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.

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.  

Dinosaur Shame: Emotion and Self

Prof. Heather Macintosh spoke last week at McGill on Childhood Trauma and Emotional Regulation in Psychotherapy.  She was talking about shame and jokingly differentiated between "felt shame" and "dinosaur shame," primordial shame at a level largely inaccessible to language or cognition.  She talked about the difference between feeling shame and shame as an identity. 

Shameosaurus (a.k.a. "Afrovenator abakensis dinosaur" by Mariana Ruiz Villarreal LadyofHats - Licensed under Public Domain via Wikimedia Commons - http://commons.wikimedia.org/wiki/File:Afrovenator_abakensis_dinosaur.png#/medi /File:Afrovenator_abakensis_dinosaur.png)

I am curious about how emotion, intense emotion, our own, or another's can overtake our sense of self.  Virginia Goldner, who I have mentioned before, talks about how anger, for violent spouses, can often feel dissociative.  Emotion can displace a sense of self for a while; the person becomes lost to him/herself through emotion. This reminds me of the line in the final scene of the (exploitative, yucky, though gripping) film "Seven," where the killer, John Doe, played by Kevin Spacey, urges the hero to "become Vengeance, become Wrath."  The conceit of the film was the Catholic doctrine of the seven deadly sins being incarnated in different people, but that line, and the experience it encapsulates of a self- and world-eclipsing embodiment of wrath reminds me more of Robert Oppenheimer quoting the Bhagavad Gita "Now I am become Death, destroyer of worlds" when reflecting on the detonation of the atomic bomb.  

Oppenheimer had studied the Bhagavad Gita and knew that the context was Krishna's injunction to Arjuna to destroy men in a cataclysmic battle, both friends and enemies with selflessness, for the sake of the Divine who had per-ordained their deaths.  It is a wonderful encapsulation of the sense of the self vanishing in the face of forces that feel transcendent and wildly violent.  As far as we know, no dinosaur ever experienced shame, either as an emotion or as an identity.  I love the way "dinosaur shame" evokes how primordial shame and other intense emotions can be, prior to and remote from language, as well as the feeling of destructiveness they come with.  But given that shame is a human legacy, -- "man hands on misery to man" -- perhaps a more accurate description would be from the other end of the time line; "atomic shame". 

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. 

Am I crazy?

"Do you think that you might be crazy?"  It is one of those impolite questions that I get to ask that makes being a therapist fun and rewarding.  When people come in to see me they are sometimes half-convinced that they are crazy.  Sometimes people confuse the intervention with the malady.  Smart people can have the unexamined belief that "If I take the pill, if I see the therapist that means that I am crazy."  Recently, I've started asking more.  A lot of people who come to see me are.  Worried, that is.  I guess whether they are crazy or not depends on what you mean. 

People who have a personal or family history of mental illness are often very worried about being crazy, sometimes terrified.  They may have a very particular idea of what mental illness looks like and be terrified that that's what's in store for them.  Other people come in with a fear that is augmented -- with lots of good intentions and some greed -- by attempts to broaden people's picture of who can experience mental illness.  On the one hand, attempts to destigmatize people with mental illness are laudable.  On the other hand, hyper-sensitizing people to mental illness, encouraging them to view themselves and everyone around them as psychological orchids who need specialized interventions simply to survive in the world, is IMHO, plainly nonsensical, inimical to good mental health and partly motivated by the desire to sell us stuff (medicines or other therapies) that we don't really need. 

