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Home / Living Well / A holistic approach to integrative medicine

A holistic approach to integrative medicine

As studies continue to reveal the important role the mind plays in healing and in fighting disease, a transformation is taking place in hospitals and clinics across the country. Meta description: Discover principles and benefits of integrative medicine, a comprehensive approach combining conventional and complementary therapies.

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Interested in integrative medicine? Read the following excerpt from the Mayo Clinic Guide to Integrative Medicine .

People who take an active role in their health care experience better health and improved healing. It’s a commonsense concept that’s been gaining scientific support for several years now.

As studies continue to reveal the important role the mind plays in healing and in fighting disease, a transformation is taking place in hospitals and clinics across the country. Doctors, in partnership with their patients, are turning to practices once considered alternative as they attempt to treat the whole person — mind and spirit, as well as body. This type of approach is known today as integrative medicine.

Incorporate integrative medicine alongside your treatments

Integrative medicine describes an evolution taking place in many health care institutions. This evolution is due in part to a shift in the medical industry as health care professionals focus on wellness as well as on treating disease. This shift offers a new opportunity for integrative therapies.

Integrative medicine is the practice of using conventional medicine alongside evidence-based complementary treatments. The idea behind integrative medicine is not to replace conventional medicine, but to find ways to complement existing treatments.

For example, taking a prescribed medication may not be enough to bring your blood pressure level into a healthy range, but adding meditation to your daily wellness routine may give you the boost you need — and prevent you from needing to take a second medication.

Integrative medicine isn’t just about fixing things when they’re broken; it’s about keeping things from breaking in the first place. And in many cases, it means bringing new therapies and approaches to the table, such as meditation, mindfulness and tai chi. Sometimes, integrative approaches help lead people into a complete lifestyle of wellness.

What types of integrative medicines are available?

What are some of the most promising practices in integrative medicine? Here’s a list of 10 treatments that you might consider for your own health and wellness:

• Acupuncture is a Chinese practice that involves inserting very thin needles at strategic points on the body.
• Guided imagery involves bringing to mind a specific image or a series of memories to produce certain responses in the body.
• Hypnotherapy involves a trancelike state where the mind is more open to suggestion.
• Massage uses pressure to manipulate the soft tissues of the body. There are many different kinds of massage, and some have specific health goals in mind.
• Meditation involves clearing and calming the mind by focusing on your breathing or a word, phrase or sound.
• Music therapy can influence both your mental and physical health.
• Spinal manipulation, which is also called spinal adjustment, is practiced by chiropractors and physical therapists.
• Spirituality has many definitions, but its focus is on an individual’s connection to others and to the search for meaning in life.
• Tai chi is a graceful exercise in which you move from pose to pose.
• Yoga involves a series of postures that often include a focus on breathing. Yoga is commonly practiced to relieve stress, as well as treat heart disease and depression.

Who can integrative medicine help?

A number of surveys focused on the use of integrative medicine by adults in the United States suggest that more than a third of Americans are already using these practices as part of their health care.

These surveys demonstrate that although the United States has the most advanced medical technology in the world, Americans are turning to integrative treatments — and there are several reasons for this trend. Here are three of the top reasons why more and more people are exploring integrative medicine.

Integrative medicine for people engaged in their health

One reason integrative medicine is popular is that people in general are taking a greater, more active role in their own health care. People are more aware of health issues and are more open to trying different treatment approaches.

Internet access is also helping to fuel this trend by playing a significant role in improving patient education. Two decades ago, consumers had little access to research or reliable medical information. Today, clinical trials and pharmaceutical developments are more widely available for public knowledge.

For example, people who have arthritis can find a good deal of information about it online. They may find research showing that glucosamine, for example, helps with joint pain and doesn’t appear to have a lot of risks associated with it. With this information in hand, they feel empowered to ask their doctors if glucosamine might work with their current treatment plans.

Integrative medicine for an aging population

A second reason for the wider acceptance of integrative treatments is the influence of the baby boomer generation. This generation is open to a variety of treatments as it explores ways to age well. In addition, baby boomers are often dealing with several medical issues, from weight control to joint pain, high blood pressure and elevated cholesterol. Not everyone wants to start with medication; many prefer to try complementary methods first.

Integrative medicine for the chronically stressed

A third reason for the growth, interest and use of integrative therapies is the degree of chronic stress in the American lifestyle. Workplace stress, long commutes, relationship issues and financial worries are just some of the concerns that make up a long list of stressors.

Although medications can effectively treat short-term stress, they can become just as damaging — and even as life-threatening — as stress itself is when taken long term. Integrative medicine, on the other hand, offers several effective, evidence-based approaches to dealing with stress that don’t involve medication. Many otherwise healthy people are learning to manage the stress in their lives successfully by using complementary methods such as yoga, meditation, massage and guided imagery.

Considering that many healthy people are engaging in integrative practices, it isn’t surprising to find out that they’re turning to these treatments in times of illness, as well. Here are just a few ways integrative medicine is used to help people cope with medical conditions:

• Meditation can help manage the anxiety and discomfort of medical procedures.
• Massage has been shown to improve recovery rates after heart surgery.
• Gentle tai chi or yoga can assist the transition back to an active life after illness or surgery.

Conventional Western medicine doesn’t have cures for everything. Many people who have arthritis, back pain, neck pain, fibromyalgia and anxiety look to integrative treatments to help them manage these often-chronic conditions without the need for medications that may have serious side effects or that may be addictive.

The risks and benefits of integrative medicine

As interest in integrative medicine continues to grow, so does the research in this field. Researchers are studying these approaches in an effort to separate evidence-based, effective therapies from those that don’t show effectiveness or may be risky. In the process, this research is helping to identify many genuinely beneficial treatments. In essence, both consumer interest and scientific research have led to further review of these therapies within modern medicine.

As evidence showing the safety and efficacy of many of these therapies grows, physicians are starting to integrate aspects of complementary medicine into conventional medical care. Ultimately, this is what has led to the current term integrative medicine.

Ask your healthcare team about integrative medicine and wellness

If you’re interested in improving your health, many integrative medicine practices can help. Not only can they speed your recovery from illness or surgery, but they can also help you cope with a chronic condition. In addition, complementary practices such as meditation and yoga can work to keep you healthy and may actually prevent many diseases.

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Reframing employee health: Moving beyond burnout to holistic health

At a glance.

• Holistic health encompasses physical, mental, social, and spiritual health . The McKinsey Health Institute’s 2023 survey of more than 30,000 employees across 30 countries found that employees who had positive work experiences reported better holistic health, are more innovative at work, and have improved job performance.
• For employees, good holistic health is most strongly predicted by workplace enablers, while burnout is strongly predicted by workplace demands . Providing enablers alone will not mitigate burnout, and addressing demands alone will not improve holistic health. A complementary approach is needed.
• Organizational, team, job, and individual interventions that address demands and enablers can boost employee holistic health . These may include flexible working policies, leadership trainings, job crafting and redesign, and digital programs on workplace health.

For most adults, the majority of waking daily life is spent at work. That offers employers an opportunity to influence their employees’ physical, mental, social, and spiritual health.

To support the move to better health, the McKinsey Health Institute (MHI), along with other organizations such as the World Health Organization (WHO), are highlighting a more modern way to view health beyond illness and its absence. 1 Adding years to life and life to years , McKinsey, March 29, 2022; A 2022 MHI survey on global health  perspectives found that more than 40 percent of respondents who reported having a disease still perceived their health as good or very good, while more than 20 percent of those who reported no disease said they were in fair, poor, or very poor health. Embracing the concept of holistic health—an integrated view of an individual’s mental, physical, spiritual, and social functioning 2 Previous work from MHI has defined each dimension of health in detail. For more details, see Adding years to life and life to years . Using this definition means that we emphasize “functioning.” For example: well-functioning from a mental health perspective means that respondents agree or fully agree with the statement, “I feel in a positive cognitive, behavioral, and emotional state of being” or for spiritual health, “I feel a connection to something larger than myself (for example a community, a calling, or a faith/God”). —is a vital step toward “ adding years to life and life to years ” across continents, sectors, and communities.

Previous research from MHI has focused on how modifiable drivers of health can lead to healthier, longer lives. The majority of these—ranging from quality of sleep to time spent in nature—sit outside of the traditional healthcare system, and many of these drivers could benefit from employer support. MHI’s new survey of 30,000 employees across 30 countries explores how employees perceive their health and how workplace factors may act as demands upon or enablers to mental, physical, spiritual, and social health.

The reasons to act go beyond improving health. Recent McKinsey research  finds that employee disengagement and attrition—more common among workers with lower well-being—could cost a median-size S&P company between $228 million and $355 million a year in lost productivity. 3 Aaron De Smet, Marino Mugayar-Baldocchi, Angelika Reich, and Bill Schaninger, “ Some employees are destroying value. Others are building it. Do you know the difference? ,” McKinsey Quarterly , September 11, 2023. Research by MHI and Business in the Community showed that the UK economic value of improved employee well-being could be between £130 billion to £370 billion per year or from 6 to 17 percent of the United Kingdom’s GDP. That’s the equivalent of £4,000 to £12,000 per UK employee. 4 “Prioritise people: Unlock the value of a thriving workforce,” Business in the Community, April 24, 2023.

In the MHI Holistic Health framework and research model, 5 Grounded in contemporary academic research, expanded with new concepts and psychometrically validated. we demonstrate the additional value of measuring holistic health over and above other popular health-related outcomes such as burnout or other well-being-related outcomes such as engagement or happiness. The insights presented in this article are vital for organizations determining where to start when aiming to improve employee health and how to enable them to start considering, measuring, and improving holistic health.

The majority of employees report positive overall holistic health

We found that more than half of employees across 30 countries reported positive overall holistic health 6 With positive holistic health we report the percentage of respondents that rated a 4 or higher, on average, for each subdimension (mental, physical, social, and spiritual health) and for the overall holistic health percentage, this average of 4 or higher was consistent across all subdimensions for the respondents reported. Hence the overall number can be lower than the averages of all other dimensions separately. We used a 5-point Likert scale, where 1 = fully disagree, 3 = neither disagree nor agree, and 5 = fully agree. —but there are substantial variations between countries, with the lowest overall percentage of positive scores in Japan (25 percent) 7 As with all cross-cultural research, differences in scores across countries can be driven by: 1) true differences between countries on variables of interest along with 2) differences between countries due to artifacts such as within-country response styles or context-driven stigma. As an example, in our current survey, we observed lower scores across many variables of interest in Japan compared with other countries. When reviewing cross-cultural findings, we recommend the reader considers the cultural context of the country and region. and the highest percentage of positive scores in Türkiye (78 percent). Among respondents, the largest proportion of positive scores was for physical health at 70 percent, and approximately two-thirds of global employees reported positive scores on mental and social health. The lowest proportion of positive scores were on spiritual health, at 58 percent.

