some of our best treat- Despite all our treatment outcome research, the best source
ments down to the essence, we can allow them to be fleshed of evidence is still arguably the evidence that a client is

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496 Chorpita et al.

improving. That, too, is a source of knowledge that is largely too little, or too much. As we all continue to learn more about
untapped. Despite emerging research that measurement feed- how to alleviate mental illness, we must keep in mind that
back systems can improve outcomes (Bickman, 2008; Lam- what we know is irrelevant when separated from the question
bert, Harmon, Slade, Whipple, & Hawkins, 2005), there is no of what to do with what we know.
widely used appliance for providing clinicians feedback on
their clients’ mental health outcomes—or clients with feed- Declaration of Conflicting Interests
back on their own outcomes. This is a major research agenda The author(s)declared no potential conflicts of interest with respect
requiring intensive innovation—there is currently only a to the research, authorship, and/or publication of this article.
handful of prototypes of this kind of technology, which is in
stark contrast with the hundreds of manualized treatments Funding
available. The author(s) received no financial support for the research, author-
Such feedback should also not be limited to outcomes. As ship, and/or publication of this article.
the compendia of EBTs for mental health have grown, so has
the literature on the failure to implement EBT with fidelity. References
For example, only half of service providers trained to use an Addis, M. E., & Krasnow, A. D. (2000). A national survey of practicing
EBT for HIV prevention ever attempt to implement that treat- psychologists’ attitudes toward psychotherapy treatment manuals.
ment, and only half of those providers implement the treat- Journal of Consulting and Clinical Psychology, 68, 331–339.
ment with fidelity (Collins et al., 2007). The consistency of Allen, L. A., McHugh, R. K., & Barlow, D. H. (2008). Emotional
such findings outside of laboratory clinics, regardless of the disorders: A unified protocol. In D. H. Barlow (Ed.), Clinical
specific treatment being evaluated, suggest the additional need handbook of psychological disorders (4th ed., pp. 216–249). New
for routine feedback on how the clinician is implementing the York, NY: Guilford Press.
treatment, even if only at the level of adherence to basic treat- APA Presidential Task Force. (2006). Evidence-based practice in psy-
ment elements. This is yet another knowledge management chology. American Psychologist, 61, 271–285.
issue. For a therapist’s future actions to be guided by useful Barth, R. P., Lee, B. R., Lindsey, M. A., Collins, K. S., Strieder, F.,
information, we need better methods to deliver that informa- Chorpita, B. F., . . . Sparks, J. R. (in press). Evidence-based prac-
tion, whether it comes from the literature, the client’s response, tice at a crossroads: The timely emergence of common elements
or the therapist’s own past actions (Daleiden & Chorpita, and common factors. Research on Social Work Practice.
2005). Bickman, L. (2008). A measurement feedback system (MFS) is nec-
essary to improve mental health outcomes. Journal of the Ameri-
can Academy of Child & Adolescent Psychiatry, 47, 1114–1119.
Conclusion Borntrager, C., Chorpita, B. F., Higa, C., & Weisz, J. R. (2009) Provider
We believe Kazdin and Blase (2011) have identified a major attitudes toward evidence-based practices: Are the concerns with the
failure in knowledge management. If, however, the field inter- evidence or with the manuals? Psychiatric Services, 60, 1–5.
prets this challenge as a failure in knowledge production, we Chambers, D. A., Ringeisen, H., & Hickman, E. E. (2005). Federal,
will continue in our old habits of promulgating EBTs that few state, and foundation initiatives around evidence-based practices
with mental health needs may ever encounter. The current for child and adolescent mental health. Child and Adolescent Psy-
national economic condition suggests that we should not spend chiatric Clinics of North America, 14, 307–327.
all of our time or other resources solely on producing more Chambless, D. L. & Hollon, S. D. (1998). Defining empirically sup-
treatments that are only incrementally better. We also need ported therapies. Journal of Consulting and Clinical Psychology,
new paradigms. 66, 7–18.
It is time to develop models that allow for designing treat- Chorpita, B. F., Bernstein, A., & Daleiden, E. L. (in press). Empiri-
ments across laboratories, across disciplines, and across cally guided coordination of multiple evidence-based treatments:
researchers and practitioners. We encourage researchers and An illustration of relevance mapping in children’s mental health
treatment developers to consider packaging and studying their services. Journal of Consulting and Clinical Psychology.
new treatments in discrete treatment units or modules that can Chorpita, B. F., & Daleiden, E. L. (2009). Mapping evidence-based
“plug and play” with those of other developers. We may find treatments for children and adolescents: Application of the distil-
that common practice elements, features, processes, or func- lation and matching model to 615 treatments from 322 random-
tions are robust across a wide variety of delivery platforms or ized trials. Journal of Consulting and Clinical Psychology, 77,
workforces. Meanwhile, we encourage practitioners—broadly 566–579.
defined—to be open to using those treatment elements or Chorpita, B. F., & Daleiden, E. L. (2010). Building evidence-based
modules, and to see them as supports for making their current systems in children’s mental health. In A. E. Kazdin & J. R.
work more effective. Practitioners will also need to help Weisz (Eds.), Evidence-based psychotherapies for children and
researchers understand how much of that support is enough, adolescents (pp. 482–499). New York, NY: Oxford Press.

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Chorpita, B. F., & Weisz, J. R. (2009). MATCH-ADTC: Modu- Kazdin, A. E. (2008b). Evidence-based treatment and practice: New
lar approach to therapy for children with anxiety, depression, opportunities to bridge clinical research and practice, enhance the
trauma, or conduct problems. Satellite Beach, FL: PracticeWise. knowledge base, and improve patient care. American Psycholo-
Collins, C., Phields, M. E., & Duncan, T., & Science Application gist, 63, 146–159.
Team. (2007). An agency capacity model to facilitate implemen- Kazdin, A. E., & Blase, S. L. (2011). Rebooting psychotherapy
tation of evidence-based behavioral interventions by community- research and practice to reduce the burden of mental illness. Per-
based organizations. Journal of Public Health Management and spectives on Psychological Science, 6, 21–37.
Practice[Suppl.], S16–S23. Lambert, M. J., Harmon, C., Slade, K., Whipple, J., & Hawkins, E.
Daleiden, E., & Chorpita, B. F. (2005). From data to wisdom: Quality (2005). Providing feedback to psychotherapists on their patients’
improvement strategies supporting large-scale implementation of progress: Clinical results and practice suggestions. Journal of
evidence based services. Child and Adolescent Psychiatric Clin- Clinical Psychology, 61, 165–174.
ics of North America, 14, 329–349. Layne, C. M., Ghosh Ippen, C., Strand, V., Stuber, M., Abramovitz,
Graham, I. D., Logan, J., Harrison, M. B., Straus, S. E., Tetroe, J., R., Reyes, G., . . . Pynoos, R. (in press). The core curriculum on child-
Caswell, W., & Robinson, N. (2006). Lost in knowledge transla- hood trauma: A tool for training a trauma-informed workforce. Psy-
tion: Time for a map? Journal of Continuing Education in the chological Trauma: Theory, Research, Practice, and Policy.
Health Professions, 26, 13–24. Rotheram-Borus, M. J., Ingram, B. L., Swendeman, D., &
Hawe, P., Shiell, A., & Riley, T. (2004). Complex interventions: How Flannery, D. (2009). Common principles embedded in effec-
“out of control” can a randomized controlled trial be? British tive adolescent HIV prevention programs. AIDS and Behavior,
Medical Journal, 328, 1561–1563. 13, 387–398.
Ingram, B. L., Flannery, D., Elkavich, A., & Rotheram-Borus, M. J. Schoenwald, S. K., Garland, A. F., Southam-Gerow, M. A., Chor-
(2008). Common processes in evidence-based adolescent HIV pita, B. F., & Chapman, J. E. (2011). Adherence measurement
prevention programs. AIDS and Behavior, 12, 374–383 in treatments for disruptive behavior disorders: Pursuing
Kazdin, A. E. (2003). Research design in clinical psychology (4th clear vision through varied lenses. Manuscript submitted for
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Psychological Services, 5, 201–215. DC: Author.