I recently saw a woman who is a new immigrant to Canada.  She is having difficulty learning French and is a new mother.  She felt stressed, scared, overwhelmed, sad and very lonely.  She had been prescribed anti-depressants and an anti-psychotic for sleep (the practice of GPs prescribing anti-psychotics off label without the simplest discussion of sleep hygiene is troubling to me).  On top of everything that was going on in her life she was terrified that she was crazy.  The persistency and intensity of the feelings, a family history of mental illness, her sense that she should be able to get over them and probably the fact that she had been prescribed medication all fed into her sense that she was going crazy.  This is not to say that the anti-depressant was not appropriate.  But it had a powerful meaning for her.  When I asked if she was worried she was going crazy, she began to sob.  She is scared to pick up her French classes again or try to find a job because she views herself as too anxious to take on anything new.  She is becoming more isolated.  I asked her if seeing me was going to make her think she was crazy because I did not think she was and I did not want to do anything that would give her that idea.  If coming to see me would make her think she was crazy I would refuse to see her.  Why?  Because viewing herself as crazy was making her crazy(-er). 

People have all sorts of ideas about what being crazy might look like and what it would mean.  I saw a young woman the other day who wanted to know if she had Borderline Personality Disorder.  First, I told her that I am not a doctor and I can't make a diagnosis.  Then I asked her what it would mean if she did have it.  She felt like then doctors would have some direction about how to treat her so that all the stuff that wasn't working in her life would get better.  "And what if you are sad and lonely because important people in your life have been hurtful towards you for a long time?  What would that mean?"  "Then I'm just a screw up."  Crazy might be better than the alternative; the frightening responsibilities of sanity. 

It probably isn't very wise of me to admit this but I use the term crazy in my own head sometimes when I think about clients.  Usually what I think is, "What a crazy thing to do."  It means something like 'inexplicable and self-defeating'.  In other words "Human."  One thing I don't mean is "mentally ill."  Mental illness to me means something is going on in the person's mind that is far beyond the usual degree of human irrational, self-destructive behaviour.  I think what my clients worry about -- or sometimes even long for -- is being far beyond the human pale, unable to return, irreparably psychologically destroyed. 

Resilient is the opposite of crazy in that sense.  Child birth is messy, it is occasionally very dangerous.  But our survival as a species up until the 20th century is incontrovertible proof that it can usually be done outside of a hospital.  Similarly, the fact that humans are around at all is proof that we are well-equipped psychologically to deal with hard stuff, to suffer, to hurt,  and be hurt even to go crazy and to recover. 

I am glad to live in an age of medicine.  I believe in therapy.  Part of resiliency is having people around who can help you.  But therapists also need to remember to 'first, do no harm'.  And if the cure is worse than the malady then it's no cure.  

Resistance is where the work begins

Ginger Campbell host of the Brain Science podcast, after a great interview with Norman Doidge about neuro-plasticity, said that doctors often don't prescribe behavioral therapies because they have the experience of patients not following through (1:05:00). "Many patients would rather take pills than follow treatment regimens that require them to do most of the work themselves."  I will write about Doidge at some point soon, but I thought a lot about Ginger's statement about homework and follow through. 

Recently, I have been finding that the most interesting moments in therapy come when I ask a client to try something that he/she/they won't or don't do and we unpack that resistance.  I have said before that on a handful of occasions, I have given people really good advice in therapy.  But much more common are people who know more or less what they need to do to make changes in their lives but resist it for reasons they cannot fully understand. 

I recently told a client who was feeling ambivalent about his marriage -- he couldn't commit to it and couldn't leave --  that he should try being fully invested in his relationship for 3 months.  At the end he could still leave or stay or continue being undecided, but in order to see what the relationship might be, he should try actually working at making it good for a limited amount of time.  He physically writhed at the idea.  He almost began to twitch.  What makes committing to the relationship, even provisionally, so hard? 

I told a couple that they should spend ten minutes a day talking about something tough in the day and supporting one another.  When I asked them about the exercise he said, "It feels weird because we see each other all day, she knows everything about my day."  They began to see how her being available to him for almost all his emotional needs throughout the day was not so great for their relationship. 

I told a client to meditate so that he could be a little more present to his partner.  "Sitting still for ten minutes is my idea of hell," he said.  She began to cry because she wants him to be able to be still for her.  It turns out that he has missed some crucial hurt feelings of hers because sitting still with emotions is so painful for him. 