When looking at demographic differences and nuances, those aged 18 to 24 had the lowest holistic-health scores. This complements previous MHI work  on the challenges facing Gen Z. For companies, size matters: respondents in larger companies (more than 250 employees) had higher holistic-health scores than those in smaller companies. Within role, managers had the highest holistic-health scores, while all other workers reported lower holistic health. Further, there are similar levels of good holistic health across the industries surveyed (Exhibit 1).

At a country-specific level, factors such as burnout symptoms, emotional impairment, or cognitive impairment vary. However, one common finding is a lack of energy: more than a third of respondents in 29 of the surveyed countries reported exhaustion. Comparatively, only three countries had a third or more respondents reporting mental distance or reluctance to work (Exhibit 2).

Understanding demands and enablers for employees

In this survey, MHI explored a wide set of demands , which are workplace factors that require sustained cognitive, physical and/or emotional effort, and enablers , which can offset job demands. 8 Arnold B. Bakker, Evangelia Demerouti, and Ana Sanz-Vergel, “Job demands–resources theory: Ten years later,” Annual Review of Organizational Psychology & Organizational Behavior , February 2023, Volume 10, Issue 1; In this article, we are building on the job demands–resources theory, but we have used more reader-friendly terms that better resonate with the audience. Where we describe “demands” we are referring to the term “demands,” and for “enablers” we refer to “resources” as used in academic literature. Demands can be thought of as challenges in the workplace, and enablers help to effectively offset challenges, allowing employees to move forward and experience positive growth and development.

Our research model explores how these demands and enablers influence several work-related and health-related outcomes (see sidebar “What we measured”). Building on previous research, we now consider a vital new aspect: the relationship between demands, enablers, and an employee’s holistic health.

What we measured

From April to June 2023, the McKinsey Health Institute conducted a global survey of more than 30,000 employees in 30 countries (Argentina, Australia, Brazil, Cameroon, Canada, Chile, China, Colombia, Egypt, France, Germany, India, Indonesia, Italy, Japan, Mexico, Netherlands, New Zealand, Nigeria, Poland, Saudi Arabia, Singapore, South Africa, South Korea, Sweden, Switzerland, Türkiye, United Arab Emirates, United Kingdom, and United States). The dimensions assessed in our survey included toxic workplace behavior, interpersonal conflict, workload, work hours, time pressure, work pressure, physical demands, role conflict, role ambiguity, job insecurity, access to health resources, leadership commitment, career opportunities, career customization, psychological safety, supervisor support, coworker support, authenticity, belonging, meaning, job autonomy, remuneration, person–job fit, learning, and growth. Individual self-efficacy and adaptability were also assessed (exhibit).

The role of these dimensions were tested to determine whether they were associated with several health-related outcomes (holistic health, burnout symptoms, depression symptoms, distress symptoms, anxiety symptoms, sleep hours, sleep satisfaction, happiness at work, loneliness at work, financial instability) and several work-related outcomes (work engagement, organizational advocacy, job satisfaction, work–life balance, intent to leave, absenteeism health, absenteeism caregiving, task performance, presenteeism, and innovative work behaviors).

The MHI model predicted a large proportion of the variance in holistic health, at 49 percent, well exceeding traditional research models’ predictions regarding variance in outcomes. 9 Peterson K. Ozili, “The acceptable R-square in empirical modelling for social science research,” Social Research Methodology and Publishing Results , January 2023. We are aware, however, that common method variance (using the same survey instrument to measure drivers and predictors) inflates results as well. Our research clarifies associations and correlations but does not confirm causality. The higher the explained variance, the better positioned the model is to be able to reliably predict differences between employees’ outcomes. Interestingly, we find that as scores on one subdimension of health increase, scores on all subdimensions of health rise.

Enablers—aspects of work that provide positive energy such as meaningful work and psychological safety—explain the most variance in holistic health. Those who find meaning in their work and feel they can raise new ideas or objections with their coworkers are more likely to feel they are in better health across all four dimensions (Exhibit 3).

Holistic health also offers insight into workforce performance. For example, employees with good holistic health are more likely to indicate that they are innovative at work, have better work performance, and experience better work–life balance.

When examining burnout symptoms, demands—such as toxic workplace behavior, role ambiguity, or role conflict—are seven times more predictive than enablers are.

Team-, job-, and individual-level drivers affect holistic health (Exhibit 4). This means that workers who have confidence in their ability to do good work, are adaptable during changing working conditions, and feel as though they belong to a community at work have improved holistic health.

Team- and job-level drivers affect burnout symptoms. This means that workers who are excluded, bullied, or receive demeaning remarks from colleagues or who are unclear on what is expected of them at work have higher burnout symptoms.

The relationship between holistic health and outcomes

Holistic health uniquely contributes to the prediction of several work-related outcomes, over and above related concepts such as burnout symptoms, engagement, and happiness at work. This highlights that the underlying components of health, while correlated with other workplace measures, are not equivalent to engagement or happiness at work. 10 This was also confirmed in our psychometrical tests, factor analysis, and model confirmation. For completeness’ sake: Pearson’s correlation between holistic health and employee engagement in our study was 0.46, and with happiness at work it was 0.50. In our predictive models with work-related outcomes such as innovative behavior and work–life balance, we found that holistic health predicted unique variance over and above employee engagement and happiness.

Holistic health is a strong measure of how an employee can sustain growth over time, which contributes to positive workplace performance. Having employees with strong holistic health has implications beyond short-term business performance. Community engagement beyond work is one example: when employees are suffering from poor holistic health, they are likely unable to help their communities. Relatedly, they may create a strain on health services through delaying care. This also could have implications for the role employers play in their communities—and for cities that are trying to foster good physical health and grow societal participation and purpose-driven initiatives among residents. Furthermore, employees who have strong holistic health may want to—and are better able to—work longer, which will be important for how employers approach an aging workforce .

How burnout symptoms factor into health

Consistent with our previous research on burnout , we found that 22 percent 11 This value represents the percentage of respondents scoring an average of more than 3 (on a scale of 1–5) across all four dimensions of burnout symptoms (cognitive impairment, emotional impairment, exhaustion, and mental distance) on the Burnout Assessment Tool. of employees are experiencing burnout symptoms at work across the 30 countries included in our study, although there are substantial variances between countries. Cameroon respondents reported the lowest rates of burnout symptoms (9 percent), and India respondents reported the highest rates of burnout symptoms (59 percent). 12 As mentioned previously, results need to be interpreted in relevant cultural context. When exploring demographic differences on burnout, we find younger workers aged 18 to 24, employees from smaller companies, and all workers who are nonmanagers report higher burnout symptoms.

Our survey findings underscore a critical pattern: demands—aspects of work that require energy such as dealing with toxic behaviors or role ambiguity—explain the most variance in burnout symptoms. 13 In total, our model predicts 69 percent of the variance in burnout symptoms. But burnout is only the starting point: employers have a critical role to play in addressing a range of negative (mental) health outcomes at work  beyond burnout.

It’s time to reframe how we think about employee health. Employers need to support the health of all employees—supporting those in ill health, taking preventative measures to avoid negative health outcomes, and actively building a work environment where more employees have positive holistic health.

Improving holistic health and burnout together

MHI explored how workers across our global sample were faring on both holistic health and burnout symptoms in the 30 countries we surveyed (Exhibit 5). The presence of positive holistic health doesn’t mean absence of burnout symptoms. They are negatively correlated but aren’t two opposite sides of the same spectrum. Burnout and holistic health can coexist. 14 Holistic health is negatively correlated with burnout symptoms, Pearson’s r = -0.33.

At the global level, we found approximately half of employees (49 percent) are “faring well”—well functioning across the dimensions of holistic health and simultaneously experiencing low rates of burnout symptoms. However, an average of 9 percent of employees are “stretching”—well functioning across the dimensions of holistic health and simultaneously experiencing high rates of burnout symptoms. Almost a third of employees are “managing”—experiencing suboptimal functioning across the dimensions of holistic health and experiencing low rates of burnout symptoms. The group struggling the most are those employees who are “drowning”—experiencing suboptimal functioning across the dimensions of holistic health and high rates of burnout symptoms. Exhibit 5 shows the percentage of employees that can be improved by simultaneously addressing demands and building enablers for employees. We call this the opportunity gap. 15 But again, these outcomes are also influenced by cultural differences in survey responses.

Looking at holistic health and burnout symptoms together could help employers in different sectors better differentiate the true drivers of outcomes. For example, physicians, nurses, teachers, and others in the social or healthcare sectors often report finding meaning in their work, yet often also report high rates of burnout symptoms and consideration of leaving their jobs. 16 Gretchen Berlin, Ani Bilazarian, Joyce Change, and Stephanie Hammer, “ Reimagining the nursing workload: Finding time to close the workforce gap ,” McKinsey, May 26, 2023; Jake Bryant, Samvitha Ram, Doug Scott, and Claire Williams, “ K–12 teachers are quitting. What would make them stay? ,” McKinsey, March 2, 2023.

Driving organizational, team, and individual action—where to start?

We uncovered drivers that are most strongly associated with positive and negative employee health outcomes. Our research insights suggest a set of actions addressing the workplace demands that fuel poor health and those that build up the workplace enablers to help employees thrive.

Workplace factors at the individual, team, and job levels have the strongest influence on holistic health. In our model, workplace factors at the individual level predict 28 percent of differences between employees on holistic health, while those at the job level predict 21 percent, team level 39 percent, and the organization level 12 percent. 17 To clarify: job and organization-level demands and enablers are often tackled at the organizational level; the fact that organization-level impact is lower in our model has multiple reasons: (a) we look at the outcomes through the lens of the employee and expect more proximal demands and enablers to have a more direct effect on a proximal outcome; (b) we expect organizational-level demands and enablers to possibly have a more indirect effect or to be mediated by more proximal factors; (c) therefore, we focused our model primarily at team, job, and individual levels to find the most direct impact. For more, see Emily Field, Bryan Hancock, and Bill Schaninger, “Middle managers are the heart of your company,” McKinsey Quarterly , July 17, 2023.

Comparatively, when looking at employees on burnout symptoms, in our model, workplace factors at the individual level predict 3 percent of differences between employees on burnout, while those at the job level predict 62 percent, team level predict 32 percent, and the organization level predict 1 percent. Ninety-four percent of the explained variance is driven by factors at the job and team levels.

Employees who find their work meaningful more often report having better holistic health, even when they tolerate toxic workplace behaviors. But there is a limit. While holistic health can be maintained in a highly toxic work environment if an employee finds their work meaningful, meaningful work doesn’t protect against burnout symptoms in highly toxic environments (Exhibit 6). Furthermore, when employees experience toxic behavior at work, their holistic health scores are 7 percent lower and they report a 62 percent higher rate of burnout symptoms.

In simple terms, if employers want to improve holistic health, they need interventions at all four levels (individual, job, team, and organization). If employers want to reduce immediate negative outcomes such as burnout, then focusing interventions at the job and team levels are the best place to start.

