In Ontario, a battle for the soul of psychiatry

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Norman Doidge, MD, is a psychiatrist, psychoanalyst and author of The Brain That Changes Itself and The Brain’s Way of Healing. He is on the research faculty at Columbia University’s Center for Psychoanalytic Training and Research and on the faculty at the University of Toronto’s department of psychiatry.

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.

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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. Short-term psychotherapies have an important role, but most are designed for a person who has had a setback or crisis, leading to a single, mild to moderate mental disorder, such as an anxiety disorder, or a depressive episode. It involves a limited number of sessions, spread over several months, to return the person to his or her baseline. It is usually focused on treating the symptoms of one mental disorder, in patients who are not “chronic.”

But we are doing longer-term therapy, working on rebuilding a life under dire circumstances, and also dealing with Mr. A’s past childhood traumas, depression and an untreated attention-deficit disorder.

“For me, it was crucial to deal with the pre-accident mental-health issues, even if less severe than being a quad, because I no longer had the psychic and emotional means to manage them any longer,” he told me. “Because of the burden of my disability, the situation was totally unmanageable. I needed to deal with these emotional and personality problems if I was going to survive. I know I presented to others as successful, but there was a deep, underlying anxiety, and insecurity and inadequacy, and a sense of worthlessness that I had before the accident. My sense is that the problems I had before the accident were serious and severe enough that if my accident hadn’t happened, I still would have had to deal with them.”

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.

The plan, which is described by its advocates as “radical,” is designed to eventually get psychiatrists out of providing continuing care to patients altogether. If it goes through, it will be the biggest change in psychiatry in the history of the discipline in Canada, and turn psychiatrists from “treaters” into “consultants” who will diagnose patients in a single session, and make recommendations for others to follow, then wave goodbye.

Diagnose, and adios.

These proposed cuts, their advocates claim, will improve access to psychiatrists, but it is easy to show it will immediately worsen access. They argue we can no longer afford intensive psychotherapy, and promise to save $13.2-million (out of an overall health budget of $61.3-billion). In fact, critics of the new proposal say, these cuts will boost health-care costs immediately, and much more over the medium and long term, and that this is easy to show, and the math is simple.

In any case, these cuts are so deep they will only support several months of short-term psychotherapy. It is a one-size-fits-all plan, and a quick-fix mentality. No serious person, with a modicum of empathy or life experience, could possibly believe that I, or anyone, would be able to help an individual such as Mr. A. “snap out of it” with a handful of sessions and some pills.

A person such as Mr. A who – quite humanely in Ontario – could get the better part of a year of help for the physical part of the injury, would, under the new proposal, get the equivalent of three-quarters of a day’s worth in hours of psychotherapy after which radical disincentives kick in, designed to discourage any more treatment of the mental part of his suffering. So much for parity for mental health.

In doing so, the Ministry of Health shifts into an impersonal bureaucratic mode of thinking. It views Mr. A as a “cost driver,” a “drain on the system,” an expense that is “taking away” something. But the people proposing to limit his treatment have not met him, don’t know him and don’t understand the power of intensive psychotherapy, or of his ability to make use of it. I can already see that Mr. A is someone who, despite his personal catastrophe, is actually going to add to life. To his, and to the lives of those around him. But right now, he’s not at his strongest. He needs our help for a while.

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LET’S NOT TALK

The Health Ministry’s proposal to cut funding for intensive talk therapy became public on Jan. 11, 2019,. It comes despite the fact that Canadians, according to Statistics Canada, say their single most unmet mental health need is psychotherapeutic counselling. Should these cuts go through in Ontario without scrutiny, other jurisdictions across Canada could be tempted to follow suit.

Some history: The first time intensive psychotherapy cuts were proposed was under Bob Rae’s NDP government in 1992. The Health Ministry argued that intensive psychotherapy was for “the worried well,” that it didn’t work and contemptuously put it on a list of “borderline cosmetic” services to be cut that included tattoo and hair removal, and breast reductions and enlargements. They targeted psychodynamic therapies and psychoanalysis, and any other treatment that required a significant number of sessions. (Psychoanalytic psychotherapy – also called psychodynamic psychotherapy – and psychoanalysis, on which it is based, are treatments for chronic disabling problems usually based on childhood trauma, or blockages that occurred in psychological development.)

