The case for publicly funded therapy | Hacker News Reader

The case for publicly funded therapy

theglobeandmail.com

62 pointsthe_duck34 comments

"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-yo...

50-65% improve with SSRIs compared to 30% with placebos

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-Behavio...

Which isn't even mentioned in the article.

A family member has suffered for a long time with a mental disorder that included major depression and even a serious suicide attempt. For a large part of her life therapy was drug-focused. It was very difficult to achieve consistency, both for the patient and for the care-givers (medicine changes, hope of better optimizing medications, changing insurance coverage, etc). Only since she has also been receiving talk therapy (including CBT) in addition to some drugs has she seen serious improvement and a better ability to rely on herself and make good decisions when it gets difficult. Talk therapy is expensive, but the cost of medications can also be extremely high, and the cost to the family and society when things goes wrong can also be huge.

In many cases medicine works wonders... but there are a lot of disorders (e.g. personality disorders like borderline) where medicine has far less of an impact (none or only treat some very specific symptoms).

I'm really optimistic about our developing knowledge about brain chemistry and developing newer and better treatments, but it is very naive to think that they can solve problems with drugs that are fundamentally interpersonal issues. It's very difficult to resist the sexiness of replacing hours with a therapist with a pill, especially in a profit based health system.

A counterpoint is that in contrast to these studies most/many private therapists offer at least some forms of treatment that are not at all evidence-based

The answers are "sometimes" and "it depends."

I'm of the opinion that research dollars should go towards more cost-effective treatments. Therapy appointments are in general pretty expensive, both in actual cost and in time spent. However, one treatment method I found out about recently seems to tackle both these drawbacks of traditional therapy. That treatment method is called cognitive bias modification.

It's based on the premise that anxiety disorders and related mental illnesses are maintained by cognitive biases in the sufferer, attention and interpretation biases specifically, and by changing these biases people who suffer from mental illness can see relief. One way to accomplish changing these biases is by presenting people with stimuli they would normally encounter in their environment and training them to identify positive stimuli, in effect modifying their attention bias towards positive stimuli.

If you do a search for cognitive bias modification in your device's app store, you can already find apps that claim to help. The efficacy of these apps is not scientifically established, but it does point to the promise that CBM therapy can be both cost-effective and easily accessible. It might not even be necessary to subsidize people's access to this kind of therapy, but instead to simply subsidize the production of apps that assist with this kind of therapy.

Here is a paper explaining the current state of the field (as of Dec 2011): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3092585/

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.

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.

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?

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).

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?

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.

"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.

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/

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.

Heh, if you can actually get people to do all of that, it will be $150 well spent.

It's all about execution. :-)

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).

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.

I already commented, but I'll make one more point here: I don't disagree that there are a lot of steps you can take to improve your mental health: exercise, diet, etc definitely help. The problem though with saying most of the problems people have just require them to focus is that no one can measure other people's internal struggle/pain. We don't have _really_ objective tests on this yet, we have inventories where you check a box. Because of this, it honestly comes down to what someone can handle.

So this is the problem: I totally agree, if those things you said work for you great, but saying that most people don't have hard-core mental illness is really bad is really bad to say. In a world where it's already hard for people to come forward that have this problem saying something like this is going to push people into the dark more - telling them that causes thought patterns like: "well, most people don't have this, so I probably don't, it's really unlikely, and you know, my friends have down periods too, I bet they've cut themselves before, it's probably fine".

I know from experience.

PLEASE don't tell this to people, don't promote this line of thought, don't promote anything like this. If you want to communicate what I think you're trying to say, maybe this is a better way to put it:

"For me, I've found exercise and diet have helped me feel better, but if someone feels like things are out of control they should see a doctor and see where they should go."

"saying that most people don't have hard-core mental illness is really bad is really bad to say."

But it is true - most people struggle with ups and downs but don't have hard-core mental illness.

For you, drugs and therapy help. Wonderful! Do what works for you.

Just because something is true does not make it useful or good to say, depending on how it is presented. If you said "most people with chest pain don't have heart trouble, they should just lay down and get the hell over it" that is probably not something useful and promotes people ignoring problems. If you, on the other hand, say something like "chest pain isn't always bad, and most chest pains won't be a heart attack, but you should always treat something that potentially serious seriously" that is not bad.

