Therapy: who decides?

Nobody knows why therapy helps.  We have theories but no solid understanding of the mechanisms involved and we probably won't for a long time. Therapy isn't alone in this. Nobody knows, for example, why SSRIs, a commonly prescribed class of anti-depressant works either.

 André Picard of the G&M: "As it stands, mental-health care remains an orphan. We can take another big step toward correcting this by adopting a more rational approach to the use and funding of psychological care."

André Picard of the G&M: "As it stands, mental-health care remains an orphan. We can take another big step toward correcting this by adopting a more rational approach to the use and funding of psychological care."

We do know that for certain categories of psychological problems -- some couple and family distress, mild to moderate depression or anxiety, certain personality disorders, and some psychotic disorders -- psychotherapy helps a significant portion of people and has minimal down sides (there are possible negative consequences to therapy some of which I discussed here).

These two points -- that therapy works and that we don't know why it works -- are important to emphasize because government and private insurance are increasingly involved in the practice of psychotherapy.  An example; this week the Order of Psychologists of Quebec announced that it is proceeding against two people for practicing psychotherapy without a license.  Here, in Quebec, since 2012 you must have a license from the Order to offer psychotherapy, which is defined as follows...

A psychological treatment for a mental disorder, behavioural disturbance or other problem resulting in psychological suffering or distress, and has as its purpose to foster significant changes in the client’s cognitive, emotional or behavioural functioning, interpersonal relations, personality or health. Such treatment goes beyond help aimed at dealing with everyday difficulties and beyond a support or counselling role.

Clearly, the provincial government is taking psychotherapy more seriously.  Also it is clear that it is hard for lawyers to write a good definition of a process that we don't understand very well.  How far in can the government wade?  So far it has been restrictive legislation.  André Picard of the Globe and Mail, who writes as well as anybody in Canada about psychiatry, mental health and mental illness, has written a very good piece aimed at beginning (again) a discussion around the funding of psychotherapy through public health insurance.  Currently, no provincial government funds non-MD-provided psychotherapy in the same way that it funds medical procedures.  Here in Quebec, non-MDs -- psychologists, social workers, creative arts therapists sexologists etc. -- who work as psychotherapists in the public sector get paid a salary through their institution, they don't charge per procedure.  They are also increasingly rare.  The vast majority of out-patient psychotherapy is provided by private practitioners for whom clients pay out-of-pocket and either get reimbursed by their private insurance or not.  This means that people who might greatly benefit from psychotherapy but can't afford it are unable to access it.  The more seriously mentally ill a person is the more likely it is that he or she is poor, and the less likely it is that he or she has private insurance so this way of delivering non-emergency mental health care is seriously off. 

I like the idea of people being able to access psychotherapy regardless of income.  But I have some serious reservations about the idea of public health care funding for psychotherapy.

  1. Psychotherapy is one thing that can help with mental illness.  There are lots of other non-medical treatments that can help the mentally ill: stable, supportive housing is a big one; case management is another.  If we want to spend billions helping the mentally ill do better in the hopes that we will benefit as a society, we need to take these two as seriously as psychotherapy and medication. 
  2. It can be a bonanza for some and create rich, entrenched interests that distort psychotherapy.  Research into psychotherapy can make for very dispiriting reading. It often looks like this; I have developed Wexler's Wonder Therapy (TM).  I test WWT (TM) on people with depression by giving them 8 sessions.  I exclude from my study anybody who has a drinking problem, couples problems, a history of childhood trauma, depression that has been treatment resistant or anyone with a cat because these other factors would confuse the research.  I begin with 15 people who meet these criteria.  Six drop out.  Of the remaining nine, six experience greater relief than they would if they were on a waiting list.  Wexler's Wonder Therapy (TM) is 67% effective!  It works on non-drinking, non-childhood trauma, non-treatment resistant, non-cat owning depressed people in only 8 sessions so it is incredibly cost effective.  It becomes the treatment standard for psychotherapy for depression.  I will train clinicians in WWT (TM) for a mere 1200$.  With that money I prove that WWT (TM) is also effective for anxiety and couples difficulties.  And so on.  This is not to say that psychotherapy isn't effective.  It is.  But for many conditions there does not seem to be much daylight between different therapies.  And people are a lot more complex in clinical settings than in research trials, which means that claims to deliver highly-effective, short-term psychotherapies are often over-hyped.
  3. Psychotherapy isn't medicine. These difficulties come of trying to shoehorn psychotherapy, and psychological care generally, into a medical model.  Psychotherapy is connected to medicine because of its origins and because there is real overlap, but it isn't the same thing and trying to use our health-care system to pay for it means putting a square peg in a round hole.
  4. It seems very unlikely to happen.  Quebec is in the midst of cutting hundreds of millions of dollars from its health care system and psychiatric outpatient care is being hit hard.  Proposals to take on additional expenses seem likely to be DOA here and elsewhere. 