A public firestorm erupted. Patients came forward and shared their stories in the media. Studies showed that patients in intensive psychoanalytic therapy in Ontario (and elsewhere) had multiple psychiatric diagnoses, and sky-high rates of childhood trauma such as early parent death, traumatic separations and sexual, physical and mental abuse and neglect. In Ontario, 82 per cent had tried less intensive forms of treatment and medication before their physicians recommended intensive psychotherapy. Researchers showed scientific evidence demonstrated intensive psychotherapy (including psychoanalysis) was effective, and that it saved the government money by keeping people out of hospital.

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For a period in the 1990s, before I turned my attention to the neuroscience of brain plasticity, I was considered an expert on what kinds of patients were in intensive psychotherapy, did research studies on their diagnoses and studied what works for these patients. I was chosen by American psychiatrists to present this research at the White House, during the Clinton administration.

As head of the diagnostic assessment clinic at the Clarke Institute of Psychiatry (which became part of the Centre for Addiction and Mental Health, or CAMH), and also the psychotherapy centre there, I saw it wasn’t just waiting lists that delayed people getting treatment. The stigmatizing castigation that people who get intensive psychotherapy are self-involved slackers, and “the worried well,” played a role. People with mental illness often feel profound shame and if authorities endorse the idea they don’t have “real problems,” they avoid treatment.

The OMA and the Ontario Psychiatric Association (OPA) opposed the cuts. In the legislature, the Progressive Conservatives supported keeping therapy. Ultimately, the Rae government reversed itself, and these treatments continued to be available in Ontario.

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Now, once again, advocates are calling intensive psychotherapy “cosmetic.” And again, they claim the treatments don’t work.

The means of the cuts are different this time. The Ministry of Health is proposing to introduce powerful incentives on physicians that transparently pit the physician’s financial interest against the patient’s need for treatment, by actively rewarding physicians for not seeing sicker patients. Thus, they will pay a doctor twice as much for seeing less-ill patients, who don’t need intensive therapy, than they will pay them to treat the sicker ones who do.

You read that correctly. It is an incentive that cruelly disfigures, debases and guts the doctor-patient relationship.

Patients currently in treatment, or those who fear they will be unable to access what they have been waiting for, should know that the psychiatrists who have actually been elected to represent the profession – for instance those in the psychiatric section of the OMA, and in the OPA – and the family physicians who provide psychotherapy are against these proposed cuts, which will exact a human toll on patients and their families.

The claim that the cuts will “improve access” to psychiatrists makes no sense. When people are depressed, and say to their family doctor, “I think I need to see a psychiatrist,” it is for a specific reason: to get treatment. That is what patients mean by access, not just a single visit and a label. Ending a core treatment doesn’t improve access. That’s sophistry.

Furthermore, though instituted in the name of lowering mental-health-care costs, these changes will immediately raise them. OHIP already pays a physician less for doing psychotherapy than doing consultations. If psychiatrists stop doing psychotherapy, and do more consultations – as the changes intend – OHIP billings go up, immediately.

Publicly funded psychotherapy programs that include intensive psychotherapy have significant savings, or “cost offsets.” 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.

Such savings have been replicated in Ontario. 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.

In 2004, another German study found patients getting psychoanalysis showed, “evidence of a lasting and remarkable stable reduction in work absenteeism and a low level of inpatient treatments.” In short: These therapies save money in hospital costs, and also bring in new funds for government, because people who work are not on welfare, and pay taxes.

The Ministry of Health has its facts wrong. They claim there is no evidence that more than “short-term” works. This is shockingly inaccurate.

There are now so many randomized control trials of these more intensive treatments that we have “meta-analyses” summing up what they show cumulatively. Three recent summations, in the last several years, show that long term psychotherapy is an “evidence-based” treatment.

