Sunday’s New Zealand Herald ran a story on cuts to funded talk therapy options.The cuts come from the private sector, with Sovereign Insurance looking to cut expenditure on counselling sessions, and in the public sector, with the Family Court cutting relationship counselling entirely, the Ministry of Social Development tightening up counselling services to the mentally ill on disability allowances, and ACC reviewing the treatment of sexual abuse and assault victims. These moves are all wrong-headed in different ways.
Sovereign’s chief medical officer gave a quote that sums up the problems with line of thinking: “A guy whose wife has just left him might be depressed and struggling to cope but it doesn’t mean he necessarily has to see a counsellor. Anti-depressants like SSRIs (selective serotonin re-uptake inhibitors) are proven to work.” Let’s pull this apart. We have our poor dude, whose wife has just up and left. He’s struggling to cope with the adjustment – hell, it’s not easy – but he *does not* have anything wrong with his brain chemistry. Giving him pills is not an answer, because he does not have clinical depression – he has situational depression. He needs someone to talk to, to learn some coping strategies. If that doesn’t work, and if he keeps getting worse, then you start looking at pharmaceutical options. Before that point, you’re just opening him up to the possibility of side effects, without actually giving him anything that helps.
Recommendations for mild and moderate depression are usually based around two things – self-help (reducing stresses, eating better, exercising more, and so on) and talking therapies. There’s a good reason for this – because *that’s what works*. Throwing drugs at the problem is not a solution, because it simply does not work with people suffering from mild to moderate depression. Sovereign is working off a bad assumption, and they are forcing doctors to prescribe treatments that don’t work, and can do harm.
Counselling is expensive, and many antidepressants are cheap – fluoxetine (Prozac) is three cents per pill, as is citalopram (Celexa). Three to six cents a day seems very attractive when compared to the hundred-plus dollars it costs for each counselling session. So in economic terms, antidepressant therapy seems like the obvious choice. Economic concerns, however, do not equate to good therapeutic choices. This is good for Sovereign’s bottom line, but not so much for their clients. If Sovereign were saying that chemotherapy was too expensive, and that they wouldn’t pay for it for cancer patients, people would be screaming. Chemotherapy, radiotherapy, and surgery are all parts of a treatment plan, and taking one away because it was too expensive is compromising people’s care, and increasing the chance that they will not recover. It’s exactly the same with mental health treatment plans – all options need to be open, and the best one selected for a patient’s needs.
When someone with few resources walks into a doctor’s office with depression, the process is simple. They fill out a questionnaire to ascertain the degree of their depression. If it comes out as mild, they’re told to wait and see – come back in two or three weeks if you’re not getting better. If it’s moderate or severe, the doctor will write a prescription for their favourite SSRI, and tell them to come back in six weeks if it’s not getting better. If the doc is REALLY worried, they’ll refer on to the hospital mental health team. Things like talk therapy are off the table unless you can pay, or find somewhere that does cheap-to-free counselling. It’s a bit of a lottery.
People with health insurance are paying more out of their own (or their employer’s) pocket, with the expectation of better care if they need it. They’re paying to be treated with the best treatment protocol, not the best that the cash-strapped health care system can afford. And the best treatment out there for many people is talk therapy. What are these people paying for if it’s not to be treated better than the public health system can afford? What Sovereign is proposing is simply what you’d get from your GP if you were broke.
Meanwhile, the Family Court is killing off their free relationship counselling services, and replacing them with ‘separation mediation’ sessions. Access to cheap relationship counselling is even spottier than that for solo counselling, and this will cut off one of the last reliable sources. Apparently, the government is less interested in sorting out struggling relationships than they are with making sure that the separation goes smoothly. Tell me again about how they don’t want people on the DPB?
The Ministry of Social Development is making it harder for people on the Disability Allowance for mental health to access counselling. After all they’re just bludgers, leeches on society. Why should the government pay to help them become well? Why don’t they pay for it themselves, after all, people live a life of luxury on the dole.
And finally, ACC is looking at cutting the amount of counselling available for sexual abuse and assault victims from sixteen sessions to as little as four. Four. For people that have already had to relive their personal hell in order to access the counselling, retraumatising themselves in order to get the help they need. Four sessions to try and work through the horror they have been through. Sixteen is often not enough. How the hell do they think four will do?
These issues come from a fundamental misunderstanding of mental illness. People, medications are not magic bullets. They don’t just make everything better. Mental illness is complex, and requires some combination of medication, self-help, and talk therapy to recover. Talk therapy is slow and expensive, and it’s not as sexy as a magic potion that solves everything, but it can be the basis of life-long wellness, as people learn better ways of thinking and dealing with what life throws at them. Taking that option, and those tools, away from people is wrong.