From the Editor
Earlier this month, the University of Toronto Department of Psychiatry held a one-day conference on the Future of Psychotherapy. Speakers included Harvard University’s Dr. Vikram Patel, who has worked to expand access to care in low-income countries, and the University of Oxford’s Dr. David Clark, who has co-led the world’s largest program to improve access to evidence-based psychotherapy.
Here in Ontario, the future of psychotherapy will be influenced by several factors, including government payment. The day after the conference, when Drs. Patel and Clark were travelling home, a long essay ran in The Globe and Mail discussing a provincial government proposal to limit physician compensation for psychotherapy to 24 sessions a year; currently, there are no restrictions on the number of psychotherapy sessions billable per patient, allowing public funding of psychoanalysis. Dr. Norman Doidge, a psychoanalyst with affiliation with both the University of Toronto and Columbia University, argues strongly against the proposal. Psychiatry, he writes, will be left with “diagnose, and adios” – or worse, “diagnose, overdose, and adios.” Dr. Doidge – a bestselling author who has written on topics as diverse as the Palestinian conflict and brain plasticity, and who wrote the introduction to Jordan Peterson’s popular book – puts forward a well-crafted case.
The past of psychotherapy – but not its future?
In this Reading, we consider Dr. Doidge’s essay and some responses to it.
Therapy and Funding
“In Ontario, a battle for the soul of psychiatry”
The Globe and Mail, 6 April 2019
When we met, Mr. A. had recently turned 30 years old. He was thoughtful, courteous and uncommonly articulate. He had also just spent the past seven months in hospital.
He’d hit a patch of black ice while driving a rented SUV – later determined to be defectively designed. It flipped, rolled and the roof caved in. In an instant, he became what is called ‘a C7, complete motor,’ a term that denotes a severe spinal-cord injury starting at the bottom of the neck. He became quadriplegic.
He no longer had control of the movement of his hands, or muscles from his chest down to his feet, and the barest sensation in those areas. He would never stand, walk, bathe or dress himself again. He would develop bedsores and urinary tract infections. A young man, in his prime, his sexual function became severely compromised.
In the few seconds the SUV flipped, Mr. A.’s life expectancy shortened 15 years. More immediately, each individual day was shortened by at least four hours, because that’s the time it takes an attendant to help get him out of bed, bathed, dressed, change his catheter and help evacuate his bowels. Then there’s the incalculable time lost throughout the day trying to navigate a world of cellphones, computers and elevator buttons without the use of his hands or fingers.
He was referred to me after he was discharged from the rehab hospital to deal with depression. Although he hadn’t been diagnosed with PTSD from the accident (probably because he suffers from amnesia), the aftermath was another matter. He faced the death of every dream he’d ever had – he discovered, for instance, he’d never work in the fast-paced industry he’d trained in. He was a fiercely independent personality, and the injury deprived him of that, too. And, of course, he was, above all, dealing with how this affected his prospects to marry and have children, which he had dearly hoped for. His grief was immense.
Antidepressants only partly helped. It helped a lot that I was a physician, with an appreciation of his injury. The therapy we started – intensive psychoanalytic psychotherapy – is not what is called ‘short-term’ psychotherapy…
So begins an essay by Dr. Norman Doidge.
He argues that that the sort of care Mr. A received is at risk:
If the Ontario Ministry of Health has its way, the type of intensive psychotherapy Mr. A. has been receiving will end. A proposal the ministry made in January would radically limit psychotherapy provided by psychiatrists and family physicians. The ministry’s proposed new approach, modelled on U.S.-style, managed care, is designed to limit the type and amount of treatment individual patients will receive, regardless of their presenting symptoms. The Ontario Medical Association (OMA) opposes it, and both groups are meeting about it now.
Dr. Doidge sums things up provocatively – should the Ontario government proposal succeed, it will be: “Diagnose, and adios.”
He makes several points:
- “The first time intensive psychotherapy cuts were proposed was under Bob Rae’s NDP government in 1992.” That effort failed.
- Evidence supports psychoanalysis: “In Germany, where intensive long-term psychoanalytic psychotherapy and psychoanalysis are publicly funded, one study showed patients who had these two therapies had a two-thirds decline in hospitalizations, but also a one-third decrease in medical visits of all kinds, a two-fifths decline in lost work days and a one-third decrease in the use of all medications. These declines were sustained 2.5 years after the completion of psychotherapy.”
- And that evidence can be applied to Canada: “Our average psychiatric inpatient stay costs $11,000. Ruth Lanius and Isolda Tuhan of the University of Western Ontario recently showed that long-term intensive therapy for traumatized patients with personality problems reduces inpatient stays by 65 per cent, reduces emergency visits by 45 per cent and increases school and work functioning by approximately 700 per cent. Intensive psychotherapy is effective preventive medicine.”
Dr. Doidge worries for the future of psychiatry:
These proposed changes make me wonder: Will Canadian psychiatry become a shallow technocratic discipline, focused on checklist diagnoses and recommending drugs (which is all there is time for in a brief managed-care style consultation), or will it be a discipline that admits human complexity?
He argues that the government proposal is based on a paper written by Drs. Paul Kurdyak, David Goldbloom, and Benoit Mulsant that fails to understand the nuances of payment.