People have reasons for not changing.  Sometimes it is a cost benefit analysis: "This requires a lot of work and I don't have enough confidence that it will make a difference."  I think a lack of confidence that medical science actually knows what is good for us is an important and neglected part of that cost benefit analysis.  It is hard to take your doctor's prescription seriously if you don't think s/he understands what is going on with you and what you want.  That doesn't come in 15 minutes.  Sometimes the road to such confidence comes from taking the time to unpack what else makes change hard.  

It is ironic that most doctors probably know that just prescribing behavioral change is unlikely to get people on board, yet they still do it.  Another opportunity to ask the question, "What makes it hard to do this?" And perhaps the beginning of real change. 

4 ways therapy can do harm and why that is good news.

My former supervisor and teacher, Sylvia, used to tell me, "If you are stuck with a client, you need to put that on the table.  If you and the client can't get unstuck, stop the therapy."  I have been thinking about what great advice that is and how hard it can be to follow.  Clients will often say to me, "More therapy can't hurt, right?"  I even hear that from medical professionals and sometimes mental health professionals.  Generally, people know that insulin can hurt, and they don't take it just 'cause.  People don't undertake minor surgery for no reason.  Aspirin if taken improperly can put a person in grave danger.  If a therapy is capable of affecting someone's well-being for good, then it can also do harm if administered when it isn't indicated or in ways that aren't indicated.  Stated another way; If it can't do any harm then it is not worth doing.  I am not talking about an abusive or incompetent therapist or an unproven therapy.  I am talking about how psychotherapy can hurt when administered properly for the wrong situation or in the wrong dosage.

1. Psychotherapy directed towards a fundamentally well person in a bad situation can make the person feel responsible for his or her situation and aggravate worry.

This one happens with kids a lot.  The parents come into a therapist's office and say, "My kid is anxious/sad/angry all the time.  We don't want to discuss our fighting/grief/parenting.  Work with the kid."  The therapist can treat the kid using behavioral techniques for tackling whatever his/her symptoms might be.  I have heard therapists say, "At least I can offer the kid tools for dealing with X that may alleviate one difficulty in a difficult life."  I don't agree with this.  I think treating that kid in isolation gives the parents license to continue their behaviour and can put the spotlight on the child whose symptom is really the family's.  This may exacerbate feelings of responsibility for the family's difficulties.

2. Therapy that doesn't change the music.

This one happens with couples often.  Couples will come into therapy and insist on having the same arguments that they have at home.  I often say to them, "It's okay to fight in therapy, but I want you to at least have a different fight than you have at home."  Therapy is about making change in patterns and if you are doing the same thing in therapy that you are doing at home, you aren't changing a pattern, you are rehearsing it and you may be reinforcing it.   Some couples can't stop this, which is painful for therapists and the clients, but rather than have a bad experience of therapy and a lot of extra practice doing what hurts, it is better to stop therapy.  The couple may be able to come back when they are in a different place or work with a different therapist who can get them pointed in a different direction. 

3. Psychotherapy in place of something else that would give more well-being.

People are busy.  Therapies can be expensive.  People may prioritize psychotherapy over other things, either other therapies or other activities that could improve their well-being.  People are often choosing between therapy and a gym membership or a babysitter or a speech therapist or a soccer practice.  Those can sometimes be false choices but I actually think that more often than not, they are real.  I am all in favour of people prioritizing their mental health and their close relationships but the best expression of wellness is living a full life, not being in therapy.  Sometimes people believe, mistakenly, that because they are in therapy, they are taking care of their well-being when, in fact, they are using therapy as a smoke screen.  A good question for clients and therapists is "If the client wasn't here, where would s/he/they be?  What does missing X mean?"

