Without access to long-term, intensive psychotherapy, psychiatrists cannot do the job they are specially trained for, and patients, our citizens, suffer immensely.
Imagine suffering from a heart disease and being told that treatments for severe heart problems are not covered by OHIP. The Ontario government proposes to reduce funding for the most effective and powerful treatment available to address dysfunctions of one of our most important organ systems – the mind. If uninformed administrators have their way and your mind is in pain – depressed, sad, anxious, angry or stressed – you will be out of luck as OHIP may not cover one of the main available treatments many need – intensive long-term psychodynamic psychotherapy.
What follows is a more comprehensive analysis of the problem. Please also refer to a shorter summary blog about this same topic entitled ‘The Ontario Government Threatens A Core Psychiatric Treatment‘.
The mind as an organ system
In this context, I use ‘mind’ instead of ‘psyche’, in the understanding that mind entails our awareness, our subjective experience of being alive and our vital capacity to regulate our emotions and mental states. Consider the mind as an organ system in its own right, following its own scientific laws of functioning, and requiring its own specific treatment approaches. This might appear strange to any layperson, including politicians and lawmakers, given that you cannot physically touch or see the mind. Like early-stage cancer patients, who deny the seriousness of their illness, people can sometimes pretend for a while that the mind doesn’t exist. They think it is unimportant, or that they can fix it themselves when it hurts and they experience unhappiness, depression, sadness, anger, anxiety or stress. They sometimes feel embarrassed to admit to an emotional problem they believe only ‘crazy’ people have – all it takes is biting your lips and soldiering on with life. Eventually they crash and realize that they cannot fix their minds on their own.
The mind is a very tricky and difficult organ system to understand and treat. Just as surgeons spend four to six years training in how to successfully cut into people’s bodies, psychiatrists who specialize in the mind spend an equal amount of time training in how to help people explore and use their minds to rewire their brains. These unique and elusive characteristics of the mind invite deeper reflections.
Mind and brain are not the same, and the mind is not just a function of the brain. It’s an erroneous, albeit rampant belief, that all you need is to feed the brain with medication and you will feel better – your mind will follow suit. For some it can work that way, but for many it doesn’t, particularly when childhood attachment and trauma issues or more complex emotional challenges play a role. Many patients may have their brain treated with psychiatric medications to mitigate certain symptoms, and yet not become more functional, self-assured, or content in their daily lives. The mind is an organ system with its own separate identity, scientific and psychological laws that govern it, and separate treatment approaches. It is impossible to treat the mind by treating the brain alone. My psychotherapy practice is full of patients, who originally came to me after months, sometimes years, of medication and short-term psychotherapy treatments that did not lead to social and professional rehabilitation. Only after intensive, long-term medical psychotherapy are they able to fully reintegrate into society and their professional life, often in fact, without medication.
The difference between mind and brain
While three medical specialties treat the brain (neurology, neurosurgery and psychiatry), only psychiatry also treats the mind. Neurology and neurosurgery treat the brain to address structural issues, pain, epilepsy, brain diseases and both motor and sensory functions. These specialties treat the brain for brain diseases. Psychiatry on the other hand, treats both the brain and the mind for mind diseases. Because of neuroplasticity of the brain, we can use the mind to rewire the brain, which is psychiatry’s specialty. In short, psychiatry can treat the brain to treat the mind, and treat the mind to treat both the mind and the brain. The way psychiatry treats the brain directly is through medications, electro-convulsive therapy (ECT), transcranial magnetic stimulation (TMS) and light therapy. To treat the mind, various types of psychotherapy and mindfulness techniques are required.
