Across Canada, short and long-term mental health treatments and supports have been chronically underfunded and need to become a nation-wide health system priority. 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. Here is my view ‘from the trenches’ of a 35-year private psychiatric practice, 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 several new assessments weekly, 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 on average three to five years.
My observations are designed to address what is in plain sight, yet overlooked. It begins with the thorny challenge of properly interpreting studies that claim to provide 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 the 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. Second, like anti-inflammatories and antibiotics, CBT and psychoanalytic psychotherapy address fundamentally different mind processes and have therefore different indications.
The patients I see speak volumes about the current state of both Ontario’s (where I practice) and Canada’s mental health systems, most of the time desperately seeking treatment they cannot get because of lack of funding support. I have identified three common themes over my years in practice based on my studies, observations, and conversations with colleagues:
- 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.
- From non-medical psychotherapists or counsellors, patients often don’t get the treatment they find useful. Psychotherapy is a difficult skill that takes at least approximately 4 years to learn. There are well-trained non-medical psychotherapists out there, but good training is hard to come by, most of it geared towards short-term interventions. Almost all non-medical psychotherapists my patients saw before me provide either supportive counselling, or short-term CBT and other short-term modalities, none of which address many patients’ need for the in-depth long-term intensive work designed to treat the root causes of their symptoms that keep fuelling various dysfunctions. The majority of patients cannot possibly afford a long-term psychotherapy, which is why expanding funding by well-trained psychiatrists is essential.
- Patients 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 are 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 own 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 provincially-funded access to all necessary treatment options; and in psychiatry, weekly long-term psychotherapy must be integrated as one of the fundamental pillars of treatment, without which many of our patients will be unable to experience significant gains in their mental health. I urge both my colleagues and all Canadians to lobby provincial and federal governments for the removal of all financial barriers to short- and long-term mental health services and supports.
Dr. Stéphane Treyvaud M.D., F.R.C.P. (C), FMH (Switzerland) Psychiatrist