7 ms·

The case for publicly funded therapy

62 points by the_duck 11y ago

petea 11y ago
"The Centre for Addiction and Mental Health has purchased advertisements to accompany this series. While CAMH professionals are quoted in this story, the organization had no involvement in the creation or production of this, or any other, story in the series." What I can surmise from this article is basically that most Canadian therapists want the high steady income like medical doctors.
- briandear 11y ago
  That's exactly it. I'm the cofounder of online therapy company iCouch and the number 1 problem I hear about among therapists: getting and retaining clients. Primary care doctors don't have that problem. It isn't because of lack of funding, at least not in the United States because nearly all health insurance plans cover some number of yearly visits to a mental health practitioner. The problem is that there is a certain percentage of the therapy/mental health profession that engages in unscientific quackery which diminishes the perceived value of the other percentage of professionals who practice science-based mental health care. There are licensed practitioners who are often little more than faith healers; there aren't actually any standards of care for mental health. Of course there are license requirements, but there isn't really an "FDA approved" method of therapy to treat depression; so there gets to be a lot of problems with clients actually NOT benefitting from a particular therapist. It's pretty much certain that if you went to a licensed family doctor with a sore throat that you'd get treatment that would likely cure the sore throat. If it were a bacterial infection (i.e. Strep,) then you'd be prescribed an appropriate anti-biotic. If it were viral, there's be treatment for the symptoms and in a few days, the problem would be cured. If you went to a licensed therapist for anxiety treatment, there's a likelihood that they'd attempt whatever "method" they've "developed" to "treat" the problem yet without any accountability in terms of if their approach actually is based on the scientific literature or it is was just based on some applied wishful thinking. It's also interesting that you'll have psychoanalysts spending YEARS with a client while a Cognitive Behavioral Therapist (CBT) often gets measurable results in a few sessions. Obviously every person is different, but how can a payer (insurance) justify spending years paying a psychoanalysts when CBT works (especially for things like anxiety disorders) [1]. I have psychoanalysts violently disagreeing about CBT effectiveness, but then again, if they admitted to the evidence supporting CBT for anxiety, then they'd cause a substantial problem with their own credibility and desire for a client to see them every week for years (such as in your typical Woody Allen film.) The point is that there needs to be treatment protocols that are standardized within mental health (especially in the non-Psychiatric side of things.) Without standardized protocols, a client could be "depressed" as long as a therapist can convince them that they're still depressed. That's a dark side of this business. I'm deep in this business with iCouch -- I've seen this stuff up close for over 5 years; in fact it was one of the reasons we started the company, was to try and bring some improvements to the field. But it's like trying to move a glacier uphill! 1 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3584580/ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3584580/
scriptedfate 11y ago
Dental, Pharma, and Mental Health are the obvious holes in Ontario's (and Canada's) "Universal" Health Care. Do you want to deal with a person's psych problems or pay for their psych care?
- peeters 11y ago
  I would also add prescription eyewear to that list. These are not optional costs when you need them, and cause bigger problems when ignored. So why is it being left to employers, as if it's an optional benefit? The government is saying it's an acceptable level of health to not be able to see. Let's leave the truly extended, non-prescription services, like massages, to companies to provide as benefits.
scarmig 11y ago
"Mental illness affects one in five Canadians. It is a factor in 90 per cent of suicides. And its cost to the economy in health-care dollars spent, and in lost productivity, amounts to nearly $50-billion a year. Yet, no province currently pays for therapy provided by a private psychologist or social worker... Research has found that psychotherapy is as effective as medication – and in some cases works better... In 2013, a team of European researchers collated the results of 67 studies comparing drugs to therapy; after adjusting for dropouts, there was no significant difference between the most often-used drugs – selective serotonin reuptake inhibitors (SSRIs) – and psychotherapy." Naive question: Is the current consensus that SSRIs and other medications are generally effective? If therapy manages to match the efficacy of something that's not at all effective, that isn't a strong reason to fund it, even if the other thing also happens to be funded. I suspect the answers are "sometimes" and "it depends." But, yes, therapy should be funded for conditions that evidence shows will likely respond better to therapy than to pills or placebo. ETA: Found this article, which describes the issues and takes a pro-SSRI over therapy or placebo perspective: http://slatestarcodex.com/2014/07/07/ssris-much-more-than-you-wanted-to-know/ http://slatestarcodex.com/2014/07/07/ssris-much-more-than-yo...
- mattmanser 11y ago