He argues: “It’s like saying ‘every bridge in Ontario will be 24 metres,’ regardless of the body of water it is over. Neither I (nor anyone else) can tell in advance exactly how many sessions Mr. A will need, and this isn’t because I’m inexperienced or unscientific but because I have 30 years of experience, and value a scientific approach, which means: I don’t make stuff up.”
He concludes: “The Ministry of Health should withdraw the destructive proposal that will end up costing our system a fortune, and prolong untold pain. They should become better informed and advised.”
A few thoughts:
- This is a well-written essay.
- Some may criticize Dr. Doidge’s case scenario – is Mr. A really representative of the sort of patient who gets long-term psychotherapy? Clinicians like Dr. Doidge who write for the popular press often face criticism – we might be reminded of the criticism of Dr. Oliver Sacks: the man who mistook his patient for a literary career. But Dr. Doidge hasn’t written a peer-reviewed journal paper, he’s written an essay in an attempt to persuade the general public. With that in mind, he has succeeded in putting together a cogent and moving argument based on solid writing.
- But is he successful in persuading us? Some readers will strongly agree with Dr. Doidge; some will strongly disagree. I’ll remind you: Readings are about stoking debate and discussion.
- What to make of the government proposal? OMA-Ontario government negotiations are complicated, and – like all negotiations – can start with tough positions. A hard cap on psychotherapy for every patient should be seen in that light.
- Still, the proposal and this essay response raise questions. I offer several questions from different perspectives:
Are hard caps the best way of achieving better results for all patients? Are hard caps not arbitrary, like saying that all bridges should be 24 metres (to borrow a line from Dr. Doidge)?
Should the government pay for physicians to do as much psychotherapy for patients as they choose without any limitations? Should the government pay for the building of bridges of every length in every circumstance?
If the doctor-patient relationship is the building block of health care, how can we create an environment in which providers can offer the care they feel is appropriate?
How can we better offer evidence-based interventions at a time when access is so problematic?
Given the complexity of patients, should we try to offer many types of psychotherapy to patients?
Given the weight of evidence, should certain psychotherapies not be offered to patients (like psychoanalysis)?
Should psychiatrists oppose any government proposal that may limit our ability to practice, drawing inspiration from unions and guilds? And, thus, should we say no to this proposal?
Should psychiatrists try to shape public debate with proposals and counter-proposals, and work with governments? Should we thus argue for an alternative, like a cap but with exemptions for certain conditions or when supported by a second opinion?
- Dr. Doidge criticizes the work of Drs. Kurdyak, Goldbloom, and Mulsant. To explain their point of view, they wrote a short statement.
Despite increased awareness and declining stigma, people of all ages with mental illness or substance use disorders are still unable to access effective and integrated care.
They make several points based on the literature:
- “In Ontario, between 2006 and 2011, the rate of Emergency Department (ED) visits for mental health increased by 33%, and half the children and youth who visited the ED for the first time had not received mental health outpatient care. The ED should not have to be the first stop for children and youth with mental health problems.”
- “Ontarians who live in rural or remote communities, and those who are marginalized, have an even more difficult time accessing care. Family doctors, who provide the bulk of front-line mental health care, face great difficulty referring patients for psychiatric consultation and treatment.”
- “In a study exploring the impact of financial incentives to improve access to psychiatrists, 60% of individuals had no access to a psychiatrist within 6 months after a suicide attempt, and incentives did not change this rate.”
They argue: “There are just over 2,000 psychiatrists in Ontario. Toronto and Ottawa have more psychiatrists per capita than anywhere else in Ontario. Psychiatrists in all areas outside of Toronto and Ottawa are in short supply and, in several regions, the majority of psychiatrists who are working there are nearing retirement. Effort should be focused on figuring out how to best use the highly specialized expertise of these 2,000 psychiatrists to serve a greater number of Ontarians in need.”
“[W]e need to ensure that high intensity services are available for those with the highest need.”
They propose better collaboration with family physicians, nurses, and other mental health professionals.
You can find the full statement here: https://www.camh.ca/en/camh-news-and-stories/stronger-partnerships-for-better-access.
- Others commented.
The Ontario Psychiatric Association tweeted a statement from its president, Dr. Javeed Sukhera:
Evidence-based psychotherapy is essential for people suffering with mental health and addiction challenges. At a time when we should be expanding access, the suggestion to limit physician-delivered psychotherapy is absurd.
Dr. Joel Paris, the former chair of McGill University’s Department of Psychiatry, writes in the comments section:
This article reflects Dr. Doidge’s talent as a writer, but a lack of understanding of evidence-based medicine. There is no scientific evidence that long-term psychotherapies are effective treatments for any psychiatric problem. In contrast, there is good evidence that brief therapies are useful for a wide variety of psychological problems, and can do all the things claimed for longer courses of therapy. If Doidge enjoys practising psychoanalysis, he should find patients who are willing to pay him for his services. He has no right to put the burden of paying for unproven treatment on the taxpayer.
- Do you have further thoughts? The Reading of the Week invites letters to the editor.
- The psychiatric community is small, and I’ll note knowing both Drs. Doidge and Kurdyak for nearly two decades. And both have had their work featured in the Reading of the Week series.
The Reading on Dr. Doidge’s essay on Oliver Sacks can be found here:
The Reading of Dr. Kurdyak’s recent paper on practice patterns can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.