Understanding the difference between mind and brain, and how they interrelate, is not easy. This difficulty may well be at the root of many disagreements among clinicians and policymakers. Here is an imperfect analogy to clarify this issue. Our cities have roads (neurons in the brain) and cars (chemicals in the brain), and the flow of a multitude of cars is called traffic (the mind). To deal with traffic jams (mind problems such as anxiety or depression), we need to ensure good cars that don’t break down are on the road (achieved through medication). This is a car mechanical/technical (medication/brain) problem. However, good cars are not enough to safeguard the free flow of traffic. We also need wide enough and well-paved roads, as well as a sophisticated signage system to regulate traffic flow. This is a traffic management (psychotherapy, mind) problem. Brain and mind interact and influence each other in ways we currently don’t fully understand, but they are at the same time, also very different organ systems with their own unique characteristics.
The denial of our mind’s relative independence from the brain, and therefore of psychotherapy’s importance in treatment, may be rooted in a lack of information about neuroplasticity. Dr. Norman Doidge has written extensively about the science of neuroplasticity in his two books entitled The Brain’s Way Of Healing and The Brain That Changes Itself. It was groundbreaking to discover that by learning how to use our minds in various new ways, such as specialized attentional training, cognitive restructuring, the development of attuned relationships and the examination of our life stories, we actually change the structure, wiring and chemical functioning of the brain. This is why these psychological interventions lead to the resolution of many mental, emotional and relationship problems.
In short, we cannot solve traffic jams with good car mechanics alone. We cannot just change the chemicals in the brain through medication and unfailingly expect to feel mentally healthy, although in some cases that can seem possible for a while. Medications do not significantly rewire the brain. Clinical experience shows over and over again, that we also need to learn to listen to the mind and mobilize its unique tools that change the wiring and the chemicals in the brain. This is what psychotherapy is all about.
The shocking consequences of ignoring the mind
Respecting the importance of the human mind is fraught with at least two challenges. Firstly, the mind is elusive, it cannot be touched or seen, and can, therefore, be easily dismissed – at least for a while. Secondly, there is still a social stigma in admitting that something is mentally wrong. ‘Mental’ by the way, includes emotional and relationship issues. What we are up against as a society is the difficulty to see the fundamental importance of the mind. In Timeless Healing (Simon & Schuster), Harvard University professor of medicine Herbert Benson quotes copious research that shows the shocking perils of ignoring the mind. Consider the following US statistics from around the 1990s Benson lists in his book, which would not be expected to have changed much over the years. When Benson refers to ‘mind/body’ approaches, he means approaches that use the mind to rewire the brain and also affect the body in other ways:
- 60-90% of doctor office visits are from patients manifesting physical symptoms of emotional distress and related to mind/body and stress-induced conditions.
- Half of these office visits – or 37.5% of the total of all office visits – could be eliminated with a greater emphasis on mind/body health.
- 74% of medical complaints presented at medical clinics have no identifiable organic cause.
- 2/3 of patients presenting medical complaints receive diagnostic evaluations that reveal an organic identifiable cause only 16% of the time. Only 55% of these patients receive treatment at the end, and treatment is often ineffective.
- Mind/body approaches could, by a conservative estimate, save the US health care system 50 billion US dollars per year in wasted health care expenditures. This figure does not include the savings incurred by the decreased use of drugs (prescription and over-the-counter), laboratory tests and procedures that would follow the application of a rigorous mind/body discipline. It also does not include 13.7 billion US dollars of savings per year in unconventional (alternative, holistic) medical expenses.
The human mind is the most easily overlooked organ in our organism, and yet so fundamentally impactful as far as health is concerned.
A short history of mind and science
History may explain some of our societal reticence to honor the importance of the mind and its treatments. Because of its elusive, intangible and subtle nature, the mind has historically eluded scientific scrutiny. Only relatively recently has it become a major focus of empirical study. Psychotherapy and psychoanalysis have been around for much longer, but they were always seen as unscientific or marginally-scientific approaches that made uncomfortable bedfellows in psychiatry. Acceptance in the family of scientific medicine has always been a struggle for psychiatrists, who unlike any other medical specialists have to deal with two so fundamentally different organ systems, the brain and the mind. They therefore often try to find misguided legitimacy with their medical colleagues and funding agencies by treating the brain with medications, hoping to deliver more efficient and expedient results. The problem is that this only works in some cases, and often partially, at best. The moment the mind plays a major role in how we get sick, brain interventions by way of medications, and even short-term mind interventions can be limited in their efficacy, and therapy requires a paradigm shift into the science of the mind, not just the science of the brain.
