Wednesday, June 1, 2016

How to Spend Ten Million Extra Dollars per Year on Mental Health

Suppose that a community received a large infusion of money to spend on improved mental health.  What would be the best way to spend this money?

The most common situation I see in my practice, which pertains to this issue, is of patients with severe or chronic symptoms, who do not have access to a therapist who is regularly available for them to see on an ongoing basis.

It is not uncommon for patients I've seen to have had a fairly superficial course of therapy with someone who didn't have time for them.

The money, in my opinion, should go towards immediately and directly helping such patients have the type of therapeutic care which they desire.  This might be seeing a psychotherapist or psychiatrist regularly.  In other cases, it might be finding a personal trainer, an art therapist, a massage therapist, or some other specific resource of the person's choice. 

It is not necessary to spend money on new buildings, new office equipment, new computer networks, new meetings, etc.  There are many therapists in the community who are skilled healers -- but who are underemployed.   Extra money in a health care budget could help them survive and flourish. 

I have long felt that public health care providers (such as MSP in BC) or private insurers should allow much more funding for psychotherapy from non-medical therapists. Problems with efficiency and collaboration could be addressed within this regime, without spending any of the budget directly on this. 

Another simple alternative way to spend this extra money would be to simply hire more therapists, particularly if there was evidence in the community that there were fewer therapists per capita than in similar communities elsewhere.

Stepped Care

An evolving trend in mental health care is a system called "stepped care."  Basically, this is grounded on a simple principle, of not "overprescribing" more involved or expensive care than is necessary for a given problem.  This idea is a good one, necessitated by a therapeutic tradition over the past hundred years of prescribing intensive psychotherapy to almost any patient, regardless of the severity of their problems.

Yet, "stepped care" as a modern therapeutic philosophy is, to a large degree, a formalization of the obvious.  In other areas of medicine, one would not, for example, visit a heart surgeon following a first bout of angina.  There would be a rational sequence of steps, to be tried in order, to manage any health issue with the most satisfaction for you, and with the best use of resources for the system.  The heart surgeons would have less time to operate if they were spending more of their time investigating angina! But in order for a stepped care system to work fairly, there should be strong input from all levels of the system, including the heart surgeons, to determine the appropriate levels of care.

One difficulty with a stepped care idea is a subtle one:  mental health care isn't exactly analogous to cardiac health care.  There are some similarities, such as dealing with clearly defined levels of severity.  In cardiac health care, a mild concern would be low exercise tolerance; a moderate concern would be angina; a severe concern would be an acute MI (a heart attack).   In mental health care, a mild concern could be feeling stressed before a test at school; a "moderate" concern could be dealing with a loss; a "severe" concern could be a manic episode or active suicidal ideation.

     Mental Health as an Educational or Developmental Process
But part of mental health care is different.  It can be analogous to an educational process.  And it can be analogous to a developmental or relational process.  Here, a therapist can in some ways be similar to a university professor, or to a parent.    A good university professor does not only spend time with students in the class who are having the most severe difficulties.  Part of an efficient process in education is of nurturing all students, and offering special, personalized time and attention to all students, according to the students' wishes for dialog.  And an "efficient" process in parenting is of always being present and nurturing, not only in times of severe distress.   Such a process is not only healthy for students in a classroom, or for children in a family, but it is also healthy for the morale and overall well-being of the professors and parents.   

The Process of Budgeting in Health Care

The process of budgeting is a political negotiation.  Here are some steps typically taken to plan changes in health care expenditure:


 "Hire a consultant."   Data could be gathered.  Interviews of different groups ("stakeholders?") could take place.  Evidence could be presented about how other health care systems operate elsewhere in the world.

One of the issues with consultancy has to do with the biases inherent to the group which is hired to do this type of task.  Is there a particular political or philosophical agenda which the group brings, despite posing as a neutral assessor?  

In the summer of 2015, I was asked to be part of a "consultancy" team of a sort, to evaluate the mental health care at a large North American university.

I expect that most consultancy groups charge quite high fees for their services.  A first question I would have about spending a new health care windfall on consultants is "how much is their fee?"   The fees should be transparent, evident to all those who are involved in the process.   Is this type of money well-spent?  Who will do the "consultancy" about the consultants themselves? 

The fee I was paid for my role as a "consultant" was zero dollars.  My travel expenses were covered,  though not the cost of missing most of a week's work, plus the time spent afterwards helping to write the report. I suspect that similar fees are not the norm in the consultancy world. 

Consultants can be a little bit like family therapists.   In most cases, the reports are likely to contain very similar themes:  "communicate better!" --   "collaborate better!" --  "encourage self-care!" -- "keep up with technology & cultural trends!"

Optimism Bias

Once a particular plan is put into place, there is another psychological bias which comes into play.   Part of this is motivated by etiquette, and part of this is motivated by a natural process to relieve cognitive dissonance.   One can see this phenomenon at weddings, at funerals, and at political rallies, once a new leader or plan of action has been chosen.  Basically, we tend to say very positive things, about the newlyweds, about the deceased, or about the new political plan!   It would be quite rude to say something negative about the newlyweds at a wedding!

But when a major policy change takes place, we can see leaders in the process, in a reflexive rhetorical habit, tending to be excitedly positive or complimentary about the new changes, even before the changes have even started.    You might hear comments such as

 "what an excellent new model we have!"


"Our hard work has really paid off--this is an exciting time of success and change as we implement and operationalize our new ideas!"

