Long-Term Psychotherapy Jeopardized in Ontario

Psychotherapy in Ontario is facing an extinction-level crisis. The first wave took the stage at the national level, with provinces across the country reworking their residency curricula to be competency-based instead of time-based. Under that guise, those opposing psychotherapy as an integral part of psychiatric residency programs began to claim that psychotherapy was too difficult to evaluate under the new system and argued for it to be sidelined. For those already in practice, a second, more localized hit was in place as part of the ongoing contract negotiations between the Ontario government and the province's physicians. Currently, Ontario patients can see psychiatrists or family physicians for psychotherapy via our universal health care system without any restrictions on the length of the treatment course. The government is proposing that psychotherapy be limited to about 24 hours per patient per year for a given psychiatrist, alleging a lack of evidence for long-term psychotherapy. While the health care system in the U. S. operates under a very different model, the conflict around protecting long-term psychotherapy as a valuable form of treatment crosses borders.

There is solid evidence for long-term psychotherapy in the literature. We need only look to the works of Susan Lazar, M.D., Meiram Bendat, J.D., Glen Gabbard, M.D., and colleagues (for example, Clinical Necessity Guidelines for Psychotherapy, Insurance Medical Necessity and Utilization Review Protocols, and Mental Health Parity). Long-term psychotherapy is not a luxury; it can be a life-saving treatment. Patients deserve better than fast-food medicine models that focus on a one-size-fits all mentality. There is room at the table for all of the tools at our disposal, and physicians may choose to focus their practice on one set more so than another. The psychotherapy debate appears to be an extension of the stigma of mental illness; it is hard to believe that a proposal to stop covering evidence-based treatments is even on the table. I am unaware of any other medical specialty that would consider doing something similar. Yet psychiatry can be seen as low-hanging fruit, an easy target.

A recent opinion article by Dr. Norman Doidge in The Globe and Mail highlights the current conflict within our profession in Ontario. He speaks to the impact that the proposed session cap would have on long-term psychotherapy in a variety of forms, with psychoanalysis being one example. Some argue that this drastic change is necessary to cut out the supposed cancer of the mythical elite, worried-well who are engaging in self-indulgent navel-gazing at taxpayers' expense. Yet the remuneration changes are being suggested without a complete dataset/understanding of whether this feared misuse of the system is taking place on a massive scale. Furthermore, it could easily become standard practice for documentation to include a clear indication of the need for ongoing intensive treatment. We can be part of the solution around these misconceptions.

The movement against long-term psychotherapy in Ontario has also been suggesting that having more access to psychiatrists in the form of consults should ideally replace the role of treatment. Essentially, patients would be advised about possible pharmacotherapy/structured, short-term psychotherapy options and then be on their own to implement extended treatment privately. The longitudinal therapeutic relationship (whether via pharmacotherapy, psychotherapy, or both) that psychiatrists can offer is, to me, a fulfilling aspect of our work. Patients would get understandably angry by repeated consults telling them the same general impression/plan when there is no improvement in their symptoms because they are no longer covered for longer-term, intensive psychotherapy as needed.

With advances in technology that have become available via the Ontario Telemedicine Network (OTN), an encrypted form of telepsychiatry, patient access to treatment, including psychotherapy, has increased. OTN allows physicians to do virtual home visits and to connect with health teams to offer shared care. The argument that psychiatrists offering psychotherapy in Ontario are disproportionately in urban centers and are ignoring those in more remote areas falls flat.

Our patients look to us to advocate for their needs when they are at their most vulnerable. When our patients ask whether these changes will come to pass, I hope that we can collectively as a profession say "Not on my watch" and have it be true. ■