Realpolitik and the empirically validated treatment debate.

Abstract

On the assumption that most people do not get livid about things that do not matter, one may conclude that the occasionally virulent professional debate around empirically corroborated (my contribution to the terminology argument) treatments arises principally because of fear that someone might decide to do something with lists of such treatments. To this concern, one may only rejoin: Get real. Of course they will.The authors have done an excellent job of summarizing the contentious debate around the empirically validated treatment initiative and the effect it may have on training, credentialing, practice, and service funding in both the United States and Canada. A particularly important feature of this commentary is the expansion of consideration of these issues to an international perspective and the reference to collateral developments in the empirical sweepstakes affecting other professions (for example, the evidence-based medicine movement). Such developments inevitably play out on a larger stage than we imagine when we contemplate them from within our profession. In this commentary, I wish briefly to expand on an issue to which the authors gave surprisingly short shrift, namely, the likely impact on practice patterns of psychotherapy in the Canadian context of these initiatives. I believe the outline of directions for practice in Canada is clearer than the authors present and quite similar to some of the directions occurring in the U.S. context.Although the vicissitudes of the managed care debate in the United States may appear irrelevant to the Canadian health-care scene, this is a dangerously flawed assumption. Despite the public perception of Canadian health care as a universal-coverage, comprehensive, publicly funded enterprise, about 25% of health care service expenditures in Canada have historically been funded by individuals or by private-sector organizations (for example, insurance carriers). As the federal government continues to reduce its involvement in direct transfer payments to provinces for health care, and as provincial governments continue to reduce or rationalize their funding of health care services, one may expect that the role of individual and private-sector payers will increase substantially from this baseline in the next few years. Already, managed care companies are entering the Canadian marketplace, either in the role of brokering payment for currently noninsured services or in explicit attempts to introduce complementary (if one is an optimist) or alternative (if one is not) health care delivery systems into the Canadian landscape. At the time of writing, the Alberta government is just a hair's breadth away from legislative approval for the operation of hospitals in the province, despite a belated public outcry of concern about the implications of this move.What of this for psychotherapy? Canadians alternately worry about or yearn for a two-tiered health care delivery system. Within the current Canadian system, however, access to psychotherapy has traditionally occurred not merely within a two-tiered system, but within a three-tiered system. On one tier, consumers may access psychotherapeutic services provided by physicians within the publicly funded system or by psychologists, social workers, nurses, and other providers who happen to work in publicly funded health care or mental health care organizations. At a second tier, consumers may access psychotherapeutic services from psychologists that are brokered by private third-party payers such as insurance carriers and employee-assistance plans if they are fortunate enough to have benefit plans that provide such coverage. Finally, at the third tier, consumers may access psychotherapeutic services from whomever they wish if they are willing to pay the therapist from their own pockets.As access to psychotherapy through the first tier (never widely or reliably available at the best of times) shrinks with shrinking public health care funding and lengthening waiting lists, access through the second tier will most likely grow. …