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Tuesday 29 March 2011

Allocating Health Dollars: By Cost or By Benefit?

Given limited healthcare budgets, how should we allocate money for treatment?

One option is to ask how many people are affected.  If problem A affects 1 million people and problem B affects 1000, then we should first spend money on problem A and, if there is any left over, then allocate some for problem B.

Another option is to assess impact.  If problem A is mild dermatitis and problem B is aortic aneurism, then we might make funding problem B more of a priority.

A third option, much practiced recently, is to look at the economic cost of the disorder.  If problem A costs society $10 billion a year (in lost wages, reduced productivity, disability payments, welfare bills, and so on) and problem B costs $100,000 a year, then we might allocate more funds to problem A.

This third strategy has been used a great deal when arguing for increased funding for mental health programs.  When the actual societal costs of depression are added up, for example, the total is enormous – more than for many other problems that we see as essential health priorities. 

But there is a problem with all three systems.  They ignore the question of what you can buy with a health dollar.  A problem might be very costly to society, but it does not necessarily follow that spending money on its treatment will be worthwhile.

The implicit assumption of the cost approach is that we are already paying for the disorder in question, and that by treating it we will actually wind up paying less than we do now.

What if problem A costs $10 billion a year, but spending an additional $10 billion on treatment produces no benefits for those treated?  Perhaps spending $100,000 on problem B will eradicate it.  We need to focus on the effectiveness of the treatment, not just the cost of the disorder.

Imagine that problem A is appendicitis, and problem B is depression.  We do the math and determine that appendicitis, left untreated, would not cost anywhere near as much as depression, nor does it affect as many people.  Maybe we should forget about appendectomies and fund the depression treatment programs.

If we look at effectiveness of treatment, however, another decision might look better.  Left untreated, appendicitis has a high rate of fatality.  The treatment is a relatively simple surgery that, in the grand scheme of things, does not really cost all that much and that has a low risk of complication (at least when compared to doing nothing).  For a few thousand dollars you save a life.  Randomize 100 appendicitis cases into “operate” and “don’t operate” conditions and you get a huge and obvious effect.

What about treating depression?  The cost of pharmacological treatment is relatively low, particularly in jurisdictions where patients pay for their own medications.  The cost of comprehensive nonpharmacological treatment is higher.  (One study in a Veterans Administration Hospital suggested otherwise, but the treatment regime for the pharmacological approach was more elaborate and costly than in most medical practices.)

The question is impact.  Recent meta-analyses suggest that antidepressant medications are relatively weak in their effects, particularly when compared to placebos.  Evidence-based psychotherapy looks like it is about as effective, but with fewer side effects and better maintenance of gains.  But the ratio of benefit to cost is probably not as great as with appendicitis.  (The same could be said of a great many interventions for other physical health problems.)

My point is not that depression treatments are ineffective.  Quite the opposite.  But in order to convince policymakers, we will have to stop focusing solely on the costs of mental disorders and discuss the real benefits – including the economic benefits – of treating them.  This places the ball firmly in the court of science.  In order to make these arguments our treatments must be subject to rigourous scrutiny.  Inevitably, some cherished approaches will be found wanting and funding will be justly denied to them. 

Tuesday 22 March 2011

Are You a Surgeon or a Barber?

When I was trained as a clinician, there was an unspoken assumption about mental health practice.  People would come to therapy in a time of distress, they would receive an intervention, the problem would go away, and the problem would stay solved for the rest of their lives.   

It seems to be the nature of unspoken assumptions that stating them plainly and consciously makes them look a bit silly.

The surgeon model of therapy is based on the idea of a limited-term intervention, following which the problem (and contact with the client) is over.  It is the implicit standard for therapy practice. 
But few other forms of healthcare use this model.  No family physician believes that if she solves a patient’s problem she will never see them again.  No masseur imagines that a person will remain loose and relaxed four months after the last massage.  Even the most skilled barber will not render future haircuts unnecessary.  Not even psychopharmacologists believe that most patients will retain the benefits of a drug they no longer take. 

It is a remarkable feat of therapy that we can train our clients in new skills and new understandings, say our goodbyes, and the clients can go on using what we have provided for a lifetime. 

But life is difficult.  Just when we think we have our problems figured out, they take on new shapes and come at us again.  As we age we encounter new challenges and new psychological territory.  We can all achieve stability, but the idea that we can maintain absolute steadiness all our lives is a delusion that is best discarded.