4. Ending too early.

The pioneer of systemic, family therapy, Salvador Minuchin pointed out that sometimes people try something new to make a change but stop early when they see no benefit.  Some changes yield benefit in a one-to-one ratio -- a straight ascending line -- but sometimes change comes more as an exponential curve or even a "hockey stick" curve in which a person sees little benefit at first but experiences big pay-offs when s/he persists.  The down-side of ending early is that it can feel disheartening to work at something and see no result.  Depressed people often cognitively distort failures so that is all they see and they see those failures magnified.  If a depressed person tries cognitive behavioural techniques in therapy, for example, and doesn't experience change fast enough s/he can view it as yet another failure and feel worse.  Going back to the surgery analogy, if we abandon surgery in the middle the results will be not only a return to pre-surgery function but worse functioning. 

Avoiding these pitfalls is part of providing good therapy just as providing good medical care involves more than just prescribing medication, but knowing when and where to prescribe and when not to.  All this isn't meant to scare people off therapy, but rather to point out that therapy has real effects.  If a therapy isn't working, feels like it is hurting more than it is helping or feels stuck, take the time to look at that, client and therapist together. 

Radical Acceptance. Do microbes or the zodiac make you depressed?

There was a neat piece on NPR today about gut flora and mental illness which postulated a link between the health of one's inner beasties and one's mind. 

But before you run out and buy an industrial tub of yogurt and a tempeh starter kit, know that something as immutable as your birth month also impacts your risk for many diseases including several mental illnesses. From the Atlantic...

“Many contemporary scientists are loath to admit to anything resembling astrology. “It seems absurd that the month you are born/conceived can affect your future life chances,” write neuroscientists Russell G. Foster and Till Roenneberg in a 2008 study. They then go on to then point out no fewer than 24 different health disorders connected to season of birth, and ultimately admit “despite human isolation from season changes in temperature, food, and photoperiod in the industrialized nations, the seasons still appear to have a small, but significant impact upon when individuals are born and many aspects of health.””

— http://www.theatlantic.com/health/archive/2013/11/your-zodiac-sign-your-health/281358/

Marsha Linehan, the psychologist who developed Dialectic Behavioral Therapy, used for treating substance abuse and borderline personality disorder, among other mental illnesses, talks about the importance radical acceptance. 

“So what’s Radical Acceptance? What do I mean by the word ‘radical’? Radical means complete and total. It’s when you accept something from the depths of your soul. When you accept it in your mind, in your heart, and even with your body. It’s total and complete. ”

— http://www.dbtselfhelp.com/html/radical_acceptance_part_1.html

Linehan does not mean that we accept our brokenness, our faults, our failings and stay there.  As Carl Rogers said in On Becoming a Person, "The curious paradox is that when I accept myself just as I am, then I can change."  Linehan, in a very courageous move, recently talked about her own experiences of mental illness, including many attempts at suicide and her recovery from it which was prompted by a religious vision which included a profound feeling of self-acceptance. 

“I decided to get supersuicidal people, the very worst cases, because I figured these are the most miserable people in the world — they think they’re evil, that they’re bad, bad, bad — and I understood that they weren’t,” she said. “I understood their suffering because I’d been there, in hell, with no idea how to get out.”

In particular she chose to treat people with a diagnosis that she would have given her young self: borderline personality disorder, a poorly understood condition characterized by neediness, outbursts and self-destructive urges, often leading to cutting or burning. In therapy, borderline patients can be terrors — manipulative, hostile, sometimes ominously mute, and notorious for storming out threatening suicide.

Dr. Linehan found that the tension of acceptance could at least keep people in the room: patients accept who they are, that they feel the mental squalls of rage, emptiness and anxiety far more intensely than most people do. In turn, the therapist accepts that given all this, cutting, burning and suicide attempts make some sense.

NYT http://www.nytimes.com/2011/06/23/health/23lives.html?pagewanted=3&_r=0

The idea of radical acceptance, even for the purpose of change, seems profoundly lacking in our thinking about health.  In North America, at any rate, we are meant to view ourselves as our own greatest work of art, as perfectible. 

