Read letters from community groups opposing cuts to psychotherapy funding
Cutting Psychotherapy Access for Young People
A Leap in the Wrong Direction
Briar Long, MD, FRCP(C), Psychiatrist, Guelph, Ontario, January 20, 2020
Provision of psychiatric care in Ontario is on the cusp of taking a major turn for the worse.
The Ontario government is looking at ways to take out “unnecessary medical spending”. On the face of it, this is reasonable enough. They are particularly concerned about psychiatrists doing “unnecessary” psychotherapy with “the worried well”. But to achieve these cost savings, they are considering imposing an arbitrary limit on the number of times a psychiatrist can see a patient within a year, placing a 50% discount on the fee earned by the psychiatrist for providing not just psychotherapy, but ongoing psychiatric care and/or psychotherapy, after 24 visits in a one-year period. By cutting the pay of the psychiatrist for doing ongoing care, the idea is that this will cut out “unnecessary psychotherapy”. It will also incentivize shifting to a consultation-only form of psychiatric care—a form of care in which the psychiatrist sees a patient once, makes a diagnosis, and recommends what medication and other treatment is needed. It is then up to the family physician (if the patient has one) and perhaps a counsellor (if the patient is lucky and has some kind of access to this) to implement the plan. The consultation-only or limited psychotherapy model would be used regardless of the severity, complexity, or actual needs of the patient—a one-size-fits-all approach.
I work in a Student Health Service at a major Canadian post-secondary institution. We serve a population of 29,000 students, about the size of a small city. In our province (and indeed in our country), one of the greatest areas of identified need for psychiatric care is in young people, and we feel this need at our institution no differently than anywhere else. In our clinic, we have a total of 4 part-time psychiatrists providing care, delivering the hours of 1.6 full-time psychiatrists; a conservative estimate of what we need to meet the needs of a population our size would be 4 full-time psychiatrists. We currently provide psychiatric care in a variety of ways, including consultation-only (with implementation of recommendations by our family physicians and our colleagues in Counselling Services and Student Accessibility Services), consultation and ongoing care (ie, ongoing, specialist-level psychiatric care, the subject of the proposed fee change), formal case conferences (formal times when family physicians can meet with a psychiatrist to ask questions to help them in the care of the students they are attempting to treat, reimbursed by OHIP), and informal case discussions (the same thing, done informally; not reimbursed by OHIP, but we do it anyway, because it is so important). In this way, psychiatrists provide a range of services, maximize their reach, and attempt to provide care that is student-centred, rather than one-size-fits-all. And we often feel that we are not actually keeping up, because the need is so great.
I see the sickest of the sick in our clinic. These are students that typically have been seen by our very capable family physicians for some time, but still aren’t getting better. They are typically students that are clearly ill but hard to diagnose—they may not fit conventional patterns of illness, or they have so many symptoms and so much dysfunction that they are overwhelming; invariably, they have multiple psychiatric disorders at the same time. They are often chronically suicidal—they are thinking of suicide as the solution to their pain every day, and are only one step away from attempting. They are often self-harming as a means to control their distress when their symptoms are breaking through. They have often had symptoms since they were an adolescent and have been tried on multiple medications, none of which have worked. Many are on multiple medications when they are referred to me, yet they are still highly symptomatic and impaired. They feel miserable. And they are trying to get a university degree so they can be employable, but they can’t think, can’t stay motivated, and can’t keep up. They have a mounting OSAP debt but can’t complete any courses, which only increases their sense of desperation. These young people are seriously ill. They are suffering terribly. And they need help. My family physician colleagues have already done their best to turn the situation around. And they refer these students to me because they legitimately say they do not have the training to treat things that are this complicated. They feel “overwhelmed” and “outside of my scope”. Our very capable counsellors say the same things. Or “thank God you’re involved”.
Mental health concerns, and indeed psychiatric illness, always come up in a context, and this is one reason why psychotherapy and ongoing psychiatric care in a trusting relationship is so necessary. Digging down, in the seriously ill students that I see, what one finds is significant events that have contributed to the vulnerability to becoming ill. Substance disorder and suicide in a parent. A terribly acrimonious parental separation. Serious illness, psychiatric disorder, or overwhelming stressors in a parent, which negatively impacted the parent’s behaviour. Witnessing or experiencing very traumatic things, in all the ways that human beings can be traumatized. A highly sensitive temperament, such that emotions have been so intense that the only way to cope has been to self-harm, fly off the handle, binge-eat or restrict, or use a substance. And so, here they are. Really sick and badly injured, with symptoms on multiple fronts and often a number of entrenched behaviours that aren’t really working. What is needed is on-going care by someone who knows what to do in this situation. Specifically, a psychiatrist, working independently or as part of a multi-disciplinary team, and providing treatment over an extended period of time.