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 Perspectives on Psychological Science

Delivery Systems Can Determine 6(5) 498­–502

© The Author(s) 2011
Reprints and permission:
Therapy Cost, and Effectiveness, More sagepub.com/journalsPermissions.nav
DOI: 10.1177/1745691611416994

Than Type of Therapy http://pps.sagepub.com

Brian T. Yates
Department of Psychology, American University, Washington, DC

Abstract
We should go further than Kazdin and Blase (2011) in emphasizing the importance of the costs and effectiveness of alternative
delivery systems for therapies. I propose that the manner in which therapy is delivered often determines its cost, and its
effectiveness, more than the type of therapy delivered. In this article, I illustrate this argument through compiled research and
describe several inexpensive delivery systems with the aid of metaphors.

Keywords
therapy, cost, delivery system, cost-effectiveness, benefit, scientist-manager-practitioner

In their article “Rebooting Psychotherapy Research and Prac- the development, testing, and refinement of more effective
tice to Reduce the Burden of Mental Illness,” Kazdin and methods of delivering treatment—methods that use less thera-
Blase (2011) praised our progress in developing efficacious pist and client time, minimize client transportation costs as
techniques for treating a variety of severe and costly psycho- well as brick-and-mortar space, and use less of other increas-
logical problems, but they also noted the profound ineffective- ingly scarce and costly resources. Just as therapy is no longer
ness of current methods for delivering these techniques to an art but a science based on research evidence gathered in
produce socially significant reductions in mental illness and in clinical settings, so too can be its delivery. Research of this
the costs of mental illness to society. sort is not particularly popular with most graduate students,
Our focus over the past century has been, perhaps necessar- funders, or rank and tenure committees. In my experience, it is
ily, on developing psychological techniques that work most criticized as secondary in importance, mundane to conduct, or
of the time for most people for several important psychological too site- or therapist-specific to be of use to the field. Similar
problems. The promise of better living through psychological arguments were made decades ago against the desirability of
technologies developed through systematic scientific inquiry conducting research on the cost effectiveness of different ther-
has yet to be fulfilled, however. We have come only halfway at apeutic technologies (e.g., Strupp, 1981), yet this sort of work
best. To a limited extent, we have the knowledge to cure and has become popular at least in what is called for, if not in what
enhance ourselves psychologically in a number of areas, but we is often performed, in applied psychology (cf. American Psy-
have not found ways to use this knowledge to help most of the chological Association Presidential Task Force on Evidence
people most of the time for their most serious psychological Based Practice, 2006).
dysfunctions. It is as if the techniques or tools for fixing impor- Research on less costly and more effective ways to deliver
tant problems were resting in locked toolboxes, shown to one therapy is what we need, so that we can use evidence-based
person at a time with brief instruction on tool use, rented at delivery systems to provide evidence-based services to the
rather high hourly rates for a few weeks, and then locked back most people for the least necessary expenditure of resources
in the toolbox. If universities offered education via similar per person (Yates, 1980, 1994). This sort of research is only
means, most instruction would be independent studies taught by beginning to be conducted in a thorough, systematic manner
tenured full professors for an hour or two per week, to 5 to 10 that includes careful measurement of costs, and effectiveness,
individual students daily, with small amounts of reading that
kept key knowledge accessible only to the professors—and
Corresponding Author:
without any course evaluation by the few students being taught! Brian T. Yates, Department of Psychology, American University, 4400
Among the solutions to problems we now face in delivering Massachusetts Avenue, NW, Washington, DC 20016-8062
our treatment technologies to those who need them the most is E-mail: [email protected]
Delivery Systems for Therapy 499

