Public demand for quality mental health care is on the rise. In response, the Ontario government is implementing a Roadmap to Wellness. While this roadmap increases access to mental health treatment, it also ignores decades of research by promoting a “McDonaldized” version of psychotherapy. Limited taxpayer dollars now serve the province with fast, cheap and mostly ineffective psychotherapy. Ontarians deserve better to address ongoing mental health struggles, addictions crises and social inequality.
The roadmap’s psychotherapy program offers internet-based cognitive-behavioural therapy (CBT) courses as first-line treatment. If patients require more, the program may offer in-person CBT with a therapist for about six to 20 sessions. With funding targeting these brief treatments, the Ontario government has also proposed to reduce funding for more intensive psychotherapy.
Research does not support this approach. Internet-based interventions have poor outcomes. Many patients can’t finish the courses. Plus, our most marginalized patients can’t access the required technology.
CBT is also the only psychotherapy offered by the roadmap, despite it helping only a modest proportion of patients. Ontario’s diverse population needs access to a diversity of evidence-based psychotherapies.
Many patients also require over 20 therapy sessions to recover, depending on their concerns. The roadmap’s short-term treatment focus would never be accepted in other fields. Cancer patients are not provided only partial chemotherapy.
Further, the Roadmap to Wellness only includes psychotherapy for patients with uncomplicated diagnoses of mild to moderate depression, anxiety or anxiety-related disorder. However, mental health diagnoses only identify symptoms, not their complex underlying causes. The roadmap’s focus on symptoms is like a physician only treating fevers, rather than underlying cancers.
The roadmap psychotherapy program can also reject patients struggling with significant suicidality, substance use, psychosis, interpersonal difficulties or emotion dysregulation — the very issues that public psychotherapy should be addressing.
Pursuing this roadmap is like remodelling cancer care in Ontario so that patients can access publicly funded treatment, but only for stage one leukemia, and only to receive one type of short-term, low-dose chemotherapy.
Still, supporters of the roadmap like to claim that two-thirds of patients in England’s similar public system experience reduced anxiety and depression. This sounds promising, but an honest look at the numbers tells a different story.
Almost half of England’s patients never attend their first therapy session. Another 42 per cent attend only once. These votes of non-confidence indicate widespread program failure, though they are all excluded from the calculation claiming two-thirds improvement. If we instead consider all patients referred in England, a humbler one in 10 can be considered recovered. Further, the majority of therapists in England’s system experience burnout, and many quit.
While England’s program does increase access to treatment, it is also ineffective for most patients — and therapists. Why serve the same overprocessed psychotherapy to Ontarians?
Certainly, the roadmap’s narrow psychotherapy approach will please government and insurance company accountants. However, this model excludes those Ontarians who most need public mental health care — their suffering is beyond the roadmap’s borders. Regardless, the provincial government has committed to this steady diet of McDonaldized psychotherapy.
We propose an evidence-based alternative for effective, efficient and ethical mental health care. We agree with advocacy groups like Ontario Patients for Psychotherapy that Ontarians require a diversity of in-person psychotherapy options based on patient need.
To do so, patients must be understood within the context of their histories, relationships, identities, values and cultures — not just reductive diagnostic labels. We must also address root causes of patient distress by supporting their pursuit of identity development, fulfilling relationships, meaningful engagement in daily life and genuine integration in society — not just treating symptoms.
Successful psychotherapy also requires a safe and reliable relationship between therapist and patient within which to learn, heal and grow. This takes time. Longer-term treatments, including psychodynamic therapy, lead to stable outcomes and continued improvement even after treatment ends. The roadmap must include longer-term treatments for patients who need them. Doing so is both therapeutic and cost-effective.
It is time for humane evidence-based public mental health care in Ontario. Let’s ensure the Roadmap to Wellness guides us there. Lives depend on it.
Jonathan Samosh is a Ph.D. candidate in clinical psychology at the University of Ottawa. Giorgio Tasca is a professor of clinical psychology at the University of Ottawa and director of the Psychotherapy Practice Research Network.