Consider an employee who may be described as “rolling with the punches” or “able to handle what we throw at her.” Those can manifest as self-efficacy and affective adaptability, both of which are the top two drivers of holistic health—meaning they are unique workplace factors that can improve holistic health in a targeted way. When employees have self-efficacy, they feel confident they can deal efficiently with unexpected events or handle unforeseen situations thanks to their resourcefulness. They feel they can remain calm when facing difficulty because they can rely on their coping abilities.

Employees with adaptability can stay relaxed even if they must change plans, get energy from unexpected changes, enjoy it when their situation changes, and enjoy unexpected events. It should be no surprise that when challenges or uncertainty arise, these employees fare better in terms of health—an effect also seen in our previous research on burnout. 18 “Addressing employee burnout: Are you solving the right problem?,” McKinsey, May 27, 2022. Employees with self-efficacy or adaptability skills report better holistic health, regardless of which demands they face (for example, high role ambiguity), perhaps because they are more capable of transforming challenging situations into opportunities. These are trainable skills that can be developed. 19 Jacqueline Brassey et al., “Emotional flexibility and general self-efficacy: A pilot training intervention study with knowledge workers,” PLoS One , October 14, 2020, Volume 15, Issue 10; Jacqueline Brassey, Aaron De Smet, and Michiel Kruyt, Deliberate Calm: How to Learn and Lead in a Volatile World , New York, NY: HarperCollins, 2022.

Does work location influence health outcomes?

Our research indicates that when employees are working in their preferred work locations, they have better holistic health, lower burnout symptoms, and are more innovative at work. As the size of this gap between where they’re currently working and where they ideally want to be working increases, these effects are stronger, with larger gaps indicating lower health and innovation for employees (exhibit).

While self-efficacy can help maintain an employee’s overall sense of holistic health in a stressful environment, there is, again, a limit to which one can protect their health in these situations. While confidence in one’s ability to perform can protect their sense of holistic health, it doesn’t protect them against experiencing burnout symptoms in highly stressful environments (Exhibit 7). These findings suggest the best place for organizations to start may be addressing demands and building enablers for employees at both the team and job levels simultaneously.

It’s important to note that some ebb and flow of demands and enablers within an organization is inevitable. When committing to long-term change, it’s reasonable that organizations will undergo some episodic demands: for example, a seasonal rush at a retailer may create more short-term demands in an organization. Other organizations may have challenging teammates on temporary assignments. The MHI Holistic Health framework 20 Grounded in contemporary academic research, expanded with new concepts and psychometrically validated. takes this into account, exploring how multiple levels of influence can encourage positive action around employee health and well-being—organizational, team, job, and individual—and emphasizes how overweighting on only reducing demands or building enablers, over the long run, can affect employee health. 21 Organizational effects include actions from the company/senior leaders; team-level effects include actions from managers/peers; job-level effects include aspects of an employee’s job; individual-level effects include characteristics of the employees themselves. (For more on understanding work location and employee health, see sidebar “Does work location influence health outcomes?”)

Employers must commit to supporting employees to move from ill health to positive holistic health

Designing interventions to improve holistic health.

Improving holistic health at work can start with the following interventions:

• Understand the current state of holistic health in your organization . Establish a baseline for employee health and well-being, including identifying specific opportunity areas, before investing in targeted initiatives. This will ensure that the impact of your investments can be measured and that you are focusing on the areas producing real results. This can be done using existing surveys if they are scientifically sound. The McKinsey Health Institute’s (MHI’s) Employee Mental Health and Well-being assessment (available on our Employee Health Platform ) is one option which is fully psychometrically validated and free of charge to deploy.
• Develop a comprehensive intervention strategy . Ensure that your organization invests in interventions that proactively address demands before employee health and well-being become an issue, and provide reactive support once they have already taken a negative turn. For example, offering additional days of leave for colleagues experiencing mental health emergencies can be helpful, but it does nothing to avoid the escalation of mental health challenges in the first place—especially if those challenges are aggravated by workplace factors. Interventions should also target all levels of the organization , with a focus on teams as the primary body that influences workplace experience. Many companies overindex on interventions targeting individual employees, putting additional responsibility on them to manage their holistic health on top of existing workplace demands. For example, providing employees with access to a meditation app is a valid intervention to support mental health, but it doesn’t address structural issues in the workplace or within team dynamics that may compromise it in the first place.
• Implement and track your intervention strategy . Start with a pilot group to test an intervention’s effectiveness before committing to a full-scale rollout. We recommend using the same survey used to baseline the organization to retest the pilot group a few months after deploying the intervention. This allows you to clearly measure the intervention’s impact on the opportunity areas identified through the baseline assessment before deciding if it’s worth rolling out to the rest of the organization. It’s critical to track how your organization performs against clear outcomes over time to monitor improvement and justify your organization’s continued investment in your intervention strategy. Choose a senior level leader with accountability to deliver the intervention (preferably someone other than the chief human resource officer) to link your intervention strategy to the business and support successful implementation.
• Ensure holistic health is part of how your organization defines success . Once employee health is a part of your organization’s value proposition, it should be backed by measures to ensure the organization stays accountable. This can take the form of management KPIs, nonfinancial reporting, or internal incentive structures. For example, management incentives and career development should be aligned with the holistic health outcomes of their teams. Likewise, leaders should model the organization’s values and working norms to support lasting change. All leaders should be able to communicate why and how they are embracing a modern understanding of health to convince employees they are truly “walking the talk.” This requires substantial investment and patience to see the results, as well as buy-in from leaders. However, our research indicates real long-term value regarding employee work-related outcomes. Research also indicates financial outperformance for companies prioritizing employee well-being. 1 Jan-Emmanuel De Neve, Micah Kaats, and George Ward, Workplace wellbeing and firm performance , University of Oxford Wellbeing Research Centre working paper, number 2304, May 12, 2023.

In this article, MHI has presented a compelling case for organizations to reduce employee burnout symptoms and increase holistic health. Our research suggests team- and job-level demands and enablers are the place to start for improving employee health within an organization (see sidebar “Designing interventions to improve holistic health”). As employers develop strategies to fuel employee health and well-being, beyond focusing only on addressing poor mental health amid a challenging macroeconomic environment, it may be useful to examine how to support health at four different levels within an organization:

Organization : Organizational-level resources are often needed to support team-, job-, and individual-level interventions—and investment in holistic health must be supported by executives to have an effect. For example, interventions that encourage team members to act positively toward each other may fail if an organizational culture and performance system normalizes mistreating colleagues.

Second, job redesign starts from the top—while managers can help employees in job crafting and shaping, organizations that have policies that don’t support rotations or lateral mobility within an organization can undermine the effects of such interventions. Finally, while jobs should be designed with adequate compensation and benefits in mind, organizations are ultimately responsible for funding and delivering on these employee benefits.

Some examples of organizational-level actions include enrolling in living wage programs, pledging to ensure base pay is sufficient for all employees to cover their basic needs, 22 Living wage programs exist across different countries, including Canada, the United Kingdom, and the United States. offering financial programs in which employees can receive part of their pay prior to payday, providing access to remote medical care, or offering additional support or leave time for parents and caregivers.

Team : Our research highlights the important role team dynamics play in health and well-being—often the responsibility of managers and team leads. Team leaders should be trained appropriately and enabled to create healthier workplaces. In turn, they should then be held accountable for the ways they interact with others on their team and within the organization, the way their team members interact with each other, and they must intervene when employees treat each other negatively.

Interventions that promote positive behaviors and limit negative ones can help to build a team and organizational climate that promotes holistic health. Such interventions include but are not limited to manager trainings on creating psychologically safe environments and conflict resolution skills, 23 For example, Sempra provides psychological safety training to all employees alongside respect and anti-harassment modules, while Capgemini implemented dispute resolution training for HR and managers. implementing anonymous HR reporting systems, 24 For example, Ford Foundation provides a 24/7 EthicsPoint hotline to anonymously report concerns, complaints, or misconduct. and incorporating confidential upward feedback on leadership behaviors and team well-being as input for performance reviews and promotions. 25 For example, McKinsey employs an upward feedback tool at the end of projects to ensure that leaders uphold healthy work practices.

Job : Job redesign or fine-tuning for sustainable work is one of the most direct ways to reduce demands at the job level, where organizations rearrange tasks with the goal of helping employees maintain their efficiency and health over time. This is often led by or facilitated from the top.

A broad range of additional interventions can help organizations set sustainable working norms. These include setting maximum working hours (per day, per week), 26 This standard is sometimes also driven or initiated by national policies and local labor laws. limiting work communications to certain hours of the day, and providing multiple start times or self-scheduling options for shift workers. For example, Shopify recently canceled all recurring meetings of three or more people in their organization as a reset to ensure intentionality of recurring meetings and to make time for focused work. 27 Kaz Nejatian, “Shopify exec: This is what happened when we canceled all meetings,” Fast Company , May 16, 2023.

Another consideration for job design is whether those in certain roles are provided with adequate pay and benefits to cover their basic needs. Our research shows that those who can’t meet their basic needs with their pay feel more financially insecure and less holistically healthy than those who feel they are sufficiently paid. Employers may also examine what is covered for employees by health insurance, either public or private, and what requires out-of-pocket expenses.

Individual : Our research shows that having meaningful work is one of the key drivers for holistic health. Organizations can support their employees to find meaning in their work by being mission-driven, integrating their purpose into their business strategy and throughout the whole organization. Patagonia, for instance, focuses on hiring employees who are excited about the mission of “Patagonia is in business to save our home planet.” 28 Nell Derick Debevoise, “Why Patagonia gets 9,000 applications for an opportunity to join their team,” Forbes , February 25, 2020; Yvon Chouinard, “Earth is now our only shareholder,” Patagonia, accessed October 2023.

Involving employees in customizing their roles and careers—for example, through job crafting—has also been found a strong way to motivate, build capabilities, and help employees find meaning in the work they do. Other examples are capability training to help develop self-confidence  and adaptability skills . Last but not least: middle managers of today and tomorrow will have an increasing pivotal role for business success, 29 “Middle managers are the heart of your company,” July 17, 2023. helping them get better equipped for the new world of work—including as people leaders—is not only nonnegotiable, it will also support fostering a supportive growth culture that builds employees’ holistic health.

Employers have more power for positive outcomes than they know

Enabling a healthy workforce is no longer a luxury but rather a strategic imperative for organizations to navigate turbulent times in an ever more complex society. To seize the opportunities presented by employee health and well-being, employers must recognize their role. By agreeing to create workplaces where employees can thrive, organizations can prioritize holistic health as an important outcome that potentially aligns with an organization’s broader environmental, social, and governance (ESG) framework. Employers can take action by understanding how demands and enablers affect employees at various levels: organizational, team, job, and individual. As ESG metrics are increasingly used by investors as a decision measure for where to allocate their capital, we expect more research that could link employee well-being to financial performance. 30 Alex Edmans, “The link between job satisfaction and firm value, with implications for corporate social responsibility,” Academy of Management Perspectives , November 2012, Volume 26, Issue 4.

