The Ontario government’s proposal to limit OHIP funding for psychotherapy has sparked worry and outrage. Two recent articles in The Globe And Mail by Norman Doidge (April 6, 2019) and Ari Zaretsky (April 22, 2019) have addressed the issue from different perspectives.

What follows is a short summary blog about this topic. Please also refer to my other more comprehensive blog entitled ‘In Ontario, a core psychiatric treatment is endangered‘.

Here is a view ‘from the trenches’ of a private psychiatric practice of 35 years, having devoted my professional life to long-term psychodynamic (or psychoanalytic) psychotherapy and mindfulness-based stress reduction (MBSR). Psychodynamic psychotherapy addresses the historical causes that keep fuelling current symptoms. I perform weekly several new assessments, which gives me a lot of insight into how people struggle to get the mental health treatment they need. I see my patients once a week, some in individual psychotherapy for one-hour sessions, some in group psychotherapy for 2-hour sessions. When in crisis, I will see them twice a week as needed. Treatments typically last three to five years.

My observations are designed to address what is in plain sight, yet overlooked. It begins with the problem of drawing incorrect conclusions from flawed studies, believing these to be evidence-based knowledge. Dr. Zaretsky’s mention of a German research study is such a case in point. Chronically depressed patients are randomly assigned to two different treatments, CBT or psychoanalytic psychotherapy. Imagine taking patients with chronic cough and randomly assigning them to antibiotic or anti-inflammatory treatment without consideration of the underlying cause for the cough. Furthermore, and even more problematic, some patients are assigned according to what treatment they prefer, as if they were specialists in the science of mind treatment. None of this makes much sense. First, depression is not a disease entity, but just a symptom, like cough. The causes of depression symptoms are many, each requiring different treatments. To compare two groups, they would have to be controlled for what causes the depression. Second, like anti-inflammatories and antibiotics, CBT and psychoanalytic psychotherapy address fundamentally different mind processes and have therefore different indications. To compare apples to apples, one would have to compare short- and longterm CBT or short- and long-term psychodynamic psychotherapy in patients, for whom one or the other modality is indicated.

The patients I see speak volumes about mental health, most of the time desperately seeking treatment they cannot get because of lack of OHIP funding:

  1. Patients often see psychiatrists as pill pushers, giving patients twenty minutes of their time and a prescription on their way out. While psychiatric psychotherapy training provides an unmatched level of depth and rigor, there is not enough incentive for psychiatrists to pursue the treatment of the mind, and they easily default to just treating the brain. Better information on the nature of the mind and its difference from the brain is badly needed in psychiatric training.
  2. From non-medical psychotherapists or counselors, patients often don’t get the treatment they find useful. Psychotherapy is a difficult skill that takes at least approximately 4 years to learn, and has little to do with having nice and friendly chats or even giving advice. There are well-trained non-medical psychotherapists out there, but good training is hard to come by, and most of it is geared towards short-term interventions.
  3. They have been treated with medications and short-term approaches, including CBT, without or with only partial success, or with initial success that after a while subsided and the same problems arise again later. For many conditions connected to childhood circumstances, or even trauma, short-term therapy and often medication are not the appropriate treatment.

In short, claims that short-term interventions are as effective as long-term ones is simply bogus. The fact is that the mind is hugely complex, and that brain and mind interact in complex ways that require nuance and highly developed treatment skills. Each treatment approach, whether short- or long-term, has its specific indications; CBT, psychodynamic psychotherapy, EMDR, MBSR, trauma therapy, all have their unique mechanisms by which they are effective in certain circumstances. Individual and group psychotherapy are both very effective, and even though group therapy is extremely cost-effective, it gets widely neglected. At times, treatment modalities need to be combined in targeted ways.

The bottom-line: Our patients need OHIP-covered access to all necessary treatment options, and in psychiatry, weekly long-term psychotherapy is a fundamental pillar of treatment, without which many of our patients will remain sick and debilitated for life.

Copyright © 2019 by Dr. Stéphane Treyvaud. All rights reserved.