I want to ensure that people who need non-emergency psychological care can get it regardless of income and at the same time maintain a practice of psychotherapy that is flexible and not overly bureaucratized.  Here is a suggestion: borrow from the Americans, specifically Obamacare.  Rather than expand Medicare to include non-hospital psychological treatment, require private insurance companies (which are making billions of dollars a year) to offer all Canadians 25$/year mental health insurance plans.  No cherry-picking, no pre-existing condition exclusions.  All plans must cover the cost of non-hospital services like psychotherapy, case management and emergency supportive housing.  Require all Canadians to have a mental health insurance plan.  Plans that do a good job of keeping policy holders out of hospital for a year get a portion of the cost of saved hospital psychiatric care.  Incentivize non-hospital based psychological care and let groups of clinicians experiment with what gives the best results.  This is  probably more likely to happen than provincial governments finding a few 100-million$ a year in spare change at the back of the couch and might preserve some creativity and flexibility in psychotherapy as well as ensuring non-psychotherapeutic treatments are on the table when necessary.  

Why science won't improve mental illness treatment

Science made tremendous strides in treating mental illness in the years between 1800 and the 1930.  As Edward Shorter points out in his "A History of Psychiatry" perhaps the greatest challenge of 19th century psychiatry was neuro-syphilis.  Nobody treats neuro-syphilis today with talk therapy or anti-psychotic medications because we know what causes it.  In the developed world syphilis is treated with anti-biotics before it ever destroys a person's nerves and brain.  But the days of simple cures for debilitating mental illnesses are over for the foreseeable future, though, for obvious reasons, people wish it weren't so.  

Marvin Ross wrote a piece about evidence-based medicine versus alternative medicine in mental health care titled "The Only Thing That Will Improve Mental Illness Treatment is Science."  Like Mr. Ross, I am opposed to using public money for treatments that not only lack a base of evidence showing their efficacy but have been shown to have no benefit.  But I am also opposed to huge investment in research when known, effective treatments go begging hat in hand.  There are plenty of things that we know help people who are mentally ill to live healthier, safer, happier lives.  These are treatments that have been demonstrated to be effective in study after study; stable supported housing, case management, regular follow-up, early intervention for psychosis, psycho-education and, in some cases, talk therapy.  As a society we don't do them.  In fact, in most places in North America government is pulling away from offering these services at taxpayer expense. 

If there is a limited pie of government money to be spent on the mentally ill, why do we persist in spending it to look for a magic bullet that will cure schizophrenia or autism or Alzheimer's when for the same money we could treat these diseases mitigating a lot of the worst effects of the illness?  In the last forty years with all the billions of dollars in tax breaks and subsidies that has been spent on brain research there has been no significant clinical advance on the treatment of these diseases -- despite hundreds of breathless reports that a cure is just over the horizon.  If you want to look for magical, non-evidence-based practices, spending public dollars on neuroscience in the hopes of an imminent cure for serious mental illness is akin to using Reiki to treat a broken leg. 

I think there are several reasons we persist in this way of doing things. One relates directly to the rise of alternative medicine.  Both Reiki and neuroscience journalism about fantastic breakthroughs in neurotransmitters appeal to a similar human impulse; the desire for a comprehensive and elegant solution to complex problems.  But the low-hanging fruit of scientific discovery has been plucked already.  Science has become so arcane that Clarke's rule that 'any sufficiently advanced technology is indistinguishable from magic' is true of most science today for most people.  We may believe that we understand how our cellphones work but I am guessing that most non-scientists would have a hard time being able to say clearly where the limits of science (eg. the dubious theory that imbalances of neurotransmitters cause mental illness) leave off and where the limits of magic (homeopathy's dubious claims that microscopic amounts of certain natural occurring substances can treat imbalances in your body's chemistry) take up.  Add to this the hiddenness of science which is increasingly conducted behind paywalls and the result is that most people have as strong a sense as ever that "scientific" means whatever a person in a white lab coat says and the only choice is whether to swallow it whole or reject it. 

The other factor that is stopping us from treating mental illness as it should be treated is the fact that people don't get fabulously wealthy by giving home follow-up and nursing and psychotherapy and regular injections to the mentally ill.  If reimbursed properly, a lot of people might live good lives working in these areas.  Nurses and social workers, clinical psychologists and psychiatrists put more of the money they make back into the economy than executives and board members of pharmaceutical and medical tech companies.  I am not convinced that we need to choose between good research in neuroscience and effective high quality treatment of the mentally ill.  But spending on treating mental illness in the ways that we know work well is a much better investment as a society than chasing the unicorn of a single molecule to cure schizophrenia and incidentally make a few people fabulously rich.

Science can't fix our culture's obsession with quick fixes or our bent ideas about money and mental health.  It is our collective responsibility to demand that public dollars be used where they will most benefit the mentally ill.  That isn't Reiki but it also isn't putting college students into MRIs and asking them to read Jane Austen and saying you're looking for a cure to autism.