To truly understand what moves the needle on employee health, organizations should take a systemic approach to employee health that considers demands and enablers of employees, but also how they can design interventions at the organizational, team, job, and individual levels. For organizations, it’s no longer enough to consider employee health a soft metric. Rather, executives should consider employee health a part of leading by example, showing how better health and better business practices can allow everyone to flourish.

Jacqueline Brassey is a senior knowledge expert in McKinsey’s Luxemburg office, Brad Herbig is an associate partner in the Philadelphia office, Barbara Jeffery is a partner in the London office, and Drew Ungerman is a senior partner in the Dallas office; they are all coleaders in the McKinsey Health Institute.

If you would like to learn more about the McKinsey Health Institute Employee Holistic Health Survey, our employee health platform and the additional data and insights MHI has from the survey, please have a look here  or submit an inquiry via the MHI “ contact us ” form. The McKinsey Health Institute, as a non-profit-generating entity of McKinsey, is creating avenues for further research that can catalyze action.

The authors wish to thank Alistair Carmichael, Erica Coe, Hans de Witte, Kana Enomoto, Arne Gast, Katy George, Renata Giarola, Roxy Merkand, Hannah Mirman, Kim Rubenstein, Izzy Savage, Wilmar Schaufeli, Gretchen Scheidler, Ralf Schwarzer, Curtis Stecyk, Berend Terluin, Karen van Dam, Marieke van Hoffen, and Arjen van Witteloostuijn for their contributions to this article.

This article was edited by Elizabeth Newman, an executive editor in the Chicago office.

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• 1 University Department of Rural Health, University of Tasmania, Australia. [email protected]
• PMID: 17891313
• PMCID: PMC5901293
• DOI: 10.1100/tsw.2007.205

Beliefs that health policy-making is an inherently 'ideological' or 'irrational' process appear to have worked to prevent researchers from developing better understandings of the kind of evidence that does work to influence policy. Without a model of policy-making that positions policy decision-makers as capable of being informed by specific forms of evidence that speak to policy contexts, it is difficult for research to begin to shape health policy. Recent years have seen the development of a research industry that focuses on developing and describing research approaches for shaping health and social services policy. This analysis paper offers a highly selective overview of generic features of policy-relevant research for holistic health. It aims to support efforts to develop better evidence for health policy by exploring elements of the genre of policy-relevant research, particularly as it applies to the challenges of holistic health policy-making. First, it offers a conceptual definition of holistic health policy-making, as well as research evidence for this kind of policy making, identifying some of the generic features of policy-relevant research. Second, it outlines some of the key practices for delivering sound evidence for health policy, in ways that highlight the salient differences between doing research for holistic health policy, and doing academic research in health. The paper concludes with directions for developing better evidence for holistic health policy-making that question the assumptions of quality which often inform elite funding agencies, calling for their diversification.

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Physical activity in nature helps prevent several diseases, including depression and type 2 diabetes

Physical activity in natural environments prevent almost 13,000 cases of non-communicable diseases a year in England and save treatment costs of more than £100m, new research from the University of Exeter has found.

According to the World Health Organization (WHO) the most common non-communicable diseases -- including heart disease, stroke, cancer, diabetes, and chronic lung disease -- cause 74 percent of global mortality. Non communicable diseases, also known as chronic diseases, are not passed from person to person and deaths attributed to these diseases are increasing in most countries.

Physical inactivity is associated with a range of non-communicable diseases, including cardiovascular diseases, type-2 diabetes, cancers, and mental health outcomes. In their Global Status Report on Physical Activity 2022, the WHO estimated 500 million new cases will occur globally between 2020 and 2030 should physical activity remain at today's levels, incurring more than £21b a year in treatment costs.

Natural environments support recreational physical activity, with this new study focusing particularly on places such as beaches and coast, countryside, and open spaces in towns and cities like parks. Using data including a representative cross-sectional survey of the English population, researchers at the University of Exeter have estimated how many cases of six non-communicable diseases -- major depressive disorder, type 2 diabetes, ischaemic heart disease, ischaemic stroke, colon cancer, and breast cancer -- are prevented through nature-based recreational physical activity.

Speaking about the findings, published in Environment International, Dr James Grellier from the University of Exeter Medical School said: "We believe this is the first time an assessment like this has been conducted on a national scale and we've almost certainly underestimated the true value of nature-based physical activity in terms of disease prevention. Although we have focused on six of the most common non-communicable diseases, there are several less common diseases that can be prevented by physical activity, including other types of cancer and mental ill health. It's important to note that our estimates represent annual costs. Since chronic diseases can affect people for many years, the overall value of physical activity at preventing each case is certainly much higher."

Increasing population levels of physical activity is an increasingly important strategic goal for public health institutions globally. The WHO recommends that adults aged 18 to 64?should do at least 150 to 300 minutes of moderate intensity aerobic physical activity (or at least 75 to 150?minutes of vigorous-intensity aerobic physical activity) per week to maintain good health. However, globally 27.5 percent of adults do not meet these recommendations.

In 2019, 22-million adults in England aged 16 years or older visited natural environments at least once a week. At reported volumes of nature-based physical activity, Exeter researchers estimate this prevented 12,763 cases of non-communicable diseases, creating annual healthcare savings of £108.7m.

Population-representative data from the Monitor of Engagement with the Natural Environment survey were used to estimate the weekly volume of nature-based recreational physical activity by adults in England in 2019. Researchers used epidemiological dose-response data to calculate incident cases of six non-communicable diseases prevented through nature-based physical activity, and estimated associated savings using published costs of healthcare, informal care, and productivity losses. It's estimated the healthcare cost of physical inactivity in England in 2019 is approximately £1b.

Dr James Grellier from the University of Exeter Medical School said: "For people without the access, desire, or confidence to take part in organised sports or fitness activities, nature-based physical activity is a far more widely available and informal option. We believe that our study should motivate decision-makers seeking to increase physical activity in the local population to invest in natural spaces, such as parks, to make it easier for people to be physically active."

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• James Grellier, Mathew P. White, Siân de Bell, Oscar Brousse, Lewis R Elliott, Lora E Fleming, Clare Heaviside, Charles Simpson, Tim Taylor, Benedict W Wheeler, Rebecca Lovell. Valuing the health benefits of nature-based recreational physical activity in England . Environment International , 2024; 187: 108667 DOI: 10.1016/j.envint.2024.108667

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Q&A: To protect human health, we must protect the Earth's health

by Johns Hopkins University Bloomberg School of Public Health

Human activities have transformed and degraded Earth's natural systems. But it's not just the planet that endures the harms of things like pollution and climate change. Changes like rising ocean temperatures and CO 2 levels have cascading effects that threaten the future of humans.

In this Q&A, adapted from the April 22 episode of Public Health On Call , Joshua Sharfstein, MD, talks with Sam Myers, MD, faculty director of the new Johns Hopkins Institute for Planetary Health and founding director of the Planetary Health Alliance, about this interdisciplinary approach to understanding how the state of the planet impacts human health and well-being.

What is planetary health?

Planetary health is a cross-disciplinary field that has emerged in the last eight or nine years. It focuses on how our transformation of nature—our degradation and alteration of all of our planet's natural systems—is coming back to affect our health.

Climate change, biodiversity loss, global-scale pollution of air, water, and soil, changes in land use and land cover—all driven by human activity—are resulting in increased burdens of disease and impacting all dimensions of human health. We want to understand what those dynamics are and how we can address them.

What are some examples of changes impacting human health?

We know that ocean warming is changing the size of both fish and fisheries. It's also changing where the fisheries are located, moving them away from the tropics and toward the poles. We did a study to determine how many people depend on wild-harvested fish for critical nutrients and live close to a threshold of insufficient intake of those nutrients—what we define as the vulnerable population to these changes. We found that over a billion people fall into this category.

We've also found that crops like rice, wheat, and maize—foods that provide most of the calories in the global diet—tend to lose essential nutrients when grown at elevated concentrations of carbon dioxide like the ones we expect to see by about the middle of this century.

In our free air carbon dioxide enrichment (FACE) experiments , we grew 41 cultivars of those kinds of crops in seven locations across three continents over 10 years. We found that growing these staple food crops at high CO 2 levels significantly reduces the amount of iron, zinc, and protein they contain.

We then modeled what these findings would mean for populations in 150 countries and found that the CO 2 effect alone would cause around 150–200 million people to be pushed into nutritional insufficiency of these nutrients.

Other research has shown that growing different cultivars of rice at elevated CO 2 resulted in B vitamins being reduced by almost 30%. We used that data to model what that might mean for the risk of things like neural tube defects, and we found really large impacts.

What other environmental factors does planetary health consider?

Changing levels of CO 2 in the atmosphere is just one very specific biophysical change, but we're changing all the biophysical conditions that our entire food production system has been developed to be optimized for: temperature, precipitation, amount of arable land, pollinators, and pest and pathogen relationships.

All of those things are now changing in response to human activity in ways that usually represent headwinds for global food production, in terms of both quality and quantity.

How does planetary health address the extreme scale of the changes humans are causing the environment and the consequences of those?

The field of planetary health has emerged out of a recognition that the pace and scale at which we're transforming all our natural systems has become a global health crisis .

The global health impacts of the Earth crisis are kind of a silent pandemic, and there are parallels to the COVID pandemic we've just come out of. The COVID pandemic required massive mobilization of new technologies, investments in economic stimulus and foreign assistance, respect for science, and urgent global behavior change. This silent pandemic is probably much more impactful to human health. It could be addressed in a very similar way, but we're doing very little.

You can't respond to a crisis until you recognize that there is a crisis. As you are trying to raise concern over planetary health, how is that warning signal being received?

The field is growing very quickly. We started the Planetary Health Alliance about eight years ago, and we now have more than 400 organizations involved in more than 70 countries. There's been a very rapid proliferation of new courses, degree programs, and journals in planetary health. We're also seeing government agencies adopting planetary health as a frame, including the European Union, certain national governments, and the UN system.

There has been a rapid understanding and recognition of the global health urgency related to the Earth crisis, but it's a drop in the bucket of what is really needed to fully mobilize and address the crisis.

Are there solutions that can address multiple problems at once?

Yes. From a policy standpoint, the goal is to find opportunities to both optimize human health and well-being and reduce our ecological footprint. In order to protect and regenerate the Earth's natural life support systems, we have to change the way we're living. The good news is there are a lot of ways we can do this, and many of these changes also have major co-benefits.

For example, switching to clean, renewable energy is important to addressing climate change . Doing so also reduces the amount of air pollution, which drives something like 9 million deaths every year. Greening our cities and designing them to be walkable and bikeable not only reduces greenhouse gases and increases biodiversity; these changes also provide major mental and physical health benefits.

What is the Planetary Health Alliance and what does it do?

Contrary to what it sounds like, the Planetary Health Alliance doesn't fight for the planet's health—they're fighting for human health and the health of other species.

It's a recognition that the well-being of all life on earth depends on stable natural life support systems. Things like degradation of biodiversity, pollution, and land use change all interact with each other in very complex ways that affect these foundational conditions for all life on Earth:

• The quality of air that we breathe.
• The quality of water that we consume.
• The quality and quantity of food we can produce.
• Exposure to infectious disease and extreme weather events.