Studies show that for complex patients, such as Mr. A., who have traumas that affect their personality development, long-term intensive psychoanalytic psychotherapies have significantly better outcomes than short-term treatments. And for young children, who can’t take drugs, intensive psychotherapy is our primary intervention.

This is why these intensive therapies became part of the evidence-based Standards and Guidelines of the Psychotherapies put together by the OMA and the OPA.

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? This can only be appreciated over time, with the physician getting continuing feedback. Because of the shame attached to mental illness, a key component of treatment is the physician having time to earn the patient’s trust, and demonstrate a continued personal caring for the patient. There is a healing power in that kind of doctor-patient relationship.

These changes threaten the very soul of psychiatry. I know, I know: To speak of “mind” or “soul” with regards psychiatry may seem unscientific, and be caricatured as a mystical departure from the practice of medicine. But there is nothing un-medical, or un-psychiatric, about it.

The word “psychiatry” comes from the Greek: “psyche” which means “soul, mind or spirit,” and “iatreia,” which means healing, or care. Psychiatry was set up as the discipline, within medicine, to heal and care for the tormented psyche of the mentally ill person, and not only to “diagnose disorders” in less than an hour in which a person, being asked a torrent of questions, often barely gets a chance to reveal themselves. Creating psychiatrists who are no longer allowed to care for patients is like creating a generation of surgeons who are trained not to operate.

There is a final problem, which relates to the future of psychiatry. Ending OHIP funding for intensive psychotherapy will also end existing funding to teach it. But this training is where psychiatrists learn how to empathize and relate better with others, how listen to and talk “with” and not “to” patients.

“I honestly can’t think of a better and more efficient way to kill our discipline, never mind the terrible impact on our patients," said Misha Hartfeil, who is not primarily a psychotherapist but rather a newly graduated forensic psychiatrist at CAMH.

Taking psychotherapy out of psychiatric education is taking the “psyche” out of psychiatry. Prohibiting psychiatrists from treating patients is taking the “iatrist” out of psychiatrist. Psychiatry will exist in name only, and cease to attract the people we need in the field: people who actually see their calling as caring for others.

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THE STUDY BEHIND THE PROPOSALS

One way the Health Ministry has tried to justify these cuts is to quote a study by Paul Kurdyak (who consults for the MOH) that shows some psychiatrists treat fewer patients than others. Along with his co-authors, David Goldbloom and Benoit Mulsant – all three work for CAMH – Dr. Kurdyak argues that these psychiatrists must be the ones who do more intensive psychotherapy, and this is why wait lists to see psychiatrists are long. In what must have been music to the ministry’s ears, they insist we have more than enough psychiatrists. The problem is that psychiatrists are permitted to do intensive psychotherapy. So, best to just cut it.

Their own statistics show that the average number of visits by a psychiatric patient to a Toronto or Ottawa psychiatrist was seven a year, compared with four in the under-serviced areas. They presume, although never explain why, that average of seven is too many sessions. What if the problem is four sessions is too few? After all, under-serviced means “under” serviced. By what clinical standard are they decreeing that a sick person seeing a psychiatrist four times a year is most certainly way too little, but seven is most certainly way too much? That is a quality of care issue. But the term “quality of care” never appears in their study.

Interestingly, the authors claim physicians who use talk therapy “elect to provide care to a number of patients whose care is relatively easy to manage and who reliably show up for their appointments, since this is easier than providing consultations or acute care to seriously ill, unstable patients with schizophrenia, bipolar disorder, or severe depression.” In an op-ed that appeared in The Globe and Mail in 2014, Dr. Kurdyak and Dr. Goldbloom claimed these psychiatrists “tailor their practices in a way that suits their preferences, but does not necessarily align with greatest public need.”

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The study’s methods were criticized. First, their estimate of how many patients psychiatrists saw was based on OHIP billings. As Douglas Weir, past president of the OMA pointed out, OHIP is just one of 19 ways in which psychiatrists are remunerated in Ontario. A significant number earn their income through a combination of OHIP fee-for-service for individual patients, but also by helping to care for a variety of patients outside of OHIP, through one of the 18 other schemes – such as by supporting family doctors. These non-OHIP patients weren’t captured in the study.