This can serve to boost morale, and help the changes to take place more effectively.  But it can also serve to stifle important critical questioning or debate.  Examples of this type are especially alarming in political movements, and we do not need to look far in the world's political history to see examples of harmful changes in a population moving forward at at an alarming pace, fueled by the reflexive excitement and enthusiasm of the citizens, with dissenting voices being suppressed or discouraged.
To prevent this phenomenon, it is important to always encourage a devout, reverential respect for the notion of free speech.  Dissent and questioning should not only be allowed, it should be sought out and encouraged as a core part of our value system in a free, healthy society.

     Population Surveys about Mental Health

I am particularly wary of consultants in the mental health area who claim to have surveyed the population, through interviews and similar data collection.

Quite a few of the most severely affected patients in a mental health population would be unwilling or unable to participate in such a survey!

Others might be willing, but are less apt to be aware of the presence of a consultancy group doing interviews.  Interviews of this sort are already biased, due to the very mental health concerns that the consultants are intending to address.

I think the viewpoints of many of my own patients would be valuable to consider in such a consultancy process.  As a specialist, my patients are analogously comparable to the  patients of a heart surgeon, in a discussion of cardiac health (when I say this, I do not mean to say that my patients' problems are necessarily  more "severe," nor do I claim that I am any more an "expert" than anyone else, but it certainly is true that it was harder for most of my patients to have found me, usually after being on a wait list and seeing various other counselors--just as patients of a heart surgeon have usually waited and seen other caregivers before).  If one were conducting a survey about the goodness of cardiac health care, it would be severely remiss to only have open surveys of the general population, without talking to patients who had seen the surgeon!   

The need for humility in consultancy reports

The report generated by my own group last year had a remarkably striking resemblance to other reports generated by other consultancy groups in similar situations, perhaps with some specific infusions of pet interests among the individual members of our group.

My own two pet interests, which I felt were most important to include in the report, were these:

1) I felt it was not possible to adequately understand the dynamics of a place after only a brief assessment period.  I thought it was a bit like visiting a new country, or a new culture, spending a few days there, then presuming to write a report about what you think is wrong with how the place runs!   This is also similar to a psychiatric consultation with a new patient -- the obligatory report generated after spending an hour or two with a person you've just met must be offered with deepest humility about its limitations, especially if the report is making categorical pronouncements about who the patient is as a person, or about "what is wrong."

It is therefore necessary to be very humble about reports of this nature, to acknowledge their limitations, and the limitations of its authors.   Humility is key.  It shows respect for the people and the institution you are visiting.    It is perhaps less compelling to read a report in which the authors admit their own limitations.  But it is more honest.  It is just like seeing a therapist.  Many people want clear, decisive advice from a therapist.  Sometimes it is possible to give such advice.  But a therapist's response to a suffering patient is much, much more powerful if it is patient and humble.  Some advice can be given right away, but in most cases a promise to work together, to learn more, to promise to understand,to empathize, and to admit your limitations, is far more effective.

Empathic dedicated human contact as a foundation of care

2) I believe the foundation of care comes from empathic, dedicated human contact.  It should never come from treating people like  numbers, or like cogs in a system.  Efficiency is important, but personal care must always be the transcendent value.

The wisdom and helpfulness of a family therapist (or consultant) does not come from the report generated from the "assessment."  The assessment is likely to contain bland generalities, which, however, might be framed in assertive or rhetorically engaging ways.   Furthermore, the ensuing interpretation or application of such a report, must not occur in a narrow or dogmatic way. 

 In family therapy, the helpfulness or positive impact comes not from the report which advises communicating -- but from actually communicating, possibly with the help of the therapist as mediator!

What about Economics & Evidence-Based Science? 

It is very difficult to conduct a good scientific study demonstrating a superior way to allot a large sum of money.  One could plan to do follow-up studies to measure health outcomes, but this actually proves much less than it seems!   For example, if the entire extra mental health budget was spent on building and maintaining a new ice rink, or a new flower garden, or on free trips to tropical resorts,  I would expect that we could see improvements in some mental health outcomes!   Surveys of people using the ice rink would most likely show that people were quite happy with the new facility!   This would appear to justify the expenditures.

If the money were spent on a new health care centre, we could generate numbers showing large numbers of people using the service, and perhaps symptom score data showing that people were experiencing relief of symptoms after visiting the centre.

But even larger numbers of people could have been seen, with even larger symptom score improvements, if we had simply given the money directly to the patients, to use as they saw fit, such as with the many struggling, underemployed private therapists in the community.

A core problem with this issue is the difficulty of conducting a controlled prospective study of different budgeting choices. 

The bigger question is about spending wisely, with a view to improving health care in the short term and the long term, with the biggest possible improvements from each dollar spent.

Heart Surgery

 I have often thought of cardiac health as an analogy to mental health.   How should we best divide up a budget windfall to help improve cardiac health?

We could correctly observe that the best improvements in cardiac health come from fostering good lifestyle habits in the population:  to eliminate smoking, to encourage healthy nutrition, and to encourage regular exercise.   So we could spend most of the extra budget on quit-smoking clinics, improving access to vegetables, and improving affordable gym facilities.

The thing is, these lifestyle changes were already possible without spending any extra money!  Gyms are actually not needed to encourage more exercise!

I would not oppose building more gyms, or building a better communication infrastructure, or planning regular meetings between cardiologists, surgeons, dieticians, and fitness instructors...but imagine it was known that the the heart surgeons in the community were under tremendous strain, were having long waiting lists, were having trouble finding available time in operating rooms, and were having declining morale, yet were being told to see more people in a more time-efficient way...

In this situation, I would not want to send the surgeons away to have more planning meetings...I would hope that the surgeons could be given the opportunity to do their work, with the basic resources which they and their patients needed or desired. 

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