  50-65% improve with SSRIs compared to 30% with placebos http://www.rcpsych.ac.uk/healthadvice/treatmentswellbeing/antidepressants.aspx http://www.rcpsych.ac.uk/healthadvice/treatmentswellbeing/an... There was a discussion on here recently which had some evidence of the "therapy is even better than SSRIs", but therapy is a lot more expensive as a treatment I think. Like in the UK it's £45 per session. Here in the UK I know you can get 6 weeks therapy on the NHS, but as the article laments, it just stops even if you're not cured which seems bizarre and there's a waiting list which doesn't help in the case of severe anxiety when you need help now. On the other hand, you can get fairly inexpensive self-help books which you can use to teach yourself a lot of the CBT techniques: http://www.amazon.co.uk/Overcoming-Anxiety-Self-Help-Behavioral-Techniques/dp/1849010714 http://www.amazon.co.uk/Overcoming-Anxiety-Self-Help-Behavio... Which isn't even mentioned in the article.
  - furyg3 11y ago
andyl 11y ago
Here's some therapy: eat right, work hard, exercise, turn off the TV, join some sort of group, practice some sort of spirituality, perform public service, get a full night's sleep, be generous, accept the ups and downs in life, go for it, live in balance. That will be $150.
- rrss1122 11y ago
  Heh, if you can actually get people to do all of that, it will be $150 well spent.
  - andyl 11y ago
    It's all about execution. :-)
- eivarv 11y ago
  Yeah, that's not how mental illness works. However, your statement is pretty indicative of the confusion and lack of knowledge surrounding the phenomenon (and illustrates one of the prerequisites for stigma).
  - andyl 11y ago
    I've had quite a bit of experience with therapy, and from my experience it is mostly a quack profession. In my experience mood stabilizers and therapists are a band-aid that is mostly about getting you hooked and dependent and compliant. Managing your mood, maintaining focus and purpose is tremendously difficult - I can attest. I've had ups and downs, tried a bunch of methods, and watched my peers and family struggle. I really believe that the recommendations I made are better for most people than therapists and mood enhancers. Having said that - if therapists and mood drugs work for you, I applaud you. Try everything and do what works for you. Note: mood/focus/purpose is not mental illness - it is part of normal human experience. Real mental illness - schizo/paranoid/anxiety stuff - can literally kill and requires chemical/medical intervention. But most people don't have hard-core mental illness, and I believe most would get more benefit from diet/temple/gym/sports league than a therapist couch.
Sharlin 11y ago
In Finland the social security services subsidize private psychotherapy for up to three years by roughly 40 euros per visit (typical therapist's fees are 60 to 90 euros per visit.) It's not an automatic benefit, and it's reevaluated every year, but it's pretty cool.
hackuser 11y ago
Kidney problems are covered. However, a failure in the most important organ in our bodies often is not covered. Here are some common explanations: * It's hard to point to a physical cause. Really this amounts to saying, the causes are more complex than we currently can comprehend (at a high level of precision), therefore we'll pretend that there is no cause at all. * It's a matter of laziness / willpower. Think this through: All you need to do is drive through town, or look in the mirror, to know how absurd this analysis is and how ineffective this solution is. All those things you should be doing and are not -- are you just lazy? All those unhappy people -- they are just lazy? They only need more willpower? If so, willpower is a very hard thing to come by and therefore a poor solution. * I take care of myself, so can they. 'My kidneys work fine, therefore nobody else has a kidney problem'? Also, you may have a few problems yourself.
perfectlySane 11y ago
Because the human psyche can very happily transform itself into a bottomless money pit when so inclined, and has been known to do exactly that, on many occasions, with alarming frequency. If a rational measure of objective sanity doesn't satisfy a human being, will that person concur that their depression has been alleviated? Will they self-identify as mentally healthy? If an individual doesn't declare themselves healthy, was the money for the treatment well spent? How does a disagreement between a healthcare professional and an unwilling patient truly resolve itself?
- furyg3 11y ago
  This is an incredible position to take. People can complain equally endlessly about physical ailments as they can mental ones, all of your questions apply there as well. This does not mean that we should just throw our hands in the air at this intractable problem and say "welp, no healthcare for anyone!" Just as in 'physical' care, a well functioning 'mental' healthcare system makes decisions about disorders, their severity, their coverage, incentives, and responsibility. Are we going to treat schizophrenia? bi-polar? general depression? psychopaths? divorce counseling? career advice? I put these in quotes because the line between what is a physical problem and what is a mental one is hardly clear... but just because something is more mental does not mean it's effects on society aren't enormous. Structures need to be put in place to prevent patients and doctors from abusing collective insurance (over diagnosis, shopping for diagnosis, etc). This is a huge problem in both physical and mental health care, especially in highly privatized health care systems. Frequently occurring but less severe conditions may need to be incentivized (physical therapy is covered for X sessions in a year but after that the co-pay is much higher).