My concern is not that you are saying something not true, my concern is that what you're saying is dismissing what is potentially a serious concern, and that people with these problems should not have more obstacles insofar as other people saying they probably don't have problems.

There is a huge stigma around this already - throwing up more information telling people to ignore their problems is not helping anymore than telling people with chest pain to "man up" helps them. It took me a lot of time to get over the fact that everyone around me told me I didn't have a problem, and a lot of things in my life that were really bad could have been avoided if I had not had people saying exactly what you're saying.

Tone policing and speech repression are what contribue to stigma. Are your feelings hurt because I won't phrase things in a way that pleases you? Too bad. Oversensitivity makes things worse, not better.

That conclusion is specious and unfounded, and if you'd like I can cite some studies to the contrary if you'd like to discuss more offline. It isn't about what pleases me, it's about decreasing stigma around mental illness. It's not about oversensitivity it's about not increasing stigma. Those are not the same thing. It's actually a pretty bad argument tactic to assume anyone that disagrees with you is "oversensitive".

Also, I'm not saying you can't say what you're saying, I'm saying if you do you're contributing to the stigma and hurting people. If you don't care about that, then fine, say whatever you want - but my previous assumption was that you didn't understand, not that you just didn't care, but if you really don't care, then we have nothing more to discuss - you just don't give a crap if you hurt people in these situations, and that's fine.

Edit: To put it another way: we've tried the "tough love grow thicker skin" approach forever, and it hasn't worked - it has created the stigma - saying people just need more of it doesn't make sense.

In my experience, direct words and direct action are much more effective than sensitive hand-holding. Your experience is different. I have no problem with that, and I encourage you to do what works best for you.

Fair enough - you're free to say whatever you want of course, and I'm not trying to tell you what to say or not to say, just be aware that what you say may have unintended consequences for others - my point was only to try to explain what those consequences might be in this case to you. Thanks for discussing.

You might claim that lexicalscope is being oversensitive [0], but others might claim that your arguments lack substance and/or evidence.

I read lexicalscope's argument as one of pragmatism; We'd do well to lower the barrier to entry for those that truly need help, many of whom are likely to already be underestimating their suffering and/or minimalizing their problems.

There is also the fact that research does not show diet and exercise to have curative properties with regard to mental illness - not to mention that those affected are in many cases genuinely unable to do some of these things.

Also, we known what contributes to stigma [1], and it ain't "tone policing and speech repression".

AFAIK, poor nutrition/eating habits and lack of exercise may contribute to poor mental health, but you cannot eat or train your way out of a crisis (although diet and exercise are factors in a healthy lifestyle, which I'd imagine would help maintain mental health).

[0]: http://en.wikipedia.org/wiki/Master_suppression_techniques

[1]: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1489819/

What don't you get about 'in my experience'?

I read lexicalsope as trying to control my speech, and to deny my own true experience.

The only "in my experience" i can find is one followed by generalizations about medication and therapy (or maybe it just reads that way to me.)

  "In my experience mood stabilizers and therapists are a band-aid that is mostly
  about getting you hooked and dependent and compliant."

The sentence reads as if you're inferring what mood stabilizers and therapists ARE (in general) from your personal experience.

If you were talking about either:

a) your experience; e.g. "I think they were trying to get me dependent (for reason X)" or "During my treatment, I found that medication didn't help me to overcome my problem. Diet, exercise and focus, however, did (and here's how I attempt to prove the causal relationship)"

b) general knowledge; e.g. "Research shows [citation needed] that diet and exercise shows curative properties with regard to some disease" or "Medication and therapy is all about fostering dependence [citation needed]."

I'd have no problem.

You also state that

  "I really believe that the recommendations I made are
  better for most people than therapists and mood enhancers."

Which I can agree with, if you mean most people in general, as they have no need for treatment. Therapy and psychiatric drugs have, however, been demonstrated time and again to yield better treatment outcomes for most people with mental illness (i.e. diagnosed disorder.)

So I guess what I don't get is how you think your claims and allegations and are justified.

As far as I can tell, no one is denying your experience. We are, however, saying that your experience is probably not generalizable, given what is known. The way I see it, lexicalscope is obviously saying that while it is true that "most people don't have hard-core mental illness", we should avoid inadvertently instilling the "it's probably nothing"-attitude because this leads to people ignoring warning signs/not getting help, especially given that it is already happening with the current lack of knowledge and stigma surrounding mental illness. Were the situation different, this would not be such a big deal.