I am in the change business.  If diet can help people with mental illness then I want to know about it.  But I also believe that sometimes a hyper-developed sense of agency, which is pretty much the modern condition, oddly, keeps people stuck.  Sometimes we have to accept even our darkest feelings, "meet them at the door, laughing, and invite them in" before we can learn what they came to teach us.

The Guest House

This being human is a guest house.
Every morning a new arrival.

A joy, a depression, a meanness,
some momentary awareness comes
as an unexpected visitor.

Welcome and entertain them all!
Even if they are a crowd of sorrows,
who violently sweep your house
empty of its furniture,
still, treat each guest honorably.
He may be clearing you out
for some new delight.

The dark thought, the shame, the malice.
meet them at the door laughing and invite them in.

Be grateful for whatever comes.
because each has been sent
as a guide from beyond.

-- Jelaluddin Rumi,
    translation by Coleman Barks

Who delivers mental health care?

Dr. Suzanne Koven has just written a great blog post that is required reading for anyone who cares about mental health care in North America, called "Should Mental Health Care be a Primary-Care Doctor's Job?"  She points out the degree to which medical mental health care has been downloaded to primary care docs who may or may not feel up to the task. 

“I’m comfortable helping people get through life’s more common emotional challenges, like divorce, retirement, disappointing children. If you’re hearing voices, or if you walk into my office and announce that you’ve decided to kill yourself, as someone did not long ago, I know exactly what to do: escort you to a psychiatrist. But what about the lawyer who’s having trouble meeting deadlines and wants medication for attention-deficit disorder? Or the businesswoman whose therapist told her to see me about starting an antidepressant? Or the civil servant trying to shake his Oxycontin addiction? They’ve all asked me to treat them because they don’t want or can’t easily access psychiatric care. ”

Here in Quebec, the recent Bill 21, which regulates the act of psychotherapy, gives physicians automatic access to the title of psychotherapist though their training in mental illness and mental health may be limited depending on what their experience in medical school and residency was.  While there are many doctors who are great psychotherapists and who have taken the time to get trained, becoming a doctor involves training in diagnosis of mental illness and some psycho-pharmacology and only a cursory understanding of different forms of psychotherapy.  (The purpose of Bill 21 is to protect the public by ensuring a minimum of training for psychotherapists.  It has serious ramifications for people who use mental health services but remains largely unexamined in French or in English media). 

Dr. Koven points out that fewer medical students are going into psychiatry in the US (sorry, I can't give Canadian stats) so both the public and general physicians have less access to doctors who specialize in mental health.  I also have seen that there is a feeling among patients that psychiatrists are pill-pushers while a GP may be more accessible and take the time to know a patient better ad this may make people even more likely to rely on generalists.  (My experience of psychiatrists has actually been that they are more likely to prescribe talk therapy with or without medication than GPs, but that is very impressionistic.) 

Recent changes to the way health care is delivered in Quebec make it harder to access a psychiatrist directly through the public system.  In order to see a psychiatrist you must first go to a public health clinic, a CLSC, rather than go to a psychiatrist in the public system directly (except for emergencies).  This can be good because people can be seen by a social worker or psychologist at a CLSC which may be what they need, but it re-enforces the model of psychiatry being practiced only with the very seriously mentally ill or the very wealthy.  Finding a psychiatrist to really follow someone with obsessive compulsive disorder, for example, to ensure that medication is appropriate and effective and to consult with the therapist, whether s/he is a GP or a social worker, is very hard.  It may account for why fewer people want to go into the field, too.  After all, who wants to go into a medical specialty where you are supposed to fathom the mysteries of the human heart and human relationships but are unable to form relationships with patients because you see them on an assembly line, and on top of that, you will mostly see people whose illnesses can at best be managed but are without cure?