Counselor Troi is not Scalable

In anticipation of this year’s Medicine X Conference, some reflections on one of the stickiest problems in mental healthcare innovation…

In less than a month, the Medicine X and Medicine X | Ed conferences will kick-off in Palo Alto, exploring the intersections of emerging technologies, healthcare, and design, with an emphasis on empowering patients to be active, driving forces in their care. I’ll be participating in the conferences as an ePatient Delegate to share my experiences using technology to support recovery from mental illness, and I’ll also be taking part in the IDEO Design Challenge, spending a day exploring possible solutions to systemic challenges in mental healthcare. I’ve been a huge IDEO fan for years and often share their design tools as supports to help people navigate the complex systems of mental illness and recovery, so I’m beyond excited to spend a day at IDEO HQ (sticky-note heaven!). I’m also very excited to see what new innovations in healthcare will be unveiled at the conference. In particular, when it comes to mental healthcare, I’m curious to see progress we’re making to overcome a problem in our mental healthcare system that I like to call, the Counselor Troi Problem. Let me explain what that’s about…

For those not familiar with Counselor Troi, she was the ship’s counselor on the starship Enterprise on the TV show “Star Trek: The Next Generation”. She was telepathic, she wore tight purple jump-suits and dresses during the first years of the show instead of the uniforms that the rest of the crew wore, and she basically did talk therapy — crew members came to her to explain their inner struggles and she asked them questions. When the show launched in the early nineties, she typified the popular view of therapy at the time: you sat and talked to a nice person that tried to read your mind while helping you uncover insights that solved all of your problems.

Counselor Troi’s role also reflected the popular view of mental illness at the time: other people had them. Despite the prescient innovations the Star Trek universe imagined for physical healthcare — like tricorders and replicators — its vision for the future of mental healthcare was basically Sigmund Freud in a low-cut leotard (I apologize if I just destroyed anybody’s adolescent Deanna Troi fantasies).

Since the nineties, I’d say there’s a greater awareness that mental illnesses are more common than most people assumed, and you can’t just talk about your feelings and make these illnesses go away. Now consumers expect their therapist to practice an evidence-based form of therapy like CBT, DBT, ACT, etc. There are methodologies, healthy actions that patients can take, and recovery is becoming a clearer path for consumers and providers. But there’s still the expectation that you have to learn those methodologies and walk that path of recovery with a therapist, with your own version of Counselor Troi. And this brings us to the Counselor Troi Problem:

Counselor Troi is not scalable.

If everybody must work with Counsellor Troi to improve and maintain their mental health, the ship is going to fall apart in a mess of mental illnesses. There are not enough Counselor Trois on the Starship Enterprise to meet the mental health needs of the crew.

There are approximately 1000 people on the Enterprise, so let’s say it’s an even thousand. Current research estimates that, in any given year, about 20% of people experience a diagnosable mental illness. That’s 200 people on the ship with mental illnesses of varying severity, likely requiring care and attention at different levels of intensity. For the sake of argument, I’m going to be optimistic and assume Counselor Troi is a very effective, solutions-focused counselor who only sees clients for six months, meeting once per week for an hour, and then those clients have the tools to continue recovery successfully on their own. So for those 200 people to see Counselor Troi for six months each (24 weeks) at a maximum of 1 hr per week, that requires 4800 hrs of her time (200 x 24).

But if Counselor Troi works for 40 hours each week of the year, with no vacation, that would only total 2080 hours (40 x 52). That’s not even enough time to complete treatment for half of those people already struggling with a mental illness. And if you’ve seen the show, you know Troi spends more time telling people how to eat chocolate than she spends time telling people how to handle intrusive thoughts.

Given that Counselor Troi, like most contemporary therapists, doesn’t spend every hour of the week counseling clients, and she doesn’t work every week of the year, the Enterprise would need at least two other therapists on the ship simply to meet the demand of the people already struggling. That’s assuming the additional therapists are as effective as Counselor Troi, which is the second aspect of the Counselor Troi Problem: quality.

The reality is that not every therapist is effective. It’s not uncommon to hear of somebody working with a therapist for years and only getting worse. Our current system depends heavily on the competency of individual practitioners, with little ability to measure or control effectiveness and quality between therapists.

So simply dealing with those struggling is going to be difficult, and we haven’t even started to look at prevention and maintenance. Everybody has a brain, so everybody on the Enterprise has varying levels of mental health. Many are on their way to developing a mental illness but if the services on the ship are already over-stretched dealing with people in crisis, then it’s likely that those showing less-severe symptoms will get bumped to the bottom of the waiting list. On the Enterprise, as in North America, the price of admission to mental healthcare services would likely be severe symptoms, personal disasters, or the threat of harm to yourself or others.

Illness, disasters, and violence should not be the prerequisites for health. That’s no way to design a sustainable healthcare system.

The future, as imagined on Star Trek, also demonstrates why, even with all barriers to access removed, the Counselor Troi Problem would persist. On Star Trek, humans have mastered interstellar travel, can communicate in real-time across the galaxy, and can beam people from a spaceship to a planet’s surface. They have no issues when it comes to accessing a therapist. But whether Counselor Troi sees somebody in-person or counsels them from across the galaxy, she still doesn’t have enough hours to see everybody on the ship.

There are startups tackling our earthly accessibility challenges when it comes to therapy, using apps that connect you remotely to a therapist, but I don’t see those as the types of transformative, disruptive innovations we need. That’s more like trying to stick faster horseshoes on a horse-drawn buggy than inventing a totally new mode of transportation. There are still very basic supply and quality issues.

We either need to drastically change how we educate therapists, the number of therapists we educate, and how they practice, or we need an entirely different way of connecting mental healthcare consumers with the products and services they need to support better mental health. From the patient perspective, innovation to completely transform how we deliver mental healthcare supports is what gets me most excited — innovation that fundamentally transforms how people can travel the journey of recovery.

Around the world, we’re struggling with the Counselor Troi Problem on a massive scale — on a ship with billions of crew members. If we don’t solve this problem, we will perpetually have a mental healthcare system that’s overworked, unable to meet demand, and struggling with quality issues as more and more people get sick to get help.

How can we give tools to those 200 people struggling with mental illness on the Enterprise to improve and maintain their mental health together? What if we gave them tools to share with others to prevent the same illnesses? What if those tools could learn from successes and challenges to improve their effectiveness with real-world, consumer experience? How can we empower 200 consumers to become producers and providers?

Those are the questions that are going to be on my mind as I head into Med X 2015, thrilled to be connecting with others that are asking those same questions in all areas of healthcare, as we transform physical and mental healthcare with innovations even more amazing than warp drive and phasers.

Originally posted on Medium: medium.com/@thepathtochange