Science has progressed significantly, and what was previously seen as unscientific and belonging to philosophy or even religion, has now become mainstream. Psychiatry is the medical discipline that straddles these two organ systems, the brain and the mind. The scientific tendency to veer off into the tangible world of molecules, cells and physical organs, has been a stubborn problem that only recently, has begun to command more rigorous scientific questioning. The human imagination links physical medicines with measurable, quick results. Take an antibiotic, and much of the time you are rid of your illness within 10 days. Not so with our elusive psyche. Take a medicine for emotional and psychiatric symptoms, and despite common expectations, the results can be comparatively poor or incomplete. As I already stressed, mental health is not just dependent on brain function, but also on mind function, and the mind will not simply acquiesce to the principles by which the brain works.
The mind is undoubtedly a tough system for scientific study and treatment with its own rules and regulations not found in the brain, but science has progressed to the point where these old historical struggles to understand the mind and its relationship to the brain can be put to rest. It is now time to learn from this new understanding and give all treatments for the mind their overdue support.
The unique time frame of in-depth mind treatment
We now have to deal with yet another obstacle getting in the way of intensive psychotherapy acceptance. The mind is not amenable to quick and fast changes like the chemicals in the brain are, because the mind’s health hinges on neuroplasticity, which takes time to stimulate. The laws that govern treatment of the mind are subject to the inescapable reality of neuroplasticity. This forces us to accept the fact that in many cases, psychotherapy takes intensity, regularity and time. Short-sighted, results-oriented and productivity-obsessed administrators such as insurance companies and governments don’t relish having to deal with this fact.
Most of my psychiatric colleagues, who unlike me, specialize in medication-based brain treatment for psychiatric conditions, regularly refer patients to me for intensive long-term psychodynamic psychotherapy, recognizing that so many patients also require specialized mind treatment in addition to medication. Vice versa, when I deem it necessary for a patient to have access to medications, I will send them to one of my colleagues who specializes in this area. Given this general respect for each other’s specialization in the two different psychiatric disciplines of brain and mind treatment, it is astonishing that some biologically-oriented colleagues mentioned in Dr. Doidge’s recent Globe and Mail article entitled ‘In Ontario, A Battle For The Soul Of Psychiatry’ (April 6, 2019), seem to advocate an approach towards the mind that minimizes its legitimacy by claiming that intensive long-term psychotherapy is a luxury psychiatrists should not get involved in. Such misguided and confused ways of thinking about a complex scientific challenge is disingenuous and counterproductive in our difficult task of educating laypeople, such as policymakers and politicians, in the understanding of the relationship between brain and mind, and the immense impact such clear understanding has on good governance.
Treatments of the mind require intensity, regularity and time. To be more precise, there are short-term mind treatments such as cognitive-behavioral therapy (CBT) or other short-term psychotherapies requiring anywhere between five and twenty sessions – in other words, not that much time. These are scientifically proven to be effective indeed, mostly focused on treating symptoms and designed for relatively circumscribed psychological problems that manifest as a single, mild to moderate mental disorder, such as anxiety or a depressive episode. In complex psychiatric situations, they can also be useful as adjuncts to the intensive psychotherapy needed.