from multiple perspectives (cf. Tate, Finkelstein, Khavjou, & Differences in Therapy Cost Versus
Gustafson, 2009). Differences in Therapy Effectiveness
How much of a difference can a delivery system make in the
Delivery Systems for Therapy: Sieves, effectiveness or cost of a therapy? Meta-analyses of random-
Golden Ladles, or Plastic Spoons? ized clinical trials of a wide variety of therapeutic techniques
The delivery system used to provide a therapy is, arguably, a have shown repeatedly that many therapy techniques work,
stronger potential determinant of the effectiveness and cost of and do so reasonably if not similarly well, for some psycho-
that therapy than the effectiveness and costs of specific tech- logical problems (e.g., Shadish, Matt, Navarro, & Phillips,
niques used in the therapy. Consider the common plastic spoon 2000; Smith, Glass, & Miller, 1980). Rigor of design, training
as a metaphor for the delivery system for the “medicine” of of practitioners, and other variables have been examined in
therapy, with the ingredients of the medicine being the specific these analyses. The consensus is clear: Therapy works, pretty
techniques that are carefully combined by the practitioner to well, most of the time for most people and a variety of prob-
help a client with a particular problem. Suppose the practitio- lems. With several notable exceptions (cf. Siev, Huppert, &
ner has studied research regarding which combinations of Chambless, 2009), different therapies can be surprisingly sim-
ingredients work best for this sort of client presenting this par- ilar in their effectiveness, depending on several factors, includ-
ticular problem. The ingredients most likely to be effective are ing characteristics of the therapist and other components of the
chosen. Perhaps the therapist even considers the expense of therapeutic delivery system. Most are better than no therapy,
those ingredients. For example, the therapist might decide measurement and attention controls, or placebo therapies (cf.
whether to prescribe time-consuming hourly recording of cat- Smith et al., 1980). Almost all of these studies use one-on-one
astrophizing and self-negating cognitions, or a simpler and therapies, however: golden ladle delivery systems!
quicker daily check-off log for occurrence of catastrophizing Research on the effectiveness of different means of provid-
and self-negating cognitions. The therapist proceeds to select ing the same therapeutic techniques remains, unfortunately,
the ingredients that fulfill the requirements of best evidence- rare. What research there is on delivery systems suggests that
based practices and that minimize client resources consumed. considerable savings could be achieved with little or no reduc-
Having identified and optimized an evidence-based amalgam tion in therapy outcomes if a “plastic spoon” delivery system
of techniques, should the practitioner “pour” this carefully was utilized. A substantial research literature finds, for exam-
developed mixture into . . . ple, little evidence for the incremental effectiveness of using
doctoral rather than trained paraprofessional therapists to
•• . . . a sieve, from which the medicine largely dissi- deliver therapy techniques for a wide range of psychological
pates before it reaches the client? problems (cf. reviews by Berman & Norton, 1985; Durlak,
•• . . . an exquisite golden ladle, which delivers the exact 1979; Smith et al., 1980, and more recently Shadish et al.,
combination of ingredients to the client with high 2000).
fidelity but at unnecessary cost? or Other research demonstrates that combinations of different
•• . . . a plastic spoon, with sufficient integrity to deliver therapeutic agents, as well as variations in other aspects of
the medicine at the minimum necessary expense? treatment provision, can have profound effects on the cost, if
not the effectiveness, of therapy. For example, overweight cli-
Clearly, the “plastic spoon” delivery system is what most ents assigned to two weight-loss treatments lost statistically
would select as the optimally effective and least costly deliv- similar amounts of excess adipose tissue, but at an average
ery system for most clients. I believe that we have the right cost of $44.60 versus $3.00 per 1% reduction in excess weight
medicine but are using golden ladles to deliver that medicine, (Yates, 1978)! (Note that these cost-effectiveness ratios were
which prevents it from getting to most people—particularly to in 1976 dollars.) This difference in cost was accounted for
those who need it the most and can least afford it. largely by the former treatment’s use of highly paid staff meet-
Research comparing delivery systems that promise to trans- ing clients several days weekly for a standard number of weeks
mit most or all of the potential effectiveness of a psychological in prestigious offices. In the latter treatment, former clients
technique while using fewer resources (and costing less) has implemented a program detailed in manuals for groups of cli-
begun, particularly for problems related to physical health (cf. ents who met in plain and often donated space and who paid
Ritterband & Tate, 2009). The variety of potential “plastic per session attended.
spoons” researched to date includes Internet-based interven- Similarly, Siegert and Yates (1980) randomly assigned par-
tions addressing everything from social anxiety and panic disor- ents to one of three systems for delivering the same behavioral
der to eating disorders, automated phone interventions teaching training for managing disruptive behaviors of their children, or
self-management of exercise to diabetics (Handley, Shumway, to a measurement and attention control condition. All three
& Schillinger, 2008), and video-based motivational and cogni- training systems produced strong and statistically similar
tive-behavioral interventions for HIV risk reduction in females improvements in behaviors targeted by the parents. All three
in military service (Essien et al., 2011). training systems required different mixtures of different types
500 Yates

of resources. The individual in-office delivery system required In sum, Bandura et al. demonstrated that inexpensive com-
clients to participate in traditional one-on-one sessions for binations of therapy techniques and delivery systems (i.e.,
child management training in a therapist’s office. The group modeling delivered via client-controlled film projection) could
in-office delivery system had clients participate in group train- be significantly more effective than traditional delivery sys-
ing sessions in therapist offices. The individual in-home deliv- tems (such as the one-on-one in-office provision of technolo-
ery system had therapists train clients in clients’ homes. gies such as systematic desensitization). Newer information
Depending on whether client time and client transportation technologies could enable even greater cost savings. The film
resources were included in cost calculations, the individual in- showing the snake interaction models, for instance, now could
office delivery system was substantially more expensive than be offered at near-zero cost in transportation and computer
the individual in-home delivery system and often more than resources by streaming Internet video directly to clients’
the group in-office delivery system as well. smartphones, and not necessarily in therapist offices, possibly
Similar research using random assignment of 1,827 with similar effectiveness.
severely disturbed adults to referral or nonreferral to consumer- Bandura et al.’s findings also show that, for a small incre-
operated services (COS) found little difference between mul- ment in resources (i.e., an average 0.6 hr of client time, plus
tiple sites and techniques in COS effectiveness. Profound dif- perhaps 2 hr of provider time) and an evidence-based choice
ferences were observed, however, in the amounts of monetary of treatment technology (i.e., modeling as opposed to system-
as well as donated resources consumed by delivery of COS atic desensitization), the effectiveness of therapy for achieving
services to individual clients (Yates et al., in press). a rather complete “cure” can be increased from an average
33% to 92% of clients. This is the sort of information that,
when provided on a larger scale for a variety of therapeutic
Research on Effectiveness and Costs of techniques for the wider range of delivery systems now avail-
Delivery Systems Can Save Resources able, could provide therapists with evidence on how to provide
An example of how different delivery systems can affect treat- treatment both effectively and inexpensively.
ment effectiveness as well as treatment costs is provided by a
slight reinterpretation of a randomized clinical trial reported
by Bandura, Blanchard, and Ritter (1969). Snake-phobic par- Monetary Benefits of Delivery Systems
ticipants were assigned randomly to either (a) a measurement Need to Be Measured, Too
control condition, (b) systematic desensitization, (c) modeling While adjusting our research to examine the relative effective-
of successively more anxiety-provoking interactions with ness of different delivery systems for therapies according
snakes delivered by a film that participants could pause or to traditional psychological measures, we also might include
reverse, or (d) modeling of progressive snake approach by a among our measures client reports and other indices of how
paraprofessional model. Bandura et al. did not entirely control their productivity and income were affected by therapy and
time spent in each condition, allowing it to vary as long as it how their use of health and criminal justice services may have
did not exceed 5.25 hr. Resources common to all treatments declined. These are the types of monetary measures that can be
conditions were office space, advertising for research partici- contrasted to the costs of providing therapy through one deliv-
pants, and clients’ own transportation expenses. ery system or another to determine which combinations of
Bandura et al. (1969) found that the live delivery system for therapeutic techniques and delivery systems are most cost
modeling techniques of snake phobia reduction allowed 92% of beneficial (i.e., which pay for themselves soonest and most
participants to achieve the “terminal” step of sitting for 2 min fully; cf. Yates, 2005). Third-party funders will likely support
with their hands at their sides and a four-foot nonpoisonous only those combinations of technique and delivery system that
snake in their laps. This combination of delivery system and return their investments most quickly and enduringly. Once
technique was found to consume surprisingly few temporal this is shown, that combination may be widely implemented as
resources: an average 2.17 practitioner hours and a similar num- it would be readily reimbursed.
ber of client hours in direct service. Snake approach modeling
via film allowed 33% of participants to achieve the same termi-
nal step, requiring a mean 2.77 hr from clients plus a few min- Additional Suggestions for More Cost-
utes of a paraprofessional’s time to show clients how to operate Effective Delivery Systems
the film projector. The measurement control delivery system Many therapists will note that issues of client confidentiality
was inexpensive but had no effect whatsoever on snake and the need for privacy may prevent some delivery systems,
approach. Both live and film delivery systems for the modeling such as group therapy, from being used for some clients. That
technique were superior in effectiveness, and they consumed does not mean that one-on-one, face-to-face, breathing-the-
substantially less provider and client time than the mean 4.53 hr same-air interaction is required for effective delivery of ther-
consumed for clients who were delivered the usual technique of apy. Video and audio links are widely available at low cost to
systematic desensitization (which enabled only 25% of clients anyone with even temporary access to a smartphone, a tablet,
to reach the terminal step in snake approach). or a computer and can be kept confidential and possibly
Delivery Systems for Therapy 501