In short, their issue is with the likely result of what you suggest.

Expertly put and exactly what I'm trying to say - thank you.

"maybe it just reads that way to me"

Bingo. WRT your speech coaching: give it a rest. IMHO tone policing and silencing is harmful and help give rise to stigmas.

Well, help me understand what you mean then.

I'm not sure how "stabilizers and therapists are a band-aid that is mostly about getting you hooked and dependent and compliant" can be construed as something specific to your situation.

You claim to speak specifically about your experience first, but then state that you think what apparently worked for you is "better for most people". You really can't have it both ways.

Also, no one is tone policing (nor commenting on your tone at all), but suggesting there might be repercussions from a specific way of framing the issue for people; This criticism can hardly be called silencing.

I'm glad what you've described previously have worked for you, but you are plainly incorrect in claiming that it is the best approach for most of those affected by mental disorders - which is what people are taking offense with in this thread.

First of all, I'd say it's a bit much to claim that psychotherapy is a quack profession [0] - even if you've had some negative experiences with it yourself.

I'd rather say that if you've been diagnosed with a mental illness, and you are able to keep it in check or feel that you're making progress using only diet and exercise (no cognitive or behavioral tricks, for instance), I applaud you.

Exercise is moderately more effective than no therapy in for reducing symptoms in cases of mild depression [1], but that's it (as far as I know). I'm sure you belive in your recommendations, but as research literature and experts of various fields disagree with your opinion, I don't.

As for your note, I'm not sure what you mean about "hard-core mental illness", and the whole "chemical" thing is debatable [2] (i.e. "chemical imbalance" is in many cases not the complete truth), but no one is conflating mental illness with the moods and regular ups and downs of life. Real mental illness (i.e. diagnosable disorders) is what I am talking about, at least.

[0]: http://psycnet.apa.org/psycinfo/1996-13324-001

[1]: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004366...

[2]: http://en.wikipedia.org/wiki/Biopsychosocial_model

Mental illness doesn't actually exist, it's just because people aren't doing enough public service? Spend some time in a psych ward, look at some PET scans and perhaps run a gene-chip or two and maybe you'll want to revise your "prescription."

True mental illness isn't "cured" by living in "balance." There's an actual biochemical process happening. Your suggestions though do reveal the depth of ignorance amongst a large percentage of people, so thanks for that. However, I would argue that there is potentially an over diagnosis of mental illness, especially among residents of the Upper West Side. True mental illness isn't some mild social anxiety or a fear of public speaking. True mental illness is something that, when left untreated, will destroy your life.

Unfortunately the Woody-Allen crowd seems to think of therapy as analogous to a trip to the salon which belittles the more serious struggles of the severely depressed, bipolar and other chemically-based illnesses. "Mother issues" or "fear of commitment" stuff isn't mental illness any more than the majority of the gluten-free cult actually represents sufferers of Celiac disease.

Yeah - I have bipolar disorder, and this is why people with mental illness don't speak up, because we're afraid of this attitude. When you have to be on mood stabilizers and go through a lot of therapy to begin to not blame yourself for everything that your illness caused just because it's invisible it can be a real setback to tell people and have them say "Well you don't look sick..."

Same thing, ironically, happens to people with other chronic and non-visible illnesses: lupus, fibromyalgia, etc. "You don't look sick - get off your ass" - meanwhile their immune system is eating them from the inside out.

Anyways - to the original point - therapy can be very effective in treating anxiety and depression, but we should also not completely eliminate the possibility of SSRIs, MAOIs and related drugs for controlling depression. The reality is that depression is often multifaceted and the biological and psychological components of it are mixed in ways we don't entirely understand. I know a lot of people that have required an antidepressant to be able to _deal_ with therapy, and then were able to discontinue slowly after they went through therapy.

People with more serious mental illnesses (waves) can be helped through counseling, but often will be dependent on medication for the rest of their lives - but counseling for these people can still result in a net benefit for society, as often we can contribute quite a bit (and many of us are very high functioning!) if we are given the opportunity.

Anyways - to parent - thanks for illustrating everything that is wrong with our society's thinking about mental illness. I will literally link people to your comment when I have to explain in the future :). In all seriousness though, please get educated on this or study it more, I am hoping you're just ignorant on this topic and not malicious or mean.

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