As a psychiatrist, I am uniquely poised to help the sickest of the sick. As much as a psychiatric consultant can recommend medications and a form of psychotherapy (and such consults are indeed quite helpful for many, but not all), when seeing the sickest of the sick, what is needed is the unique skills the psychiatrist brings. Even when I think I have figured out the diagnoses and the treatment direction (which in many cases takes more than one visit), the person in front of me is often terribly discouraged or understandably scared to try yet another medication or another trial of a psychotherapy when this didn’t help last time or had painful side effects. They often think they are beyond help, and they have their reasons. What they need is listening, listening, listening. The slow making of the case for treatment. The psychiatrist, seeing the patient on more than one occasion and over an extended period of time, coming to understand the unique perspective of the patient and all the obstacles in the way of the needed treatment. Using psychotherapy skillfully and wisely, to promote taking medications that could actually help and to resolve old hurts and old scares and therefore modify strong beliefs that are keeping them sick. Tweaking the classic recommendations or manual-based psychotherapies in a way that is acceptable to the patient but still evidence-supported and likely to work. Drawing from all the psychotherapies—not just Cognitive Behavioural Therapy, the classic, time-limited psychotherapy, but other psychotherapies that are also supported by evidence, including Dialectical Behaviour Therapy and others, which take longer, because they are designed to help people with deeper injury. And by creating a relationship of trust and partnership in which a person can get better. The psychiatrist has the unique combination of the skills and specialized training required to do this. It does take time, and often more than 24 visits in 12 months; sometimes weekly visits, not forever, but maybe for a while. It takes time to get something very complex to move in a different direction. Hard work, on the part of both patient and psychiatrist. And it is not “unnecessary”.
What can I say about what happens when young people with serious psychiatric illness get an extended period of psychiatric care? For the psychiatrist, sometimes wanting to pull your hair out. And a lot of fretting. But these patients get better. Maybe not completely better (because many have illnesses that will be with them life-long), but much better. They go from being in the emergency room multiple times a month to not going there anymore. From self-harming to knowing other things that will work to reduce distress. From not being able to complete courses to being able to graduate. From feeling miserable to having some sense of well-being. From being overwhelmed by illness symptoms to knowing what to do when symptoms are aggravated. From needing a weekly visit to needing a check-in every few months. And seriously ill people who get much better, because they got ongoing psychiatric care, without arbitrary limits set by bureaucrats, are going to make better employees, better parents, better friends, and better citizens.
I feel afraid of this proposal by government. What will this proposal, if it is implemented, really produce? Less psychiatric care for the seriously ill, and therefore less recovery. More people who are legitimately ill but not treated because they need a special kind of care environment to implement the treatment direction. In the absence of treatment, more visits to the emergency room as they reel from crisis to crisis. More revolving door admissions to hospital. More applications for Ontario Disability Support Program, because symptoms remain, and they can’t work. More OSAP debt that has to be forgiven, because they can’t work and can’t pay it back.
We need to speak up about the importance of achieving access to good-quality psychiatric care that can be sustained long enough for people to get better. We need to continue to look after our most injured and our most sick. We need to look after our young people. There are reasons that I became a physician. To try, in my own small way, to reduce suffering on the planet. To use my considerable training and experience in a useful way. We need to speak up about the need to continue (and in fact grow significantly) access to psychiatric care, not just psychiatric consultation. Look at measures to cut unnecessary costs. Make changes that will improve our system and access to care for all who need it. But not this specific change. It will take us in the wrong direction.
National Initiative for Eating Disorders (NIED)
Letters about OHIP funding for outpatient psychotherapy
Here is an excerpt:
"We are writing to express our deep concern over a proposal being considered by the Ministry of Health and Ontario Medical Association (OMA) Appropriateness Working Group (AWG) to limit full OHIP funding for outpatient psychotherapy to 24 hours per year.
"For many patients, psychotherapy is medically necessary. Treatment decisions must be left up to a person’s primary care provider and care team, particularly when providing medical care to a person diagnosed with a mental illness, whose recovery journey is not one-size-fit-all.
"Reducing outpatient psychotherapy to 24 hours per year is at-best arbitrary and fails to recognize that people with serious mental illness, and particularly Eating Disorders, may have disease trajectories (we know from research) that are difficult to predict."
Here are the letters