And these impacts are driving an urgent set of health problems.

The Alliance functions as sort of the backbone organization for this growing global field. That includes curating new knowledge, writing the first textbook for the field, developing core competencies for education, creating a platform to support educators and planetary health around the world, organizing an annual meeting, and putting out a newsletter.

One half of the Alliance's focus is to create and support a global community of practice. The other half is what we call "mainstreaming planetary health," which means taking that community of practice, the new knowledge, and conceptual frameworks out of the field and connecting them to action.

We're working to ensure that policymakers, the private sector, and the general public are aware that the Earth crisis now represents a humanitarian crisis and that there are a variety of solutions that benefit both people and the planet.

Tell us about the Planetary Health Institute you've started at Johns Hopkins

The Institute is the first example of a major university using planetary health as a lens to bring faculty and students together across all of its schools and centers. The Institute is bringing together people in the arts and humanities, engineers, natural scientists, and people in government, law, and policy around this central project of planetary health.

We'll focus on research, education, policy, practice, and clinical programs. And already, there are all kinds of interesting interdisciplinary initiatives at Hopkins that are focused on planetary health: One on planetary health cities, one on Indigenous health, and another one on food systems, just to name a few.

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• Volume 58, Issue 9
• Preventing hip osteoarthritis in athletes: is it really a mission impossible?
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• http://orcid.org/0000-0001-8691-1830 Joshua J Heerey 1 ,
• Pim van Klij 2 ,
• http://orcid.org/0000-0002-0645-093X Rintje Agricola 3 ,
• http://orcid.org/0000-0003-3166-1357 Hendrik P Dijkstra 4 , 5 ,
• Lindsey Plass 6 , 7 ,
• http://orcid.org/0000-0001-5892-129X Kay M Crossley 1 ,
• http://orcid.org/0000-0002-9234-1923 Joanne L Kemp 1
• 1 La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport , La Trobe University , Melbourne , Victoria , Australia
• 2 Department of Sports Medicine , Isala Hospital , Zwolle , Overijssel , The Netherlands
• 3 Orthopaedics , Erasmus MC , Rotterdam , Zuid-Holland , The Netherlands
• 4 Medical Education Department , Aspetar Orthopaedic and Sports Medicine Hospital , Doha , Qatar
• 5 Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford , Oxford , UK
• 6 Plass PT & Performance , Chicago , Illinois , USA
• 7 The University of Chicago Medicine , Chicago , Illinois , USA
• Correspondence to Dr Joshua J Heerey, La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia; j.heerey{at}latrobe.edu.au

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• Osteoarthritis
• Preventive Medicine

Hip osteoarthritis (OA) in athletes is important to acknowledge, with early hip OA associated with elite-level high joint impact sports, such as football, ice hockey and handball. 1 Current management of hip OA is largely reactive (when OA disease is established and irreversible). Identifying athletes at risk of, or with early-stage hip OA, may improve treatment success and reduce disease burden. Clinicians and researchers need to understand the natural history of OA in active populations, risk factors for early hip OA and whether OA in athletes can be prevented. In this editorial, focussing on elite athletes, we aim to describe the natural history of hip OA, consider the role of primary cam morphology in hip OA development and provide clinical and research recommendations for the prevention of hip OA.

The natural history of hip OA in athletes

Understanding the natural history of hip OA across the lifespan ( figure 1 ), could empower clinicians and athletes/patients to prioritise appropriate evidence-based interventions (eg, education, clinician-led incremental exercise rehabilitation or surgery) for better hip health:

Adolescence : Changes in articular cartilage composition—a biomarker of early-stage OA—are evident in elite adolescent football players, possibly affecting its tolerance to high joint loads and increasing susceptibility to pathological change. 2 This concept is supported by a recent longitudinal study of adolescent athletes where cartilage damage increased over 24 months. 3 Primary cam morphology develops due to load-related femoral capital growth plate changes during maturation—from around 9 to 10 years of age in girls and 11 to 12 years in boys. 4 This developmental process is more pronounced (ie, larger cam morphology) in elite-level athletes and continues until growth plate closure with likely no further development after maturation. 4 5 We do not fully understand the pathological interaction between cam morphology and joint structures, although it appears to be inconsequential in most athletes. 2 6 Cam morphology might not influence joint structure until after skeletal growth. 2

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Hip OA in athletes, natural history and research recommendations. OA, osteoarthritis; THA, total hip arthroplasty.

Adulthood : Roughly 50% of athletes (men and women) have intra-articular hip joint pathology (often only seen on MRI) by the third decade. 7 It is unclear if hip joint pathology progresses over time or if specific factors expediate structural joint change. When and how rapidly hip pathology progresses in adulthood—if at all—likely pivots on multiple intrinsic and extrinsic factors including the extent of hip morphology, exposure to high joint impact exercise and/or occupational load, and other biological factors.

Older age : Former male and female elite athletes have a higher prevalence of hip OA and are more likely to undergo total hip arthroplasty when compared with the general population. 1 However, not all older athletes will progress to end-stage hip OA, with many still benefiting from evidence-based treatments.

Cam morphology and aetiology of symptomatic hip OA

Primary cam morphology is a causal factor for hip OA in older non-athletic adults (mean age, 59 years). 8 Despite being common in athletes, the role of primary cam morphology in hip OA development in younger athletes is still unclear. Recent evidence supports the role of cam morphology in early hip OA. 6 However, primary cam morphology and structural changes should not be made scapegoats for painful hips—it is likely more complicated. 6 Primary cam morphology and associated soft-tissue pathology are equally present in athletes with and without hip pain. 6 7 Repetitive hip movements (eg, combined hip flexion and internal rotation) may also play a key role in symptom and OA development in athletes with cam morphology. Further work is needed to understand why only some athletes with cam morphology develop symptoms. We suggest that clinicians consider intra-articular findings together with injury history, athlete characteristics, physical examination, athletic demands and wider physiological, psychological and social factors.

Can we prevent the high rates of intra-articular hip damage among young, physically active adults?

Hip OA is not exclusively a disease of older people. We cannot ignore the high incidence of intra-articular hip damage in more than half of athletes by the third decade. 7 Should clinicians wait until patients present with symptoms, or should they intervene in asymptomatic individuals? While primary prevention represents the ultimate goal for athletes and clinicians, preventing primary cam morphology development is complex. For example, recommendations to reduce external (athletic) loads during adolescence may conflict with recommendations for young individuals to engage in regular exercise and sports. Such a prevention programme may coincide with a time of skill development and talent identification in some sports, which can jeopardise a young athlete’s ability to reach the elite level. Until we know if primary cam morphology can or should be prevented, we cannot recommend a reduction of exercise loads during adolescence. 9 The challenges associated with primary prevention make secondary prevention more attractive. However, the optimal secondary prevention programme for hip OA has not been determined, with research efforts often hampered by the lengthy follow-up needed to evaluate OA development and consensus on definitions for symptom and structural progression. 10 It is likely a programme consisting of education, exercise-based interventions, and, in some, surgery, may be useful, as recommended for the knee. 10 Interventions—including education (eg, identification of symptoms, risk factors for early hip OA development and the effectiveness of different treatment approaches) of all stakeholders—to prevent hip OA, should be implemented across the lifespan, particularly in athletes participating in high joint impact sports.

The increasing burden of hip OA in athletes and its complex natural history, including, the development and prognosis of primary cam morphology makes prevention challenging. Clinicians and researchers—with athlete and patient partners—have prioritised research to grapple with these complexities. 9 To prevent hip OA in all athletes, we should: (1) work to better understand how primary cam morphology and other relevant hip morphologies develop and their causal role in early hip OA; (2) develop and evaluate secondary prevention strategies to slow/prevent hip OA development; and (3) perform qualitative research of athletes with hip OA to understand the lived experience. Hip OA prevention in athletes might then become ever more possible!

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

• Nilsen DH ,
• Kroken G , et al
• Fernquest S ,
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X @JHeerey, @RintjeAgricola, @DrPaulDijkstra, @LindseyPlassDPT, @kaymcrossley, @JoanneLKemp

Correction notice This article has been corrected since it published Online First. The fifth affiliation has been updated.

Collaborators Not applicable.

Contributors All authors contributed to the conception and design of the editorial, writing and revising the manuscript and final approval of the article.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

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Explaining the Department of Labor’s new overtime rule that will benefit 4.3 million workers

The U.S. Department of Labor issued a final rule today making changes to the regulations about who is eligible for overtime pay. Here’s why this matters:

How the overtime threshold works

Overtime pay protections are included in the Fair Labor Standards Act (FLSA) to ensure that most workers who put in more than 40 hours a week get paid 1.5 times their regular pay for the extra hours they work. Almost all hourly workers are automatically eligible for overtime pay. But workers who are paid on a salary basis are only automatically eligible for overtime pay if they earn below a certain salary. Above that level, employers can claim that workers are “exempt” from overtime pay protection if their job duties are considered executive, administrative, or professional (EAP) —essentially managers or highly credentialed professionals.

The current overtime salary threshold is too low to protect many workers

The pay threshold determining which salaried workers are automatically eligible for overtime pay has been eroded both by not being updated using a proper methodology, and by inflation. Currently, workers earning $684 per week (the equivalent of $35,568 per year for a full-time, full-year employee) can be forced to work 60-70 hours a week for no more pay than if they worked 40 hours. The extra 20-30 hours are completely free to the employer, allowing employers to exploit workers with no consequences.

The Department of Labor’s new final rule will phase in the updated salary threshold in two steps over the next eight months, and automatically update it every three years thereafter.

• This is the equivalent of $43,888 per year for a full-time, full-year worker.
• In 2019, the Department updated the salary threshold to a level that was inappropriately low. Further, that threshold has eroded substantially in the last 4+ years as wages and prices have risen over that period, leaving roughly one million workers without overtime protections who would have received those protections under the methodology of even that inappropriately weak rule. This first step essentially adjusts the salary threshold set in the 2019 rule for inflation.
• This is the equivalent of $58,656 per year for a full-time, full-year worker.
• This level appropriately sets the threshold at the 35th percentile of weekly wages for full-time, salaried workers in the lowest-wage Census region, currently the South.
• The salary threshold will automatically update every three years thereafter, based on the methodology laid out in the rule, to ensure that the strength of the rule does not erode over time as prices and wages rise.

The final rule will benefit 4.3 million workers

• 2.4 million of these workers (56%) are women
• 1.0 million of these workers (24%) are workers of color
• The largest numbers of impacted workers are in professional and business services, health care and social services, and financial activities.
• The 4.3 million represents 3.0% of workers subject to the FLSA.