anonymous. When integrated with Web-based, e-mailed, or combinations of lay, paraprofessional, and professional staff,
downloaded manuals and worksheets, plus videos illustrating all making optimal contributions to service delivery.
how various psychological techniques can be applied, wide- Some will take unintended offense at the comparison
scale administration of a variety of therapeutic techniques between dental services, HMOs, and mental health services. I
seems both possible and affordable for most rather than some apologize! I do not mean to demean mental health services, or
people. For example, Mihalopoulos, Vos, Pirkis, Smit, and dental or other health services for that matter. Many service sys-
Carter (2011) found that both bibliotherapy and group therapy tems function similarly, from ophthalmology to general practice
were effective delivery systems for preventing depression, to vehicle maintenance, with work distributed among staff and
with bibliotherapy providing more than twice the impact per display media according to their abilities. Similar service sys-
dollar invested. tems using a mixture of staff with varying levels of expertise
The idea of integrating evidence-based techniques of ther- have been developed and implemented for some time to deliver
apy with means of delivering treatment services that have particular mental health services (e.g., Tharp & Wetzel, 1969),
themselves been shown to be both effective and not inherently thus meeting needs for student training as well as treatment for
expensive is not particularly new (cf. Yates, 1995), and yet is communities of clients. Some have achieved notable commer-
only beginning to take hold. Some psychological practices cial success and have been funded by major health service sys-
could emulate the delivery system used by some dentists in tems (e.g., Cummings, O’Donohue, & Ferguson, 2002).
private practice, who see the costs and evidence of success in Arguably, externships, if not internships, provide some parapro-
their monthly accounting records and patient rolls. Technolo- fessional service delivery as well in mental health contexts,
gies for preventing and treating dental problems are, perhaps, albeit often within the same one-on-one delivery system.
no less inherently expensive than are psychological technolo- To conduct and apply delivery systems research, doctoral
gies. Moreover, many dentists continue to focus on one client training models for psychologists who would become
at a time as many therapists wish to continue to do. Often these scientist-manager-practitioners have been proposed (e.g.,
dental techniques are delivered literally face-to-face. Other DeMuth, Yates, & Coates, 1984). We now need to implement
services dictated by these decisions are performed by parapro- these models and these delivery systems and examine their
fessionals trained and supervised by the dentist. In one-dentist effectiveness, costs, and benefits with the same research meth-
practices, a receptionist makes appointments, greets patients, odologies we used to maximize the effectiveness of treatment
manages the office, submits bills, and accepts payments. A techniques. The people we serve, and who ultimately fund our
dental assistant interviews new and returning patients, periodi- treatment and research, expect and deserve no less.
cally updates patient medical records, and takes X-rays as
needed according to a schedule determined by the dentist. Declaration of Conflicting Interests
Technologies not requiring staff time may be used as well. A The author declared no potential conflicts of interest with respect to
looping video viewable as I wait for X-ray results informs me the authorship or the publication of this article.
about the latest cosmetic procedures available, but also could
remind me about the best way to floss. My dentist cleans and References
inspects my teeth, but could avoid the former activity if he did American Psychological Association Presidential Task Force on Evi-
not so relish discussing his latest motorcycle exploits, or the dence Based Practice. (2006). Evidence-based practice in psy-
cost of college tuition for his daughter, without having me chology. American Psychologist, 61, 271–285.
talking back. He even provides me with a cognitive-behavioral Bandura, A., Blanchard, E. B., & Ritter, B. (1969). Relative efficacy
intervention of sorts that I regularly self-administer and sug- of desensitization and modeling approaches for inducing behav-
gest to others: “Only floss the teeth you want to keep!” ioral, affective, and attitudinal changes. Journal of Personality
A high-resolution paper display, aka “chart,” on the wall of and Social Psychology, 13, 173–199.
the examining room informs me about root decay and root Berman, J. S., & Norton, N. C. (1985). Does professional training
canal procedures, providing further motivation for preventive make a therapist more effective? Psychological Bulletin, 98,
self-management cognitions and behaviors. The receptionist 401–406.
schedules the next appointment. Total time in the office: about Cummings, N. A., O’Donohue, W. T., & Ferguson, K. E. (2002). The
45 min. Total dentist time directly serving me: 5 to 10 min. impact of medical cost offset on practice and research: Making it
The result is a substantial savings of his time and my monetary work for you. Reno, NV: Context Press.
resources, relative to what I would pay if he performed all of DeMuth, N. M., Yates, B. T., & Coates, T. (1984). Psychologists as
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 Perspectives on Psychological Science

Reducing the Burden of Mental Illness in 6(5) 503–506

© The Author(s) 2011
Reprints and permission:
Military Veterans: Commentary on sagepub.com/journalsPermissions.nav
DOI: 10.1177/1745691611416995

Kazdin and Blase (2011) http://pps.sagepub.com

Denise M. Sloan, Brian P. Marx, and Terence M. Keane

National Center for PTSD, VA Boston Healthcare System, and Boston University School of Medicine, Boston, MA

Abstract
Clinical psychology as a profession owes much to the recognition of the psychosocial needs of servicemen and women returning
from World War II and the Korean conflict. The current conflicts in Iraq and Afghanistan represent another opportunity for
substantial advancements in assessment and treatment practices. Stimulated by the prescient article by Kazdin and Blase (2011),
we briefly describe innovations in evidence-based practices currently being implemented in the Veterans Health Administration
to best serve the more than 2 million returning servicemen and women. The largest healthcare system in the nation, the U.S.
Department of Veterans Affairs began a wide range of innovations early this century to include dissemination of evidence-based
mental health treatments, the use of anonymous Internet-based interventions to reach large numbers of military personnel
who may not otherwise present for mental health service, the use of videoconferencing to deliver assessment and treatment to
individuals residing in remote locations, and the use of laypersons (e.g., peers) for treatment delivery. In addition to describing
the strengths of these efforts to reduce mental health burden, we also discuss persisting barriers and limitations of these
innovative efforts within this system of healthcare.