The focus of this article is not on these short-term approaches, which as Dr. Doidge points out in his Globe article, are often used by detractors to make claims about treatment results that are blatantly false. What I am focusing on is intensive, long-term psychodynamic psychotherapy, which requires significantly more time, and is designed to treat beyond symptoms, the root causes that keep producing recurring psychiatric symptoms and endless relapses with chronic emotional dysfunction. This treatment modality addresses a person’s background history and experience that wired the brain to be susceptible to breakdowns in the face of life’s challenges. Decades of struggling with life experiences that caused our brain to become vulnerable to stress, cannot possibly be undone in a few weeks or even months. On the other hand, through intensive psychotherapy it takes far less than decades, usually a few short years, to repair the damage in a more solid and lasting way. There is no shortcut possible in these cases, quite like you have to wait several years when you plant a new hedge before it gives you the privacy you want from your neighbours. Just as trees can’t grow any faster than they do, minds cannot rewire brains any faster than nature allows, and this kind of intensive psychotherapy takes time.
An example of a patient’s journey to mental health
The idea of ‘long-term’ raises the hackles of money managers, because they associate it with waste and expense. However, this is flawed reasoning that does not correspond to reality. To make the point, here is an example of a patient I treated, an intensive care nurse I will name Sophie.
Self-esteem issues caused by dysfunctional parenting in childhood caused Sophie to become very stress-prone as an adult. Relationships became very difficult for her, because she kept pleasing, chronically intimidated by forceful colleagues and unable to stand up for her rights. Life at home with her three children and husband became very difficult, because she was in constant mental anguish and conflict with her spouse. In a relentless state of anxiety and depression, she ended up having to go on stress leave and disability. By the time she came to see me after one and a half years off work, she already had two courses of CBT with two different therapists, one of dialectical behavior therapy (DBT), one 8-week anxiety group and one 6-week daily coping group, as well as several trials of different medications under her belt. An attempted return to work under her insurance company’s pressure failed miserably. Her treatments only had marginal success, because none addressed the root causes of her illness, leaving her still debilitated enough as to not return to work and unable to live a meaningful and happy family life. Her children showed increased symptoms of distress and anxiety, and as a family they were going into debt, because her disability income did not compensate for the full nurse salary they needed to supplement her husband’s salary. The marriage became precariously estranged, with her husband at his wits’ end. She and I began an intensive, long-term psychodynamic psychotherapy, which she could never afford, were it not covered by OHIP.
After about six months of weekly treatment she began to feel significantly better, ready to begin a gradual return to work only after approximately nine months of psychotherapy. Both employer and insurance company were pressuring for a quick and full return, which we repeatedly had to stave off. It then took an additional eight months to gradually transition to full-time work at around the 17-month mark of intensive psychotherapy. Standing up to employer and insurance administrators was part of Sophie’s learning experience, and by the time she was back full-time, she was also off her medications.
This didn’t mean that her treatment was finished though. She now had to work through deep issues that only surfaced once she was back full-time, free of medications, in the midst of life’s ‘full catastrophe’. She also had to consolidate her gains through ongoing examination of how she was using her mind. The whole treatment lasted about four years, at which point she felt securely grounded in a strong sense of herself, capable of taking on anything that came her way. By the time her psychotherapy ended, her marriage was back on track, her family life had settled, her work was again a source of satisfaction, and she was confidently happy with her life. She had reached a state of health she could have likely achieved one and half years earlier, had she received the intense treatment she needed right from the start. I saw her at a local grocery store a few years later, looking relaxed and radiant, as she was telling me how well she had been doing since her therapy. She was promoted at work, and continues to live a successful life.
The point I am hereby making is to show that Sophie could only heal and thrive through this highly specialized, intensive and long-term psychotherapeutic treatment approach that specifically focused on her mind. Without OHIP coverage she could not have been able to afford the treatment she needed. If OHIP did not cover this work, it would be like telling orthopedic surgeons that hip replacements are not funded anymore. Most people could not afford the treatment they need. What hip replacement treatment is to an orthopedic surgeon’s patient, mind-exploration know-how through intensive, long-term psychotherapy is to a psychiatrist’s patient.