Expanding overtime protections is good for workers and manageable for employers

• The final rule will result in a transfer of $1.5 billion annually from employers to workers in increased pay.
• While that increase in wages will be enormously impactful to affected workers, it represents well under one-tenth of one-percent of total wages and salaries in the U.S. economy. Employers will be more than able to adjust to the rule without negatively impacting the overall economy.
• In addition to increasing pay for many workers, the overtime rule will also reduce excessive hours of unpaid work. Before this update to the salary threshold, the cost to employers of overworking salaried EAP workers who make more than $684 weekly was effectively zero. The concept of overtime pay is designed to protect workers’ most valuable asset—their time—and to push employers to value it too.
• Automatic updating is a smart and easy way to  simply maintain the labor standard established in the proposal. If the threshold is not updated automatically over time, it will steadily weaken as a labor standard until the next rulemaking, covering fewer and fewer workers as the salary distribution naturally rises over time with inflation and productivity growth.
• With automatic updating, employers will know exactly what to expect and when to expect it. They will also be able to get a reasonable sense well in advance of what the next threshold will be, because they will be able to track on a dedicated Bureau of Labor Statistics website how the 35th percentile of full-time salaried worker earnings in the lowest-wage Census region is evolving over time.

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Marquette receives $1.5 million gift to fund College of Health Sciences research and future expansion of Athletic and Human Performance Research Center

• April 23, 2024
• 4 min. read

Bob and Kim Eck, an alumni couple, have made a $1.5 million gift to Marquette University through the Eck Family Foundation that will impact two areas across campus, President Michael R. Lovell shared today. The gift will provide seed funding and focus on highly innovative projects within the College of Health Sciences aimed at applying new technologies, novel therapies and research to help address substance abuse disorders.

In addition, a portion of the gift will support a new men’s basketball practice facility in a future expansion of the Athletic and Human Performance Research Center. Bob, who served as the chair of Marquette’s Board of Trustees from 2020-23, graduated in 1980; Kim completed her degree in 2013.

“Like so many families, ours has felt the impact of addiction and the difficulty in finding effective treatment,” Bob and Kim Eck said. “Finding funding for early-stage research can be very challenging.  Our hope is that our gift leads to progress in developing new treatments that may free so many people from suffering.”

Driving holistic wellness

President Lovell shared details of the university’s new strategic plan, Guided by Mission, Inspired to Change , at his recent Presidential Address. He highlighted that the Eck’s gift would also take a step toward growing a campus of “thriving students” as Marquette strives to be a nationally recognized leader in the integration of student wellness, transformation and success.

“We are grateful for this remarkable, mission-focused gift from the Eck family. Their generosity will make a major impact on a pressing societal issue,” President Lovell said. “This gift will further our progress as a research university known for excellence and innovation — an important theme in our new strategic plan — and take our Athletic and Human Performance Research Center to the next level.”

The Eck family has helped drive wellness progress across campus in recent years. In September 2022, Bob Eck announced the university’s plans to honor President Lovell and First Lady Amy Lovell within the university’s planned wellness tower in the newly renovated Wellness + Helfaer Recreation facility in recognition of their “tremendous leadership to address mental health across Milwaukee and the region.” Within four months, the university raised $5 million in honor of the Lovells .

Turning seed money into major grant funding

Philanthropic seed funding like the Ecks’ often helps researchers advance scientific progress in ways they can then leverage into larger grant awards from the National Institutes of Health or other funding sources. Part of the Ecks’ gift will be dedicated to developing a network of collaborating scientists within the College of Health Sciences’ Integrative Neuroscience Research Center, including neuroscientists, clinicians and pharmaceutical experts focused on cognitive, emotional and motivational regions of the brain to understand and address depression, neuropsychiatric disorders, addiction, spinal cord research and bodyweight regulation.

““We have made a very intentional investment spanning more than a decade to grow our world-class scientists in the critical areas of neuroscience,” said Dr. William E. Cullinan, dean of the College of Health Sciences. “We sincerely appreciate this gift from the Eck family, which will accelerate our research efforts. Our vision is ultimately to take the discoveries in our labs and translate them into breakthroughs for families who are searching for solutions.” 

Campaign momentum continues

Marquette’s historic Time to Rise fundraising campaign is the most ambitious in the university’s 143-year history. In February, President Lovell announced that the university surpassed its $750 million goal , and he challenged the Marquette community to drive toward completion of the campaign in June 2024.

“We are very fortunate to have had two philanthropic leaders in Bob and Kim throughout our historic Time to Rise campaign,” said Vice President for University Advancement Tim McMahon. “This most recent gift reflects their values and beliefs both in the way we pursue scientific discoveries to treat addiction and the way we work to enhance the home for our flagship men’s basketball program.”

The Eck family is committing a portion of their gift to a future project to expand the university’s Athletic and Human Performance Research Center, which will include a new practice facility for the men’s basketball program and academic resources for student-athletes. In January, President Lovell shared that Marquette alumnus and NBA Hall of Famer Dwyane Wade made a gift to the project while also contributing to literacy and scholarship efforts.

The expansion will free up highly utilized space in the Al McGuire Center for the women’s basketball and volleyball programs, and increase tutoring, advising and study space for all student-athletes. The first phase of the AHPRC opened in 2019. As the university community continues to build momentum in its Time to Rise campaign, donors have expressed a philanthropic interest in supporting the second phase of the AHPRC. The facility remains in the fundraising and development phase.

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A Qualitative Approach to Understanding the Holistic Experience of Psychotherapy Among Clients

Lee seng esmond seow.

1 Research Division, Institute of Mental Health, Singapore, Singapore

Rajeswari Sambasivam

Sherilyn chang, mythily subramaniam, huixian sharon lu.

2 Department of Psychology, Institute of Mental Health, Singapore, Singapore

Hanita Ashok Assudani

Chern-yee geoffrey tan.

3 Department of Moods and Anxiety, Institute of Mental Health, Singapore, Singapore

Janhavi Ajit Vaingankar

Associated data.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Background: The study of the experience of clients across multiple service encounters (or touchpoints) is important from the perspective of service research. Despite the availability of effective psychotherapies, there exists a significant gap in the optimal delivery of such interventions in the community. Therefore, the aim of this study was to explore the experience of psychotherapy among clients integrating the before–during–after service encounters using a qualitative approach.

Methods: A total of 15 clients of outpatient psychotherapy were interviewed, and data saturation was reached. The topics included pathways and reasons to seeking psychotherapy, aspects of the therapy process that have been helpful or unhelpful, and perceived change after receiving psychotherapy. Information was analyzed using the inductive thematic analysis method. Emergent themes pertaining to pre-psychotherapy encounters were mapped onto major components that were identified in Andersen's Health Service Utilization Model.

Results: Mental health stigma and the lack of understanding about psychotherapy were the predisposing factors that impeded service use while the preference for non-pharmacological intervention promoted its use. Enabling factors such as affordability and service availability were also of concern, along with perceived and evaluated needs. The attributes of therapists, application of techniques, and the resistance of the client were found to impact the therapeutic alliance. While the majority of the clients experienced positive change or had engaged in self-help strategies after receiving psychotherapy, some cited limited impact on the recovery of symptoms or problematic self-coping without the therapists.

Conclusion: This study proposes to expand on Andersen's Behavioral Model by including therapy-related factors so as to provide a more holistic understanding of the use of psychotherapy among the clients. More importantly, the study identified several barriers to access and negative experiences or outcomes, which should be addressed to promote uptake of the psychotherapy intervention.

Introduction

The “person-centered” approach to care delivery has been valued as a core part of service design and is necessary to provide a nurturing environment that is respectful, compassionate, and responsive to the needs of the individuals. Understanding the situation of or lived experience of health services by each client has increasingly been recognized as a key element of quality healthcare to improve safety and patient outcomes. For example, patient satisfaction with service or effectiveness of interventions promotes treatment compliance and supports recovery in mental health settings (Katsakou et al., 2010 ; Urben et al., 2015 ).

Psychotherapy, also called “talk therapy,” is a process by which the emotional and mental health-related problems are treated through communication and relationship factors between an individual and a trained mental health professional (Herkov, 2016 ). Despite clear evidence for the efficacy and effectiveness of psychotherapy in general (Lambert, 2013b ), about 35–40% of patients experienced no benefit while a small group of 5–10% experienced deterioration in their condition on completing treatment in randomized clinical trials (Hansen et al., 2002 ). In a routine practice where treatments averaged four sessions, the rate of improvement was reported to be only about 20% (Hansen et al., 2002 ). Findings from numerous studies also estimated around 25–50% of patients across diverse treatment settings to “refuse psychotherapy” by failing to return to treatment after initial intake or therapy session (Garfield, 1994 ). The premature termination of sessions has been a problem that hinders the effective delivery of psychotherapeutic treatment as many patients tend not to receive the “adequate dose” of therapy, which is required for them to observe the desired symptomatic relief (Hansen et al., 2002 ; Anderson, 2016 ). Furthermore, such attrition or no-show wastes mental health resources and staff time, denies access to those in need, and limits the ability of organization to serve those in need (Joshi et al., 1986 ). Compared with those who completed treatment courses, those who defaulted are usually less satisfied with services (Lebow, 1982 ). Prior studies have shown that the optimal way to predict treatment outcome is to measure their distress pretreatment (Lambert, 2013a ). The predisposing factors are those that increase his/her inclination to health service use and may include characteristics such as demography (i.e., age and gender), social structure (i.e., education, occupation, ethnicity, social interactions, and network), and health beliefs (Andersen, 1995 ; Andersen and Newman, 2005 ). Quantitative studies have also consistently revealed being female, single or divorced, unemployed, and having a higher education level to be significantly associated with the use of psychotherapy (Olfson and Pincus, 1994 ; Briffault et al., 2008 ; Hundt et al., 2014 ) or the service utilization of mental health (Parslow and Jorm, 2000 ; Roberts et al., 2018 ; Ayele et al., 2020 ).

From the perspective of service research, the experience of the client is conceptualized as a “journey with a service provider over time during the service utilization cycle across multiple touchpoints” (Lemon and Verhoef, 2016 ). Psychotherapy service research has usually focused on understanding, measuring, and optimizing the in-session experience or the treatment process of the client, but what happens leading up to the intervention and after the intervention has received less attention. The narrowed focus on the delivery of the core service itself has prevented service researchers from recognizing the evolving needs of client for a holistic service experience, which spans all potential service encounters (Voorhees et al., 2017 ).

Therefore, this study aimed to address this gap by integrating “pre-therapy,” “during therapy,” and “post-therapy” service encounters to gain an in-depth understanding of the experience of the clients of using psychotherapy services. In doing so, we hoped to identify help-seeking pathways, as well as positive and negative experiences or outcomes from the service engagement of client, and to discuss any policy implications with respect to these findings.