62 points by the_duck 11y ago

petea 11y ago

"The Centre for Addiction and Mental Health has purchased advertisements to accompany this series. While CAMH professionals are quoted in this story, the organization had no involvement in the creation or production of this, or any other, story in the series." What I can surmise from this article is basically that most Canadian therapists want the high steady income like medical doctors.

briandear 11y ago
That's exactly it. I'm the cofounder of online therapy company iCouch and the number 1 problem I hear about among therapists: getting and retaining clients. Primary care doctors don't have that problem. It isn't because of lack of funding, at least not in the United States because nearly all health insurance plans cover some number of yearly visits to a mental health practitioner. The problem is that there is a certain percentage of the therapy/mental health profession that engages in unscientific quackery which diminishes the perceived value of the other percentage of professionals who practice science-based mental health care. There are licensed practitioners who are often little more than faith healers; there aren't actually any standards of care for mental health. Of course there are license requirements, but there isn't really an "FDA approved" method of therapy to treat depression; so there gets to be a lot of problems with clients actually NOT benefitting from a particular therapist. It's pretty much certain that if you went to a licensed family doctor with a sore throat that you'd get treatment that would likely cure the sore throat. If it were a bacterial infection (i.e. Strep,) then you'd be prescribed an appropriate anti-biotic. If it were viral, there's be treatment for the symptoms and in a few days, the problem would be cured. If you went to a licensed therapist for anxiety treatment, there's a likelihood that they'd attempt whatever "method" they've "developed" to "treat" the problem yet without any accountability in terms of if their approach actually is based on the scientific literature or it is was just based on some applied wishful thinking. It's also interesting that you'll have psychoanalysts spending YEARS with a client while a Cognitive Behavioral Therapist (CBT) often gets measurable results in a few sessions. Obviously every person is different, but how can a payer (insurance) justify spending years paying a psychoanalysts when CBT works (especially for things like anxiety disorders) [1]. I have psychoanalysts violently disagreeing about CBT effectiveness, but then again, if they admitted to the evidence supporting CBT for anxiety, then they'd cause a substantial problem with their own credibility and desire for a client to see them every week for years (such as in your typical Woody Allen film.) The point is that there needs to be treatment protocols that are standardized within mental health (especially in the non-Psychiatric side of things.) Without standardized protocols, a client could be "depressed" as long as a therapist can convince them that they're still depressed. That's a dark side of this business. I'm deep in this business with iCouch -- I've seen this stuff up close for over 5 years; in fact it was one of the reasons we started the company, was to try and bring some improvements to the field. But it's like trying to move a glacier uphill! 1 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3584580/ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3584580/

scriptedfate 11y ago

Dental, Pharma, and Mental Health are the obvious holes in Ontario's (and Canada's) "Universal" Health Care. Do you want to deal with a person's psych problems or pay for their psych care?

peeters 11y ago
I would also add prescription eyewear to that list. These are not optional costs when you need them, and cause bigger problems when ignored. So why is it being left to employers, as if it's an optional benefit? The government is saying it's an acceptable level of health to not be able to see. Let's leave the truly extended, non-prescription services, like massages, to companies to provide as benefits.

scarmig 11y ago

"Mental illness affects one in five Canadians. It is a factor in 90 per cent of suicides. And its cost to the economy in health-care dollars spent, and in lost productivity, amounts to nearly $50-billion a year. Yet, no province currently pays for therapy provided by a private psychologist or social worker... Research has found that psychotherapy is as effective as medication – and in some cases works better... In 2013, a team of European researchers collated the results of 67 studies comparing drugs to therapy; after adjusting for dropouts, there was no significant difference between the most often-used drugs – selective serotonin reuptake inhibitors (SSRIs) – and psychotherapy." Naive question: Is the current consensus that SSRIs and other medications are generally effective? If therapy manages to match the efficacy of something that's not at all effective, that isn't a strong reason to fund it, even if the other thing also happens to be funded. I suspect the answers are "sometimes" and "it depends." But, yes, therapy should be funded for conditions that evidence shows will likely respond better to therapy than to pills or placebo. ETA: Found this article, which describes the issues and takes a pro-SSRI over therapy or placebo perspective: http://slatestarcodex.com/2014/07/07/ssris-much-more-than-you-wanted-to-know/ http://slatestarcodex.com/2014/07/07/ssris-much-more-than-yo...