Next, their definition of “seriously ill” and “high need” patients (which they suggest is the qualifier for receiving treatment) summarily and arbitrarily excludes from treatment people with illnesses that are obviously severe, and hard to manage. Their definition excludes those with eating disorders, autism, borderline personality, alcoholism, brain injuries, opioid addiction, learning disorders, complex developmental trauma and post-traumatic stress disorder. And then there are the relatives of the seriously mentally ill: their children, parents, siblings often suffer greatly, too.

How did these authors know that “low-volume psychiatrists” treat patients who have such “low needs"? They just assumed it. In fact, they didn’t interview or assess a single patient of these psychiatrists. Rather they had, by their own admission, only “a crude proxy for service need” – the regional rates of hospital admissions for schizophrenia, bipolar disorder or major depression. They simply presumed that patients seen by physicians in “low-volume practices” were low need if the patients hadn’t had a psychiatric admission for one of only three illnesses in the past two years. They also concluded, mistakenly, that any physician who saw a patient frequently was providing psychotherapy, but provided no evidence for that assumption. A significant number of those billings were for a more general service – “psychiatric care” – which may not involve psychotherapy. Psychiatrists use that service to see bipolar or schizophrenic patients regularly, to keep them out of hospital.

It’s after speculating that intensive psychotherapy is the reason people can’t get enough access to psychiatrists that Dr. Kurdyak and company describe their remedy.

“In the United Kingdom, Australia, and the United States, the role of a psychiatrist has been modified,” they write approvingly, and “most psychiatrists in managed care … have a consultant-based clinical role.” Consultants in medicine, by definition, don’t take over continuing care. They give expert advice after a meeting with a patient.

The authors propose that in Canada, we need a system in which “psychiatrists provide diagnostic assessments and treatment recommendations.” That statement is notable for what it leaves out: treatment, including psychotherapy and any continuing psychiatric care by the psychiatrist. In The Globe and Mail, Dr. Kurdyak and Dr. Goldbloom admit that in the U.S. system, this role shift makes psychiatrists “limited to rapid, high-volume psychiatric drug consultations.” Diagnose, overdose, adios.

Leave aside that authors are incorrect about Australia: that country publicly funds continuing care, and long-term intensive psychotherapy, up to and including psychoanalysis.

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There was something very odd about the authors’ recommendation that Canada move to a U.S.-style managed-care-inspired model to improve access. At the beginning of their study, they wrote that in the United States, 66 per cent of primary-care physicians have trouble finding a psychiatrist for people with mental-health problems, whereas in Canada, 35 per cent of family doctors have that problem. So why is their solution to increasing access that Canada should move to a U.S.-style system?

Moving to a U.S. managed-care model will double our problem of accessing psychiatrists. Access worsens when the medical specialists who are trained to treat mental illness cease to provide continuing care. And access will be worse than that in Ontario if the proposal goes through, because it will also disincentive psychotherapy by family physicians and psychiatrists both.

So, what will happen to the patients?

The authors say they can be referred to psychologists and social workers. It is true that many in these professions do excellent psychotherapy, as do other “non-medical” psychotherapists. But these professions are not covered by OHIP, only rarely insured for full treatments, and their members don’t practice medical psychotherapy. As well, psychologists bill substantially more than physicians who are paid by OHIP for psychotherapy. Obviously, the government will not fund a service it has just eliminated. And psychologists would be unlikely take a steep pay cut to do it.

A new pilot program, of non-medical therapists, is being funded in Ontario. It is welcome, but it is only for a few kinds of short-term psychotherapies. It won’t begin to make up for all the psychiatrists and family doctors who would no longer practise psychotherapy under the Health Ministry proposals. And the fact that this would put an end to publicly funded intensive psychotherapy doesn’t bother Dr. Kurdyak and his co-authors, who elsewhere compared it to “non-essential cosmetic surgery,” resurrecting the stigmatizing idea that the patients who get it are “the worried well,” and vain to boot.