Participants, Recruitment, and Setting

This study was conducted among individuals attending outpatient psychotherapy at the Institute of Mental Health, a tertiary psychiatric hospital in Singapore. Participants were recruited using a mix of personal network and purposive sampling. The majority of patients were referred by mental healthcare professionals (e.g., psychologists and clinicians) who provided psychotherapy services in the institute. Posters were also placed in the clinic to inform the clients of the ongoing study with information on the eligibility criteria and the contact of researchers was provided for self-referral by patients. The inclusion criteria were those who were aged 21 years and above, those who were able to provide consent, and those who had attended at least two psychotherapy sessions in the past year. All participants provided written informed consent and were given a token sum for their time upon completion of the study. The approval of the study was obtained from the institutional ethics committee, the Domain Specific Review Board of National Healthcare Group, Singapore (DSRB Ref No: 2018/00870). Interviews and recruitment of new participants continued until the study achieved data saturation, which was determined by the repetition of themes or subthemes (i.e., no new information was evident). A total of 15 participants were therefore enrolled from the period of January–October 2019.

Study Procedures

This interpretative qualitative study was a part of a bigger study that aimed to understand the psychotherapeutic strategies and interventions to improve positive mental health among psychotherapy clients. Participants were first asked to self-complete a short questionnaire to obtain information on the sociodemographic background (e.g., age, gender, education, and occupation) and clinical history (e.g., diagnosis, age of onset, hospitalization, and the number of psychotherapy sessions). In-depth interviews were then conducted by a facilitator (JV or SC) at mutually agreed places using a common interview guide to ensure standardization across the participants. The interview schedule was designed to allow a free exchange in the discussion, guided by the narrative of the participants. Participants were first asked about their background in terms of their family, work, diagnosis, onset, and symptoms, as well as their recent experience with psychotherapy, and were encouraged to describe in detail. Probing questions served as prompts to elicit a richer understanding and were found in the interview guide ( Table 1 ) to ensure that the data collected across the sessions would be as uniform as possible.

Interview guide.

Data Analysis

All interviews were audiotaped and transcribed verbatim, with transcripts checked for consistency by another team member. NVivo software version 11 was used for the purpose of coding and data processing (QSR International; Computer Software, Australia). The data were analyzed using the thematic analysis that involved discovering, interpreting, and reporting patterns and clusters of meaning within the data (Braun and Clarke, 2006 ). In the first step, all study team members (JV, SC, ES, and RS) independently read a transcript each and employed either descriptive or theoretical codes to index meaningful segments or contents. The next step involved gathering of the team to compare individual analyses, reconcile any differences of perspective, and achieve consensus on the codes and their themes. From this initial inductive coding scheme, a list of preliminary themes was generated based on the summaries and collective interpretation of the coded material. To confirm adequate inter-rater reliability, a codebook was then constructed and all members coded a single new transcript using the codebook as a guide. Cohen's kappa coefficient was established to be 0.83, and team members proceeded to code the remaining transcripts independently. To capture unexpected themes that emerged during the course of reading the remaining transcripts, additional codes were created through open coding. In the final step, all identified themes were progressively integrated into higher-order key themes in relation to the research topic. To differentiate the before–during–after periods of service encounters, we have organized our findings into three distinct sections, namely, pre-, during-, and post-psychotherapy ( Figure 1 ).

Client experience with psychotherapy service utilization.

Thematic Mapping to Conceptual Framework

Our analysis was underpinned by Andersen's Health Service Utilization Model (Andersen, 1995 ), which has been used extensively in studies to understand factors that both promote and undermine the access to healthcare. Findings pertaining to the pre-psychotherapy experience provided support for the model, particularly where emergent themes relating to pathways and reasons to help-seeking could be mapped onto major components identified in the model. Andersen's Behavioral Model defined health service use as an interplay of three distinguished determinants, namely, predisposing characteristics, enabling resources, and need factors (Andersen, 1995 ; Andersen and Newman, 2005 ). The predisposing characteristics refer to the sociocultural characteristics of the individuals that exist prior to the development of an illness. The enabling factors represent the logistic aspects of obtaining care such as affordability and availability of resources at the personal, family, and/or community level. Need factors, usually identified as the most immediate cause of health service use, include potential needs for care, perceived and evaluated health, or functional state. We adopted thematic mapping onto an existing framework and discussed themes associated with each determinant to present our findings with respect to the pre-psychotherapy experience.

The ages of participants ranged between 22 and 55 years, with a median age of 32 years. Majority of them were females, Chinese, single, unemployed, completed the education of tertiary and above, stayed in purchased public housing, not hospitalized in the past year, and were without a comorbid physical problem. The number of psychotherapy sessions attended in the past 1 year ranged from 2 to 48 (median = 7.5). Table 2 provides a summary of the profile of clients.

Characteristics of participants.

Pre-psychotherapy

Predisposing factors.

As participants described their pathways or reasons to attend psychotherapy, several personal health-related beliefs and values, as identified by the authors, seemed to form their help-seeking behaviors. These included mental illness-related stigma in healthcare, lack of knowledge about psychotherapy as a treatment option, and preference for non-pharmacological treatment. The quotes representing each factor are presented in Supplementary Table 1 .

Mental Illness-Related Stigma

Participants delayed help-seeking or were initially reluctant to attend psychotherapy session at a psychiatric institution for psychological problems for fear of being discriminated against or due to mental health stigma. The presence of social stigma created barriers to healthcare access and quality care [see Supplementary Table 1 (A1, A2)].

Lack of Knowledge About Psychotherapy

Participants expressed a lack of knowledge about the purpose and processes of psychotherapy. They were either unaware of psychotherapy as a viable option for their problems or unsure about the effectiveness of this treatment in solving their issues. Most participants only became aware and tried out psychotherapy without any expectations because they were being referred by another mental health professional or came to know about it when they read about it online [see Supplementary Table 1 (B1, B2)] .

Preference for Non-pharmacological Treatment

Patients either felt that medications were ineffective for them or were reluctant to embark on taking medications to manage their symptoms due to possible concerns of “addictiveness” or side effects. Therefore, they explored other non-pharmacological options such as psychotherapy as their preferred treatment of symptoms [see Supplementary Table 1 (C1, C2)].

Enabling Factors

The enabling factors explain the factors that facilitate or impede an individual to service use. Participants highlighted several hindrances to the utilization of psychotherapy services despite wanting to try or believe that psychotherapy is effective for them. These included inability to commit, affordability of service, and availability of resources (i.e., facilities and health personnel) in the community. The quotes representing each factor are presented in Supplementary Table 1 .

Inability to Commit

While describing their experience with the utilization of psychotherapy, participants expressed the commitment issue as the main factor for not starting or continuing the therapy. The reasons cited include the lack of time, clash of schedules, inconvenience, or other personal concerns [see Supplementary Table 1 (D1, D2)] .

Affordability Issue

Despite being aware of the availability of psychotherapy services, some participants had concerns about continuing such services for a longer term as they felt it was too expensive. Some chose to engage psychotherapy services from public health providers instead of private sectors that were costlier [see Supplementary Table 1 (E1, E2)].

Service Unavailability

Few participants reported reasons related to the availability of resources, which hindered them from accessing or continuing psychotherapy service. These included the unavailability of psychotherapy tertiary care service offered in the preferred choice of a healthcare institution or the therapist of choice of a patient, as well as long waiting time [see Supplementary Table 1 (F1)].

Need Factors

This study identified both the perceived needs of patients (i.e., psychological symptoms and diagnosis) and the evaluated needs of mental health professionals (i.e., judgment about the health status of patients) as determinants that made participants seek and utilize psychotherapy service. The quotes representing each factor are presented in Supplementary Table 1 .

Self-Perceived Mental Health Needs

The majority (i.e., 13/15) of participants were diagnosed with a mental disorder such as depression, anxiety, and borderline personality disorder. Participants reported the need to alleviate or cope with their underlying clinical symptoms and, hence, proceeded to seek psychotherapy service. Others felt that they just needed someone to talk to or to get support from due to the multiple psychological and social struggles that they were facing, and few insisted on seeing a psychotherapist despite being told it was not necessary by a health professional. Some participants also mentioned that they stopped going to the sessions when they felt better [see Supplementary Table 1 (G1)].

Professional Evaluation

Those who did not seek psychotherapy on their own were mainly referred to the service after presenting to a mental healthcare professional. They were prescribed psychotherapy by their consulting psychiatrist, during hospitalization or visit to the emergency services. Some participants went into psychotherapy due to their trust in the healthcare professionals or without even knowing what to expect from the service [see Supplementary Table 1 (H1)].

During Psychotherapy

Therapy process.

Themes identified in this component pertain to common in-session experiences of the client and were contributed by the interplay of three broad elements, namely, the psychotherapist, the therapeutic modality, and the client her/himself. Participants also described the aspects of the sessions that were helpful or not helpful in improving their psychological well-being. The quotes representing each factor are presented in Supplementary Table 1 .

The Attributes and Interactions of the Therapist Impact Alliance

Participants described mainly the positive qualities of their psychotherapists: “friendly,” “nice,” “gentle,” “non-judgmental,” “intelligent,” “good,” “concerned,” “well-informed,” “patient,” “attentive,” and “well-read,” with “understanding” being mentioned the most. These personal attributes of therapist appeared to strongly influence therapeutic alliance. The alliance was important to the therapeutic process and was also highly determined by the interaction of therapists with their clients. Understanding, caring, and accepting therapists were deeply valued by clients, while feeling unheard, misunderstood, and unappreciated challenged the alliance [see Supplementary Table 1 (I1, I2)].

The Application of Techniques by the Therapist Facilitates Alliance

Besides the personal attributes and communication skills of therapists, the significance of the expertise and modality of the therapist cannot be undermined and was also identified as important to therapeutic alliance and psychotherapy process. Most participants mentioned that they felt that their therapists were able to listen to them, understand them, and offer them good advice. A range of other specific techniques and strategies applied by the therapists during the in-session activities were also found to facilitate clients in identifying, viewing, and solving problems ( Supplementary Table 2 ).

Match of Evidence-Based Treatment Modalities With the Preference of Clients

Evidence-based psychotherapy interventions were employed through either a single, integrative, or eclectic approach by therapists to match treatment to the individual and his/her psychiatric conditions. The commonly utilized forms of the evidence-based therapies based on the reports of participants were cognitive behavioral therapy (CBT) and mindfulness, while others included eye movement desensitization and reprocessing (EDMR), dialectical behavioral therapy (DBT), group therapy, exposure and response prevention (ERP), schema therapy, acceptance and commitment therapy (ACT), and psychodynamic therapy. While the majority found the assigned therapeutic approach helpful, others seemed to have their preferences and did not find certain intervention types to be helpful to them [see Supplementary Table 1 (J1, J2)].

Resistance of the Client in Psychotherapy

Despite the best efforts of psychotherapists, some clients failed to act in their best interests and engage fully in the therapeutic process. Such resistance impeded the motivation of the client and also interfered in treatment efficacy. Some participants were found to be reluctant to open up or discuss certain topics that were intrusive and distressing, particularly during the initial sessions or when therapists were new. Attending the sessions unprepared and unfocused was also a concern [see Supplementary Table 1 (K1)].

In addition, the success of the client in therapeutic outcome is usually dependent on doing homework or practicing strategies taught by the psychotherapist between sessions, in this study, the lack of motivation or effort led to non-compliance among few participants. They may have been either willing but were unable to complete the assigned task due to its length or difficulty, or simply unwilling to take it up at all [see Supplementary Table 1 (K2)].