With some clients we may be more of a barber than a surgeon.  They come to see us, we work on a problem, they say goodbye, and a few months or years later they return, perhaps with a new problem or perhaps with a new wrinkle on an old one.  If none of our clients seem to manage for long without us, we should probably examine our practice; perhaps we are unintentionally fostering dependence.  But if none return, this may have more to do with our halitosis than our effectiveness.

When I opened my private practice I somehow imagined that clients would leave never to return and that, if they did come back, it would be a sign of my failure.  Since then I have realized that some of my clients will see me as “their” therapist, just as they have a chiropodist and a physiotherapist, and that they will call me up when they get into sticky territory.  So while I still like to think of myself as a surgeon, I have come to embrace my barber practice as well.  

If you're a clinician, it's worth taking a few minutes to consider your own surgeon-to-barber ratio.  How do you see yourself?  And has this changed (or evolved) since you started out?

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Want more information on operating a private psychotherapy practice? 

Check out my book Private Practice Made Simple.  It contains information on starting a practice, creating a space, designing a website, getting referrals, managing finances, avoiding burnout, and much more.

The book is available at bookstores, from the Changeways Clinic website, and through Amazon here.

Thursday 17 March 2011

Psychological Practice: Inside and Out

Welcome to PsychologySalon, the blog.

In June 2011 my book Private Practice Made Simple will be issued by New Harbinger Publications (  In it, I advise mental health practitioners never to start a blog.  Why?  Because they will never keep it up.

So of course I’m starting a blog.

Not wanting to run dry after four posts, I decided that I would only launch once I had at least six months’ posts more-or-less ready to go – and preferably a full year of posts.  

I passed six months a while back and am now closing in on a year.  I don’t plan to slot all of these in and sit back; the backlog is a bank account to be drawn on as necessary.  With any luck, I won’t stop having ideas the moment I press “send” on this post.  (Revealing this is, of course, a setup:  I have no excuse not to last a year.)

Who am I?

I’m a psychologist based in Vancouver Canada.  After graduate school and several clinical positions in Ontario I came to Vancouver in 1993 to manage the Changeways Program at UBC Hospital.  We provided a cognitive behaviour therapy group program for people who had been recently discharged from inpatient care for major depression.

We were funded by the provincial government on the condition that we train practitioners in at least three other agencies in other parts of the province how to provide the same program.  Within a few years our team had managed to get over 45 communities to offer the program, and eventually offered the training workshops nationwide.  The program, after many revisions and updates, continues to grow in use today.

In 2002, during a period of healthcare cutbacks, I took the service into the private sector.  Changeways Clinic ( is now a private mental health centre offering one to one evidence-based psychotherapy, mental health resources for professionals, continuing professional education programs, and public presentations (the latter under the name PsychologySalon).

I’ve always enjoyed writing, and have collaborated on a number of treatment and resource manuals through the clinic.  Our assertiveness training manual morphed into The Assertiveness Workbook from New Harbinger, and experiences with the depression service became Your Depression Map.  Hopefully once Private Practice Made Simple comes out I will focus my efforts on one of the other writing projects I have lying around.

What’s the idea of the blog?

I’d like the blog to offer a kind of “behind the couch” look at psychotherapy and practice – something that will be of interest to both practitioners and the public.

The blog incorporates a series of goals.  I’m imagining that with time some may come to dominate, while others may fade.  Here are some of the themes I’d like to cover:
  1. Private practice management.  Psychologists and other therapists are seldom trained to handle all of the details involved in running a practice, and I’d like to continue the discussion of the issues raised in Private Practice Made Simple.
  2. Mental health services.  After 25 years in mental health service, I have increasingly felt concerned about service quality and organization, and I am skeptical of the way that mental health issues are discussed in our culture. 
  3. Process issues in therapy.  The so-called “nonspecific factors” in therapy appear to account for a greater proportion of therapeutic success than the attention they are given would suggest.  
  4. Cognitive behaviour therapy.  I am predominantly a cognitive behaviour therapist and believe that this way of thinking can offer a great deal to almost anyone attempting to manage life with a human brain.  

…and perhaps the discussion will flow in other directions as well.

So what’s the plan?

I will make major posts weekly, on Tuesdays.  Minor posts may also appear from time to time.  I will keep this up for a year, and then see where it leads.

Consider subscribing, or come back and visit often.

Comments will be moderated, so you won’t see your remarks appear instantly.  I welcome readers’ posts and input, however, so please add to the conversation.  

And…we’re off.

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Want more information on operating a private psychotherapy practice? 

Check out my book Private Practice Made Simple.  It contains information on starting a practice, creating a space, designing a website, getting referrals, managing finances, avoiding burnout, and much more.

The book is available at bookstores, from the Changeways Clinic website, and through Amazon here.