Keywords
dissemination, implementation, telehealth

Recently, Kazdin and Blase (2011) described the substantial Operation Enduring Freedom and Operation Iraqi Freedom
burden of mental illness experienced by many individuals and (OEF/ OIF) veterans is among the highest priorities in the VA’s
sounded a clarion call to develop alternative methods of deliv- mental healthcare system, as it is estimated that over one third
ering psychotherapy to reduce this burden. The U.S. Depart- of all OEF/OIF veterans have a mental health condition and
ment of Veterans Affairs (VA) has already developed and this number continues to rise (e.g., Hoge, Auchterlonie, &
implemented novel programs to address the mental health Milliken, 2006).
needs and associated burdens of all its veterans. In this com- In 2004, responding to the high prevalence of mental health
mentary, we pay particular attention to how both VA and the conditions among its constituents, the VA developed a Mental
Department of Defense (DoD) are utilizing technology to Health Strategic Plan (MHSP) rooted in the government-wide
improve access to care, the initiatives in place to foster lay and President’s New Freedom Commission Report to address a
peer counseling in order to deliver care to a greater number of growing population of veterans with unmet mental health care
veterans and service men and women, and how the VA is dis- needs. The goal for this strategic plan is to reduce the burden of
seminating and implementing evidence-based treatments mental illness by reducing stigma; promoting recovery; ensur-
(EBTs) for posttraumatic stress disorder (PTSD) to provide ing equal access and reducing variability of care; providing cul-
veterans with the best possible mental health care. We also turally competent care to veterans of all ages, races, ethnic
describe ongoing challenges to meeting the mental healthcare groups and genders; being veteran and family centered; ensur-
demands of a large number of veterans in need of these ing collaborative care models are used in primary-care team
services. structure; and employing evidence-based population approaches.
The VA operates an internationally recognized network of With the continuing leadership of Dr. Antonette Zeiss (Zeiss &
147 medical centers, 292 Vet Centers, and 642 Community-
Based Outpatient Clinics. These facilities provide mental
Corresponding Author:
health care services to almost 1.9 million veterans. As such, Denise M. Sloan,VA Boston Healthcare System, 150 S. Huntington Avenue,
the VA is the largest provider of mental health care services in Boston 02130
the United States. Care for the returning combat deployed E-mail: [email protected]

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504 Sloan et al.

Karlin, 2011), many initiatives have been launched over the past care services to a larger number of veterans and service mem-
several years to meet the goals of VA’s 2004 MHSP. bers in need of care, these approaches still may not reach all
Kazdin and Blase (2011) suggested the adaptation of tech- individuals in need of care, particularly individuals from a low
nology to deliver psychotherapy; the VA has recognized that socioeconomic background, lower education level, and/or
telehealth technologies (e.g., web-based, phone, video tele- individuals residing in rural communities where broadband
conference) are an increasingly important method of ensuring internet access is less common (Smith, 2010).
equal and timely access to mental health care services to Consistent with Kazdin and Blase’s (2011) suggestion, the VA
patients who would otherwise not have such access to services and DoD are engaged in several nationwide programs in which
because they live in locations that are a considerable distance lay individuals and recovered peers provide mental healthcare
from the nearest VA facility (Sloan, Gallagher, Feinstein, Lee, services. One example of such a program is combat and opera-
& Pruneau, 2011). Another advantage of telehealth technology tional stress first aid (COSFA; Nash, Krantz, Stein, Westphal, &
is its ability to provide mental healthcare services quickly and Litz, in press). A significant barrier to seeking mental health care
efficiently to large numbers of individuals. Further, these services among servicemen and women is confidentiality con-
methods may also be used to connect with many veterans who cerns. Services delivered from a chaplain remain confidential
perceive stigma associated with their conditions and would within the military; thus, servicemen and women may be more
not be inclined to present themselves in person for therapy likely to disclose mental health concerns to chaplains. The
(Pietrzak, Johnson, Goldstein, Malley, & Southwick, 2009). COSFA program has trained chaplains to deliver brief psycho-
Both the VA and DoD are funding research to examine the logically based interventions to military servicemen and women,
viability of these new technologies for the delivery of EBTs, and the program appears to be effective in terms of increasing the
including the use of videoconferencing to deliver group-based number of military personnel seeking mental health care ser-
cognitive-behavioral treatments (Morland et al., 2010) and pro- vices. Innovative programs are also underway to train VA chap-
longed exposure therapy (PE; Tuerk, Yoder, Ruggiero, Gros, & lains and VA police; these individuals represent VA employees
Acierno, 2010) and an internet-based treatment to deliver men- with whom veterans have frequent contacts and can provide a
tal healthcare treatment anonymously to military service men gateway to more intensive treatment delivery when needed.
and women (Litz, Engel, Bryant, & Papa, 2007). Smartphone Nearly a decade ago, the VA leadership in mental health-
applications are also being developed to enhance existing care care realized that EBTs were inconsistently available across
and provide self-help treatment to veterans and military service this national system of care. Although not specifically recom-
personnel who may be reluctant or unable to present for treat- mended in their article, we suspect Kazdin and Blase would
ment services. For example, VA Secretary Shinseki recently support the dissemination initiatives that began in the VA
announced that the VA and DoD have launched the PTSD Coach 5 years ago. Despite the substantial advances made in the
mobile smartphone application, a therapy augmenting tool that development and evaluation of psychological treatments,
provides information on EBTs for PTSD, tools for screening mental health care providers had not yet incorporated EBTs
and symptom tracking, skills for symptom management, and into routine clinical practice (Kazdin, 2008). The lack of dis-
direct links to support. PTSD Coach is the first in a suite of VA semination and implementation of EBTs represents a substan-
and DoD jointly developed mobile smartphone applications that tial hurdle in the delivery of effective treatments and, in turn,
will cover a range of mental health conditions. is a major barrier in reducing the nation’s mental health care
Communication between patient and provider and the provi- burden. The infrequent use of EBTs was noted within the VA
sion of psycho-education are critical features of health care in itself (Rosen et al., 2004). As the largest mental healthcare sys-
managing chronic conditions of all types. The website www. tem in the United States, and the largest provider of PTSD
myhealthevet.com provides access to important information treatment in the world, the VA is in a unique position to dis-
about a veteran’s medical care, access to components of their seminate EBTs to mental healthcare providers in the interest of
medical records, the ability to make medical appointments, and providing the best care possible to veterans seeking psycho-
the availability of wellness resources such as psycho-educational logical care, whether in Boston or in rural Montana. As part of
materials and self-screening instructions. Additional features a national mandate that all veterans have access to EBTs, the
will be added to this Internet-based website, which was designed VA has implemented multiple national initiatives to dissemi-
to support the VA recovery model of mental health care. nate and implement EBTs. This effort started with disseminat-
For different purposes, DoD, in collaboration with the VA ing PTSD EBTs of cognitive processing therapy (CPT) and PE
National Center for PTSD, has also created a website, www throughout the VA health care system.
.afterdelopyment.org, to deliver wellness resources to service This ongoing national initiative involves a multilevel pro-
members, veterans, and their families. These websites allow cess in which VA providers receive intensive, standardized,
veterans and active duty personnel to play a vital role in their and competency-based training in the delivery of CPT and PE
own health care and to be able to access needed resources (Karlin et al., 2010). Following intensive training workshops,
quickly and efficiently. Although these telehealth technology the providers continue to receive consultation and peer sup-
initiatives are breaking new ground in providing mental health port by local VA expert providers. These local expert providers