Client Unaware of Treatment Plan

When asked about the kind of intervention they received or were receiving, some participants stated that they did not know the specific name of the therapy and that they were simply following through the therapy. While there was generally no complaint among these participants, few did express some unmet needs [see Supplementary Table 1 (L1, L2)].

Post-psychotherapy

Therapeutic outcomes.

Several themes were identified in this section when participants described the perceived change in them from receiving psychotherapy. These were the reflections of the service efficacy and effectiveness or, in other words, therapeutic outcomes, which varied among participants. They included positive changes following therapy, sense of recovery not due to therapy, continued use of self-supporting strategies or online resources outside therapy, and problem coping or managing symptoms without therapist support. The quotes representing each factor are presented in Supplementary Table 1 .

Positive Change Following Therapy

All the participants noted the beneficial effects of psychotherapy and experienced positive changes to varying extents. These improvements could be in the form of reduction in symptom severity or suicidal tendency, higher psychological well-being such as confidence and self-esteem, acquisition of better coping skills, or simply feeling better and supported after talk therapy [see Supplementary Table 1 (M1, M2)].

Recovery Beyond Effects of Therapy

Several participants cited that psychotherapy has its own limitations and could only help them to a certain degree. The previously experienced symptoms and struggles of clients improved as a result of the influence of events occurring outside of therapy or when the underlying issue got addressed but not due to the therapy. Others felt that their self-healing capacity or the intrinsic self is, if not more, important than the intervention itself for recovery [see Supplementary Table 1 (N1, N2)].

Engagement of Self-Supporting Strategies Outside Therapy

Therapists routinely imparted coping strategies and recommended online resources to their patients as part of their effort to integrate self-help into psychotherapy. Most clients cited the continued use of these self-supporting techniques and tools during waiting and maintenance stages. Participants described how these have helped them to cope with struggles or manage their symptoms effectively on their own when required at home or work [see Supplementary Table 1 (O1, O2)].

Problematic Coping in Absence of Therapist Support

Participants reported some form of reliance on their therapist during treatment phase. They expressed that they were unable to manage things on their own when they halted service after prolonged treatment or when they left the therapy room. Few participants had to resume psychotherapy despite having completed a previous course of treatment as they really needed someone to support them, with one even demanding for the same therapist [see Supplementary Table 1 (P1, P2)].

This study was a comprehensive study of the experience of clients with the service utilization of psychotherapy beginning from the pathway to care, followed by the therapy process, and lastly, response to therapy. Through in-depth interviews and qualitative analysis, the study derived themes associated with each phase of the service utilization of psychotherapy.

Pathways and Reasons to Psychotherapy

Different reasons (i.e., indirect and direct) and obstacles to service access underlined themes identified in the pre-therapy stage and were found to complement the three factors, namely, predisposing, enabling, and need factors that were highlighted in Andersen's Healthcare Utilization Model (Andersen, 1995 ).

Studies have quantified and compared the strength of associations among the predisposing, enabling, and need factors with the use of psychotherapy. In a well-informed population with a high-quality insurance cover (i.e., low enabling factors), the use of psychotherapy was primarily associated with the clinical condition (i.e., need factors) rather than the sociodemographic status (i.e., predisposing factors) (Briffault et al., 2008 ). Hundt et al. found that predisposing and need factors were linked to the onset of the use of psychotherapy while enabling and need factors were linked to higher level use, and they also demonstrated that need factors were most strongly associated with the use of psychotherapy in veterans (Hundt et al., 2014 ). Findings from our study suggest that the predisposing factors such as mental health stigma and the lack of awareness of psychotherapy were significant barriers to the initial access of psychotherapy, but once overcome, these factors did not appear to influence the frequency of use. The enabling factors such as the lack of time, high treatment cost, and long wait time for the preferred therapist mainly impeded the increased or prolonged use of psychotherapy but did not affect the earlier decision of participants to embark on psychotherapy. In terms of need factors, mental health symptoms and struggles were cited when asked for the main concern for attending psychotherapy. Perceived recovery or the absence of health needs, as evidenced from the post-therapy experience, was also related to the discontinued engagement of psychotherapy.

Psychotherapy Process and Therapeutic Outcomes

The experience of clients through the in-session activities and the therapy outcomes underlined themes in the during- and after-therapy stages, respectively. A large number of studies have been conducted into the process and outcome of psychotherapy from various lenses, with a substantial body of qualitative research focusing on the perspective of clients (Timulak, 2010 ; Timulak and McElvaney, 2013 ; Levitt et al., 2016 ). The study of the experience of therapy of the clients improves our understanding of the therapeutic process by shifting focus from the techniques, actions, and competencies of the therapists to include feelings, values, and attributes of the clients (Macran et al., 1999 ). A thematic review by Timulak revealed that, while clients valued factors relating to the client–therapist alliance during therapy, therapists were perceived to focus more on therapeutic gains (Timulak, 2010 ). Bachelor ( 2013 ) also found the views of the therapeutic alliance and therapeutic work between clients and therapists to differ such that, compared with therapists, clients tend to place greater emphasis on helpfulness, joint participation in therapy work, and negative signs of the alliance. The personal attributes (e.g., respectful, friendly, experienced, interested, open, warm, etc.) and the use of therapeutic techniques (e.g., supportive, understanding, exploration, reflection, accurate interpretation, affirming, etc.) of the therapist from a range of psychotherapy orientations were found to positively influence the development and maintenance of therapeutic alliance (Ackerman and Hilsenroth, 2003 ).

In fact, the findings from our study with respect to the “during service” period were consistent with the literature. First, some of the emergent themes (e.g., alliance between therapist and client, match between treatment modality and preference of client) involved various combinations of the three main aspects of psychotherapy, namely, client, therapist, and treatment modality, and did not involve only factors relating to the therapist or intervention alone. Second, the recollection of participants on the therapy process concentrated on how a range of characteristics and techniques of therapists similar to those described by Ackerman and Hilsenroth (Ackerman and Hilsenroth, 2003 ) was helpful to them and led to the positive therapeutic alliance, as well as on how the miscommunication of therapists ruined the alliance.

Therapeutic alliance essentially captures the interactive process between the client and the therapist and has been identified as the key variable in negotiating change or a reliable predictor of positive clinical outcomes in psychotherapy (Ackerman and Hilsenroth, 2003 ; Ardito and Rabellino, 2011 ). Besides therapeutic alliance, research into the effectiveness of therapy typically found other factors such as empathy, goal consensus and collaboration, the experience of therapists, therapy modality, and the level of motivation of the client to influence successful psychotherapy outcomes (Lynch, 2012 ; Wampold and Imel, 2015 ), all of which were consistent to the findings in our study. Previous studies on therapy outcomes were divided. The description of “good outcomes” among patients was found to cluster around four themes as follows: establishing new ways of relating to others, less symptomatic distress or change in behavioral patterns contributing to suffering, better self-understanding and insight, and accepting and valuing oneself (Binder et al., 2010 ). Other patients however, described themselves as not having improved through therapy and that therapy had not met their expectations (Radcliffe et al., 2018 ). All of our participants acknowledged some gains or positive changes, although few found therapy to have limited effectiveness and may not lead to full recovery.

Apart from the perspectives of clients, recent literature has reported that weekly therapy sessions appear to increase the rate of improvement compared with less frequent sessions although we have to keep in mind that this may vary according to setting, clinical population, and outcome measures (Robinson et al., 2020 ). On the contrary, studies have also reported that the number of psychotherapy sessions has less association with the therapeutic outcome (King, 2015 ; Flückiger et al., 2020 ). In our study, we did not examine this factor specifically, but it was observed that our participants who have had more sessions tended to report improvement. The effectiveness of the sessions was also reported by those who have had less than five sessions. We could have probably observed the expected trend with a larger sample.

Expansion to Andersen's Behavioral Model

Besides the numerous predisposing, enabling, and need factors as highlighted in Andersen's Behavioral Model, we also identified an additional component, i.e., service-related factors that we deemed to be important in understanding factors associated with the service utilization of psychotherapy ( Figure 2 ). For example, clients' in-session and post-therapy experience may also impede or facilitate their decision to continue or complete treatment based on their account. Environmental obstacles, dissatisfaction with service, and lack of motivation for therapy were found to be the three most common reasons for premature termination of service (Anderson, 2016 ). Andersen proposed that the model offers flexibility in understanding health behaviors and researchers could add more factors to the original model, without disrupting its original structure to fit the purpose and nature of their research (Andersen, 1995 ). We have therefore proposed an expanded framework for the initial and continued use of psychotherapy service that incorporated the four abovementioned factors (i.e., predisposing, enabling, needs, and service-related factors) ( Figure 2 ). The revised model also proposes the use of psychotherapy service to be a function of determinants due to both the client and the therapist. One limitation, however, will be the exclusion of components related to the health service policy and the healthcare system, which have been recognized as a criticism of the original Andersen's model (Andersen, 1995 ).

Proposed expanded framework for psychotherapy help-seeking behavior adapted from Andersen's Health Utilization Model.

Limitations of Study

There were several limitations in our study. First, as patients recruited for this study were mainly referred by their consulting therapists, they may not be open to discuss about the negative experiences they had with their therapists for fear that their therapists may learn about it despite being informed about the confidentiality and de-identification of the interview content. Second, the authors were unable to identify the distribution of the themes in the interviews as clients spent more time talking about what they found beneficial and not. Finally, the study was conducted among psychiatric patients attending psychotherapy in a discretionary health service (i.e., outpatient hospital service) setting, and hence, findings may not be generalized to all forms of psychotherapy services. Further studies are warranted to provide evidence for the proposed framework for the utilization of psychotherapy.

This qualitative study may be the first to have obtained the in-depth experiences of psychotherapy of clients in Singapore, which enabled an evaluation of narratives from three phases, namely, pre-, during- and post-service encounters. The themes identified at the various stages concurred with those reported in other qualitative or quantitative studies. The study also expanded on Andersen's Health Service Utilization Model and proposed a promising framework to understand health behaviors and utilization relating to psychotherapy service. It also provides actionable information to address identified barriers to access and negative experiences or outcomes due to psychotherapy.

Data Availability Statement

Ethics statement.

This study involving human participants were reviewed and approved by National Healthcare Group Domain Specific Review Board. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

LSES and RS were involved in the conceptualization, data analysis, and drafted the manuscript. JV wrote up the protocol of the main study. SC and JV conducted the interviews. SC, RS, and LSES transcribed the audio files. LSES, RS, JV, and SC were involved in the coding process. MS was consulted for study design. HL, HA, and C-YT gave valuable inputs for the study and provided referrals for the interviews. All authors provided intellectual inputs and have approved the final manuscript.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Funding. This study was supported by the National Medical Research Council under the Center Grant Program (NMRC/CG/M002/2017).

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyg.2021.667303/full#supplementary-material

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