mattmanser 11y ago
50-65% improve with SSRIs compared to 30% with placebos http://www.rcpsych.ac.uk/healthadvice/treatmentswellbeing/antidepressants.aspx http://www.rcpsych.ac.uk/healthadvice/treatmentswellbeing/an... There was a discussion on here recently which had some evidence of the "therapy is even better than SSRIs", but therapy is a lot more expensive as a treatment I think. Like in the UK it's £45 per session. Here in the UK I know you can get 6 weeks therapy on the NHS, but as the article laments, it just stops even if you're not cured which seems bizarre and there's a waiting list which doesn't help in the case of severe anxiety when you need help now. On the other hand, you can get fairly inexpensive self-help books which you can use to teach yourself a lot of the CBT techniques: http://www.amazon.co.uk/Overcoming-Anxiety-Self-Help-Behavioral-Techniques/dp/1849010714 http://www.amazon.co.uk/Overcoming-Anxiety-Self-Help-Behavio... Which isn't even mentioned in the article.
- furyg3 11y ago

andyl 11y ago

Here's some therapy: eat right, work hard, exercise, turn off the TV, join some sort of group, practice some sort of spirituality, perform public service, get a full night's sleep, be generous, accept the ups and downs in life, go for it, live in balance. That will be $150.

rrss1122 11y ago
Heh, if you can actually get people to do all of that, it will be $150 well spent.
- andyl 11y ago
  It's all about execution. :-)
eivarv 11y ago
Yeah, that's not how mental illness works. However, your statement is pretty indicative of the confusion and lack of knowledge surrounding the phenomenon (and illustrates one of the prerequisites for stigma).
- andyl 11y ago
  I've had quite a bit of experience with therapy, and from my experience it is mostly a quack profession. In my experience mood stabilizers and therapists are a band-aid that is mostly about getting you hooked and dependent and compliant. Managing your mood, maintaining focus and purpose is tremendously difficult - I can attest. I've had ups and downs, tried a bunch of methods, and watched my peers and family struggle. I really believe that the recommendations I made are better for most people than therapists and mood enhancers. Having said that - if therapists and mood drugs work for you, I applaud you. Try everything and do what works for you. Note: mood/focus/purpose is not mental illness - it is part of normal human experience. Real mental illness - schizo/paranoid/anxiety stuff - can literally kill and requires chemical/medical intervention. But most people don't have hard-core mental illness, and I believe most would get more benefit from diet/temple/gym/sports league than a therapist couch.

Sharlin 11y ago

In Finland the social security services subsidize private psychotherapy for up to three years by roughly 40 euros per visit (typical therapist's fees are 60 to 90 euros per visit.) It's not an automatic benefit, and it's reevaluated every year, but it's pretty cool.

hackuser 11y ago

Kidney problems are covered. However, a failure in the most important organ in our bodies often is not covered. Here are some common explanations: * It's hard to point to a physical cause. Really this amounts to saying, the causes are more complex than we currently can comprehend (at a high level of precision), therefore we'll pretend that there is no cause at all. * It's a matter of laziness / willpower. Think this through: All you need to do is drive through town, or look in the mirror, to know how absurd this analysis is and how ineffective this solution is. All those things you should be doing and are not -- are you just lazy? All those unhappy people -- they are just lazy? They only need more willpower? If so, willpower is a very hard thing to come by and therefore a poor solution. * I take care of myself, so can they. 'My kidneys work fine, therefore nobody else has a kidney problem'? Also, you may have a few problems yourself.

perfectlySane 11y ago

Because the human psyche can very happily transform itself into a bottomless money pit when so inclined, and has been known to do exactly that, on many occasions, with alarming frequency. If a rational measure of objective sanity doesn't satisfy a human being, will that person concur that their depression has been alleviated? Will they self-identify as mentally healthy? If an individual doesn't declare themselves healthy, was the money for the treatment well spent? How does a disagreement between a healthcare professional and an unwilling patient truly resolve itself?

furyg3 11y ago
This is an incredible position to take. People can complain equally endlessly about physical ailments as they can mental ones, all of your questions apply there as well. This does not mean that we should just throw our hands in the air at this intractable problem and say "welp, no healthcare for anyone!" Just as in 'physical' care, a well functioning 'mental' healthcare system makes decisions about disorders, their severity, their coverage, incentives, and responsibility. Are we going to treat schizophrenia? bi-polar? general depression? psychopaths? divorce counseling? career advice? I put these in quotes because the line between what is a physical problem and what is a mental one is hardly clear... but just because something is more mental does not mean it's effects on society aren't enormous. Structures need to be put in place to prevent patients and doctors from abusing collective insurance (over diagnosis, shopping for diagnosis, etc). This is a huge problem in both physical and mental health care, especially in highly privatized health care systems. Frequently occurring but less severe conditions may need to be incentivized (physical therapy is covered for X sessions in a year but after that the co-pay is much higher).