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Mental Illness in Veterans 505

have received intensive, standardized training by experts in veteran population (e.g., depression, serious mental illness, and
either CPT or PE, and they must pass a certification process to substance abuse). The VA national initiatives to disseminate and
serve in as a VA local expert provider. In turn, VA providers implement EBTs in a standardized fashion can serve as a model
must pass a certification process for CPT and/or PE to be qual- for the field in how to successfully train large numbers of men-
ified to deliver these treatments to veterans. In addition to this tal healthcare providers in EBTs and how to effectively imple-
credentialing process, all VA providers have access to an elec- ment these EBTs in practice.
tronic VA intranet site that provides core and supplemental Although the VA and DoD have launched many initiatives
training materials, a discussion board, and other provider-ori- in recent years with the overall goal of ensuring that veterans
ented materials. The intranet provides ongoing consultation to have access to the highest quality of care, there are some
enhance education and provide support services as well as fur- remaining challenges and limitations. Perhaps the most sig-
ther ensuring CPT and PE treatments are being effectively nificant challenge is the actual implementation of these pro-
implemented by the providers. grams. In a healthcare system as vast as the VA, it is a difficult
As others have noted (e.g., Kazdin, 2008), although mental task to ensure that every VA medical center and community-
healthcare providers may be trained in EBTs, they may not based outpatient clinic fully implements policies that have
successfully implement these treatments. Successful imple- been established by VA Office of Mental Health (OMH). An
mentation of EBTs is as critical as dissemination in reducing example of a recent policy established by OMH is that all new
the mental healthcare burden. Recognizing the importance of veterans contacting a VA facility for treatment services must
implementation, the VA has instituted multiple national initia- be scheduled for an initial appointment within 14 days of their
tives to promote implementation of CPT and PE. For example, contact. Making sure that every facility within the largest
the newly launched PTSD National Mentoring Program pro- health care system in the world consistently implements this
motes regional and national communication between PTSD 14-day policy is an enormous challenge. Further complicating
clinical managers and the sharing of best practices to clinic this challenge is the fact that an unprecedented number of vet-
design and care processing. In addition, a PTSD consultation erans now receive their care from the VA, and more are enter-
program has been established in which VA providers can ing the system every day, putting additional strain on existing
receive direct consultation on PTSD assessment and treatment resources.
from PTSD expert clinical psychologists and physicians. The As previously noted, one limitation is that we do not yet
intranet site that contains the discussion board and provider- know the degree of success of the multiple initiatives launched
oriented materials also promotes implementation of PE and in recent years. We also do not yet know whether the EBT dis-
CPT. Providing a locally trained expert in CPT and PE further semination and implementation efforts will be effective in terms
promotes that these treatments will be implemented. As others of reducing the mental health care burden among veterans and
have noted (e.g., Cook, Biyanova, & Coyne, 2009; Cook, active duty personnel. Current efforts are directed towards eval-
Schnurr, Biyanova, & Coyne, 2009), having a local provider uating the efficacy of the newly developed treatments, and the
implementing EBTs and available for peer supervision appears early findings are very encouraging (Brief, Rubin, Roy, Enggas-
to be one effective approach to have other providers adopt ser, & Keane, in press; Litz et al., 2007; Morland et al., 2010;
evidence-based practices. Tuerk et al., 2010). In the upcoming years, we expect to have a
Taken together, these combined dissemination and imple- better understanding of what does and does not work, as well as
mentation initiatives have resulted in nearly all VA facilities an understanding of why certain programs and treatments may
providing evidence-based PTSD treatment to veterans, and not have worked. The knowledge gained from these multiple
over 4,400 VA and DoD mental healthcare providers are now efforts will inform us as we continue in our goal to reduce the
trained in CPT and/or PE (Karlin et al., 2010). The VA has also mental illness burden among veterans.
instituted treatment outcome monitoring within the VA to Historically, major advances in clinical psychology have
evaluate the success of PTSD EBT dissemination and imple- been tied to the needs of military service men and women
mentation efforts—an approach that is essential to examining who’ve been exposed to the traumatic life experiences second-
the effectiveness of these efforts. It is too early to evaluate ary to service in war zones. The current wars in Iraq and
whether or not these major national dissemination and imple- Afghanistan represent another opportunity for clinical psy-
mentation efforts are successful in reducing PTSD symptom chologists and other mental health care professionals to
severity and functional impairment among veterans. However, develop new approaches for lessening the burden of mental
it is clear that many mental health care providers are now illness among our returning military personnel and veterans.
trained in CPT and PE and that these treatments are being Although more work is needed to refine and improve the VA’s
implemented to veterans in need of treatment services. Effec- initial efforts to implement broadly evidence based approaches
tiveness studies are now needed. to assessing and treating psychological conditions, the VA has
Building on the success of the PTSD EBT dissemination and already taken the critical step of creating bold, contemporary
implementation programs, there are additional dissemination solutions aimed at reducing the burden of mental illness
and implementation EBT initiatives currently underway that among those that rely on it for care. Further, it demonstrates
address other mental health problems frequently seen within the the VA’s commitment to providing exceptional mental health

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506 Sloan et al.

services to the many men and women who have served our Perspectives on Psychological Science, 6, 21–37. doi:10.1177/
country and addresses many of the concerns raised by Kazdin 1745691610393527
and Blase in their seminal review. It is our hope that these Litz, B., Engel, C., Bryant, R., & Papa, A. (2007). A randomized,
advancements will lead to improvements in the mental health controlled proof-of-concept trial of an Internet-based, therapist-
and quality of life—not only for veterans, but for all. assisted self-management treatment for posttraumatic stress
disorder. American Journal of Psychiatry, 164, 1676–1684.
Authors’ Note doi:10.1176/appi.ajp.2007.06122057
The opinions expressed in this commentary represent those of the Morland, L. A., Greene, C. J., Rosen, C. S., Foy, D., Reilly, P., Shore,
authors and do not represent the Department of Veterans Affairs. J., . . . Frueh, B. C. (2010). Telemedicine for anger management
therapy in a rural population of combat veterans with posttrau-
Declaration of Conflicting Interests matic stress disorder: A randomized noninferiority trial. Journal of
The author declared no potential conflicts of interest with respect to Clinical Psychiatry, 71, 855–863. doi:10.4088/JCP.09m05604blu
the authorship or the publication of this article. Nash, W., Krantz, L., Stein, N., Westphal, R., & Litz, B. T. (in press).
Comprehensive soldier fitness, battlemind, and the stress con-
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 Perspectives on Psychological Science