The cost of Sophie’s psychotherapy pales against the potential cost incurred, had she remained disabled for years, like so many patients I see coming to my office far too late. Consider the costs incurred had she remained dysfunctional without proper long-term treatment of the mind: potential marital breakdown; negative effects on her children that would have caused long-term mental dysfunctions and susceptibility to physical illnesses; long-term, even lifelong insurance costs; the cost of psychiatric drugs; lost productivity at the workplace; loss of her expertise, etc. As Benson’s statistics show, the cost of proper mind treatment pales against the potential cost of ignoring the importance of the human mind. The cost of psychotherapy is inexpensive compared to the cost of having to deal with the health consequences of ignoring the mind. If you look at the Ontario health budget, the cost of psychotherapy is embarrassingly low in comparison to what is needed, and a drop in the bucket compared to health care spending as a whole. Cutting funding to intensive medical psychotherapy and only funding short-term approaches is tantamount to funding gastroenterological treatment only for food poisoning, but cutting funding for treatment of chronic bowel diseases such as ulcerative colitis or Crohn’s disease. It makes no sense, and Dr. Doidge made this same point very clear in his recent article, elaborating even further on the flawed notion of the ‘worried well’.
What’s at stake
As it stands, and has been the case for many years, OHIP covers psychotherapy for the full duration of necessary treatment. This is not only extraordinarily beneficial to our patients, but also a sign of progressive social thinking, awareness of prevention as good governance, knowledge of the mind-body connection, awareness of how the brain works, attunement to the importance of mind in health, forward-looking social thinking and smart money management. It is akin to our investments in education to foster a strong, competitive and productive society. All this is now in jeopardy as misguided approaches to governmental cost-cutting consider limiting one of the most powerful treatments of the mind, intensive long-term psychotherapy. This basically means cutting off a whole section of the population in need of this particular medical treatment and sowing the seeds for untold suffering and all its social consequences.
One of so many cries for help
In closing, it was too meaningful a coincidence not to weave in this request for help. On the very day I finished writing this article, I received the following email from a former patient, which I am reproducing with her permission almost verbatim, with minor changes to preserve confidentiality:
“ … For my brother-in-law, I wanted to ask you about the intensive group psychotherapy you provide for those needing to do extensive work into childhood or trauma. You mentioned you lead a group from a psychiatric standpoint, and I wondered if you could help my brother-in-law. He is having trouble finding a treatment plan, because of his complex situation. CBT, meditation, medication and counselling have not been effective for him. He had trauma in his childhood that was never dealt with, developed a life of maladaptive coping and is now living with PTSD, anxiety, depression and panic attacks that have left him with agoraphobia. As you can imagine, the traditional health care system has been unable to help. I wondered if you might have a suggestion for him. I believe that CBT and meditation may be powerful for him — but not until he deals with the trauma with a psychiatrist. He is on disability because of his mental health, so anything he tries must be covered by OHIP. He has a worker through the Canadian Mental Health Association, but so far her only recommendation has been to enter into an inpatient program, which isn’t financially feasible for him. Please let me know if you can help …”
This is such a sad, yet common story! There are not enough psychiatrists trained to do the work I am talking about in this article, which is undoubtedly intensive and long-term. He is the kind of patient my practice is filled with, and because there are so few trained specialists to provide this essential service, patients fall between the cracks with little to no chance for healing. Unfortunately, I don’t have a spot available at this time, nor do experienced colleagues I know. He will have to wait far too long.
What I say to our policymakers is this: millions of dollars are spent on medical technology to provide state-of-the-art medical treatments for physical illnesses. Without an MRI machine, radiologists, surgeons and internal medicine specialists cannot do their job. Mental illnesses demand no less – to be fully funded for all cutting-edge treatments of the mind, including intensive, long-term psychodynamic psychotherapy in both individual and group form. Without access to long-term, intensive psychotherapy, psychiatrists cannot do the job they are specially trained for, and patients, our citizens, suffer immensely.
Given the dire consequences of disregarding the importance of the human mind, let’s not be penny-wise and pound-foolish!
Copyright © 2019 by Dr. Stéphane Treyvaud. All rights reserved.