In other words, those patients – people such as Mr. A. – will be on their own.

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THE COVENANT

People will die if these changes go through. Patients with eating disorders (the highest mortality among all mental health disorders), those with suicidal tendencies, past trauma, mood disorders, addictions and psychosis, among others, all need ongoing care. Dr. Ronald Ruskin, who currently directs a partial hospitalization program at Mount Sinai Hospital for such people as they transfer from inpatient psychiatric admissions to outpatient work, has grave concerns. “We save countless lives by carefully monitoring patients and enhancing their coping ability, and this arbitrary limit robs us of the psychotherapeutic tools we need to do our work. Patients will deteriorate because of this new MOH policy. I fear many will succumb to illness and die.”

The covenant the government made with the people of Canada, and its physicians, when it moved into nationalized health care, was not that the government would “play doctor,” but that it would become an insurance agency that would cover medical care for the entire population. This meant that some people, because they are sicker, would use more resources than those who were blessed with better health. Provincial plans work by spreading risk through the entire population, because a large population is required to pay for them from their taxes. As such, we assure all that should they get sick, they will get coverage – and we won’t deny treatment if you break your arm just because that’s not as serious as cancer. We don’t play patients off against each other.

We also didn’t choose to only treat those who are sickest today. That is because, without preventative care, people who may not be the sickest today could become sicker tomorrow. It’s imprudent to wait until a person is a full-blown diabetic to treat him or her; intervening early – with dietary changes, for instance – is far more humane and leads to huge savings.

Just as physical illnesses can evolve and get worse, so can mental diseases.

Mr. A, my patient with the spinal-cord injury, obviously needed care postinjury. But he also said the childhood trauma he had from before the injury would have ruined his life, if untreated. A wise and humane system would not have withheld treatment from him even if he had a functioning spinal cord.

It is laudable that the Ministry of Health wants treatment for those with schizophrenia, bipolar disorder and depression, who are unquestionably ill, and to help those people get the resources needed. So do most physicians. And we also need to be able to treat other people who are also unquestionably ill, who require a different mode of intervention, even if it involves not only medication, but psychotherapy. It is not remotely overused. This year’s OHIP numbers show that, at most, 1 per cent of psychiatrists’ patients currently get intensive long-term psychotherapy, as the ministry defines it. It is being prescribed very selectively, for those in need.

It makes no sense to assume that because one has a condition that responds to intensive psychotherapeutic treatment that it somehow isn’t medical, or medically appropriate. It makes sense to use mental techniques as part of treating mental illness, and patients want it. It is intellectually reckless to ignore the science that shows these treatments work. And it is cavalier to say such suffering patients’ needs “don’t align with” – some arbitrary conception of – “public need.” Stigmatizing one group of patients to get resources for another group is counterproductive and wrong.

Above all, the idea that there is only one kind of therapy that works – short-term – is misinformed. My advice for Christine Elliott, Ontario’s Minister of Health: You did not develop this travesty of a proposal. You inherited it when you took office. Imagine what it would be like to meet such patients as mine, and look them in the eye, and explain why your ministry is taking away their treatment.

William Osler, the great Canadian physician, said, “The good physician treats the disease; the great physician treats the patient who has the disease.” That distinction makes all the difference in mental illness, because when we are mentally ill, our whole person is affected. And because each patient, each whole, such as Mr. A, is unique, the kind of treatment and its length can’t be determined by a decree from someone on high who has never encountered his complexity. The ideas that everyone gets the same treatment carelessly disregards the breakthrough insight that we need personalized medicine, the kind that is proving to be so helpful now in cancer treatment.

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.

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.

As for Mr. A., he tells me, his psychotherapy is working. “In a way, I’ve had the loss of everything, but because of the psychotherapy, I have a solidity and groundedness I never imagined possible for me.”

That is why he drives himself to my office, through snow and sleet in his motorized wheelchair. No roof overhead.