Interventions and Models of Their Delivery 6(5) 507–510

© The Author(s) 2011
Reprints and permission:
to Reduce the Burden of Mental Illness: sagepub.com/journalsPermissions.nav
DOI: 10.1177/1745691611418241

Reply to Commentaries http://pps.sagepub.com

Alan E. Kazdin and Stacey L. Blase

Department of Psychology, Yale University, New Haven, CT

Abstract
Our article in the January issue of Perspectives on Psychological Science (Kazdin & Blase, 2011) recommended developing a
portfolio of models to deliver psychotherapeutic interventions with the goals of reaching a larger and more diverse segment
of the population in need of mental health services and reducing the burden of mental illness. The commentaries offer several
novel extensions to advance the goals. Among the topics raised in the commentaries are the role of moderating influences,
the importance of a public health model for intervention research and application, the need to organize and manage our
knowledge base and current treatments more effectively, the potential utility of priming-based interventions, the importance
of cost measures, and novel applications to extend treatment broadly to veterans in need of services. The commentaries
stimulated additional points to address the original goals including the utility of identifying interventions (e.g., lifestyle changes)
that can reach many people in need and that can have broad outcome effects on mental and physical health, the importance
of “disruptive innovations” (i.e., innovations that qualitatively change the nature of what and how services are delivered) from
a business perspective, and the need for improved assessment to track the burden of mental illness in an ongoing way and to
evaluate subgroups not being reached with our current interventions.

Keywords
psychological interventions, reducing the burden of mental illness

The personal, social, and monetary burdens of mental illness methodological, and empirical literatures on intervention
are enormous. There is a high prevalence rate of psychiatric research have been especially influential. We address key
disorder (25% in the United States), leaving aside psychoso- issues of the commentaries, and convey how they qualify,
cial dysfunctions that do not meet formal diagnostic criteria alter, and improve on the recommendations in our article.
but do impair functioning and contribute to the burden of men- Finally, we conclude with additional points stimulated by the
tal illness (Kessler & Wang, 2008). The majority of individu- commentaries overall.
als who experience dysfunction do not receive services; the
paucity of services is particularly acute for several groups
(e.g., individuals of a minority or living in rural areas, chil- Commentaries, Rejoinders, and Perspectives
dren, and the elderly). Although advances in developing Shoham and Insel (2011, this issue) alert us to the importance
evidence-based psychotherapies have been remarkable, the of searching for moderating influences that may determine
dominant model of delivering psychosocial treatment (indi- which treatment is best for whom. The issue they raise has
vidual, in-person, one-to-one treatment) is not likely to reach broad relevance. In virtually all randomized controlled treat-
the majority of individuals in need. Our article recommended ment trials (e.g., in oncology, pharmacology, psychotherapy,
developing a portfolio of models of delivery with the dual inter alia) the usual case is that not everyone responds equally
goals of increasing the proportion and diversity of individuals well, or at all, to a given treatment—so it is important to
reached with effective interventions and reducing the burden
of mental illness (e.g., incidence, prevalence; Kazdin & Blase,
Corresponding Author:
2011). Alan E. Kazdin, Department of Psychology, 2 Hillhouse Avenue,Yale
We are delighted to have the benefit of such a diverse set University, New Haven, CT 06520-8205
of commentators whose contributions to the conceptual, E-mail: [email protected]

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508 Kazdin and Blase

determine these moderating influences and the best-suited impact. Their cogent concern is answered well in the Chorpita
individuals for each treatment. A guiding question for two et al. (2011, this issue) article in which distillation of common
generations of psychotherapy researchers has focused on the elements of treatment need not necessarily sacrifice
moderators of psychotherapy (e.g., Kiesler, 1971). The most effectiveness.
well-cited version of this is “What treatment, by whom is most The proposal by Atkins and Frazier (2011, this issue) draws
effective for this individual with that specific problem and on a successful model from a public health initiative to contain
under which set of circumstances (Paul, 1967, p. 111). The the H1N1 virus. This model integrated three tiers of interven-
importance of one of these moderating influences (“for tions at the universal, targeted, and intensive levels. This focus
whom”) was emphasized by Shoham and Insel in their discus- on reorganization of existing treatments alerts us to the need for
sion of Attribute (personal characteristics) × Intervention structuring a multilevel approach to mental health, seamlessly
effects. We agree greatly with the importance of moderators as integrating and unifying prevention and treatment and using
reflected in our own research but also in our recreational pas- multiple settings (e.g., in the community) and providers (e.g.,
time of trying to figure out what mediated moderation and lay individuals). The three tiers of intervention could address
moderated mediation are, all the while knowing they are the goal we proposed in our article, namely, reducing the burden
important. Yet, in the nature of intervention research and par- of mental illness and unifying disparate intervention models.
simony, one begins by looking for main effects (i.e., treat- We concur with their recommendation. Yet, it will still be neces-
ments that in fact can effect change in most individuals). For sary to scale up the interventions for each of the three tiers. We
example, ethnic and cultural diversity can moderate treatment noted that the intensive intervention level cannot be scaled up
but we already know that some treatments exert a main effect now, but their model actually could make the need for intensive
with diverse groups (Miranda et al., 2005) and getting these to treatment less. That is, successful preventive efforts reduce the
the people can have impact now. Also, the search for modera- need for treatment. However, this shifts the need from scaling
tors is not difficult, but their use for decision making in patient up intensive treatment to scaling up the universal and targeted
care is not at all straightforward. Among the challenges is interventions. There are many evidence-based interventions at
establishing high levels of sensitivity and specificity so that these other two tiers, but those tiers evoke the same tears we
patients are assigned to various treatments to which they might shed in relation to treatment. Can we scale them up to reach
be best suited. In addition, many seemingly straightforward most people in need? Otherwise, we risk continuing to fail to
moderators including biological and psychological character- reach the large portion of the population in need that simply
istics of the individual and environmental influences have sys- does not have access to these services.
tematic and unsystematic error we are just beginning to Chorpita et al. highlight the challenge of disseminating our
understand (e.g., jumping genes, imprinted genetic effects, existing treatments and complement the commentary by
and epigenetic effects). Atkins and Frazier. The authors contend that if we fail to orga-
Attribute × Intervention, a first-order interaction, is not nize and manage the treatments we currently offer, developing
likely to capture the “real” interactions that influence outcome. new treatments will not help us to achieve the goal of reducing
We believe the authors would subscribe to Attribute × the burden of mental illness. They highlight the need to strat-
Environment × Intervention effects to recognize the important egize better ways to use what we know to make our treatments
experience (environment) and attribute (e.g., polymorphisms more easily disseminable. The creative conceptual and empiri-
here and there) combinations. Until there is personalized psy- cal work on disseminating common elements of existing treat-
chotherapy (á la personalized medicine) that could be scaled ments could be very important in scaling up our interventions
up, we need to increase greatly the less personalized, but still for greater reach. Yet, the challenges remain: Can we scale up
effective, psychotherapy. As an analogue, the same amounts of effective intervention elements in a form that reaches most
vitamins and minerals are not needed for each individual. We people in need? Current common elements that work may still
use recommended doses (often based on research) because if be the individual, one-to-one dominant treatment model,
those doses reach most people, the health of individuals and which we argued will need to be complemented by scores of
our nation would be better. That does not gainsay the benefit other models.
for more individualized recommended doses. Effective inter- Shalev and Bargh (2011, this issue) provide a fascinating
ventions, whether vitamins or evidence-based psychosocial and novel model for reaching large groups of people in every-
treatments, need disseminable versions that can be delivered day settings. Their suggestion of priming-based interventions
on a large scale. is in keeping with our goal of using novel treatment delivery
Shoham and Insel (2011) also remind us that we do not models. Because the nonconscious automatic processes they
know the mechanisms by which therapeutic change occurs, target are unintentional and operate outside of awareness,
and this is definitely an important issue, even in current dis- priming interventions do not require the volitional engage-
semination efforts. An abbreviated intervention may uninten- ment of the patient. Thus, interventions can be scaled up to
tionally sacrifice an important ingredient, as they note. A reach many people and do not have to be costly because they
critical goal for developing a portfolio will be to scale up our can be administered through nontraditional agents and set-
interventions for greater reach while maintaining therapeutic tings. Priming techniques might promote positive emotions,

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Reply to Commentaries 509

evoke self-management or regulation strategies, or foster ther- individuals who are not receiving services. Our idea was that a
apeutic benefits related to such domains as loneliness and iso- portfolio of models of delivery would be needed to increase
lation. Such interventions might produce change that is the reach of interventions in relation to those in need of ser-
therapeutic in its own right or sensitize individuals to change vices. No one model is likely to reach even a given segment of
with other interventions that might be easily delivered but less the population because of the range of real and perceived bar-
likely to be effective on their own (e.g., communication and riers to seeking or providing services. The commentators have
public health messages, television appeals). We had argued provided novel extensions of our recommendations and have
that reducing the burden of mental illness would profit from, highlighted a multipronged approach that could accelerate
and actually require, collaborations with areas well beyond advances in reducing the burden. The commentaries have
mental health fields. Shalev and Bargh provide a creative stimulated additional points to address the original goals of
model from social psychology, a sibling field that clearly has our article.
much to offer in extending the reach of interventions that can First, we begin the research and services delivery agenda
influence mental health. with the goal of reducing the burden of mental illness. We look
Yates (2011, this issue) underscores the importance of cost to how psychotherapy might help and how current knowledge
measures of treatment in several ways: cost of delivering the might be used (e.g., common elements of treatment, less costly
intervention, monetary benefits in outcomes (e.g., patient income delivery methods, both in the commentaries), but also we look
from their employment, patient use of health care and social beyond psychotherapy to examine whether other interventions
services), and the cost per increment of therapeutic gains. might contribute. For example, are there non-psychotherapeutic
Simply put, cost cannot be ignored in any effort to extend effec- interventions that might address the goal? We have seen priming-
tive interventions so that they reach the many in need of services. based interventions as one possibility in the commentaries.
This novel measure of “impact per dollar” provides a specific Another would be lifestyle changes that can improve physical
metric that might be useful to integrate in interventions at all and mental health (Walsh, 2011). These changes include exer-
levels. Cost is related to the reach of an intervention. Yates notes cise, better nutrition and diet, time in nature, improved rela-
this aptly by conveying that the challenge is to deliver scaled-up tionships, recreation and enjoyable activities relaxation and
interventions on a plastic spoon (rather than the golden ladle of stress management, spiritual involvement, and service to oth-
individual psychotherapy) to as many people as possible. ers, several of which have an evidence base already. One or
It is inspiring, instructive, and, for us as citizens, very reas- more of these lifestyle changes may be feasible as a type of
suring to learn of the range of innovations in the Veterans intervention that can serve both to prevent and treat psycho-
Health Administration (VA), as described by Sloan, Marx, and logical impairment and dysfunction. An added strength is that
Keane (2011, this issue). The authors point out the clear intent some of the same lifestyle interventions promote both physical
of this health care system to reach as many people as possible and mental health. This adds a different dimension to our orig-
using several delivery opportunities (e.g., Internet, videocon- inal article, namely that, when possible, high priority might be
ferencing, laypersons, and cell phones). With the portfolio of given to interventions that have reach within the population in
models already in use, ever-increasing numbers of veterans need but that also produce broad or cascading therapeutic
have access to the services provided by the VA. Naturally, due effects beyond some target focus (e.g., depression, anxiety).
to its record number of clients, the system experiences the Such interventions would be very sensitive to the cost issues
strain of this unprecedented use of its resources. Thus, their also raised in the commentaries.
example wonderfully illustrates the importance of even further Second, we see diverse disciplines as relevant to reducing
broadening our portfolio of treatment delivery models not the burden of mental illness, even if all of the interventions
only to reach more people in need, but also to sustain their care were psychotherapy in one form or another. Other disciplines
once they are entered into it. As the largest health care system have specialties that will help with penetration of our interven-
in the United States, as noted by the authors, with some cen- tions to potential consumers. As one example, the notion of
tralized opportunities and challenges, the VA might be the disruptive technology or disruptive innovation in business
place to further pursue the goals and the model we suggested. refers to innovations that alter a product and its delivery in
The only additions would be to evaluate empirically the extent novel ways. The change or innovation is not the usual evolu-
of reach (e.g., proportion of individuals in need of services tionary or incremental step in product development, but
who actually receive them) and the impact on the burden of rather it provides something different and serves—indeed
mental illness (incidence of new disorders or dysfunctions and develops—a market that is not being served (e.g., Christensen,
prevalence). This knowledge might provide key insights that Grossman, & Hwang, 2009). Examples are evident in manu-
could be transferred outside of the system. facturing (e.g., interchangeable parts, assembly line in car pro-
duction), new products (e.g., cell phone, smartphone, tablet),
consumer purchasing (e.g., credit cards, apps to make pur-
Closing Comments chases with smartphones), and health care (e.g., home preg-
A central goal of our article was to focus attention to reducing nancy tests, services such as flu shots or blood pressure testing
the burden of mental illness and reaching the large swath of in stores and shopping malls). Such interventions often

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510 Kazdin and Blase

provide simpler, less expensive, or more convenient solutions to Declaration of Conflicting Interests
problems and can be scaled to reach people. Packaging our The author(s) declared no potential conflicts of interest with respect
interventions so some of them are “disruptive” could have huge to the research, authorship, and/or publication of this article.
impact for the goal of reducing the burden of mental illness.
Finally, and perhaps most central to the goal, is the need for Funding
improved assessment along two fronts. First, ongoing (regu- The author(s) received no financial support for the research, author-
lar) assessment at the national level will be needed to measure ship, and/or publication of this article.
the burden of mental illness. We mentioned in our article mod-
els already available that could be brought to bear. We will References
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