A man I’ll call Paul* is a divorced father of three teen-aged children. He has taken a leave of absence from a routine retail position due to depression and anxiety which has also severely impaired his cognitive attention and concentration capacities. Given to crying spells, suicidal thoughts, though no history of suicidal attempts or plans, his employer provides one of the more liberal employee assistance plans EAPs through which he was referred to a psychologist. However, his family doctor informed Paul that his problems could only be resolved with medication, that the insurance company which pays his salary during a medically approved leave of absence, would only do so if he complied with treatment by taking medication.
Although Paul stated emphatically that he did not want to take psychotropic meds the physician referred him to a psychiatrist for an obligatory ten sessions. He also indicated on Paul’s insurance form that he was not complying with treatment. Paul felt confused and resentful that he was not in control of his treatment and of his life, since he had also not been reimbursed for lost wages due to mental illness for three months.
In his psychotherapy Paul began to effectively address his depression by recognizing it as self-directed anger, to develop awareness of underlying feelings and to learn constructive, assertive strategies for expressing them instead of directing them against himself. In doing so the aura of pessimism and hopelessness with which he had surrounded himself also began to dissolve.
He quickly came to recognize the deleterious effect his cold, unloving and depressed mother had exerted on his self-image and self-esteem in spite of the presence of a consistently loving and supportive father. A mother who stubbornly refused her husband’s repeated efforts to provide treatment. In his prior state of poor self-esteem and lack of assertiveness Paul had contracted a marriage to a manipulative, probably personality disordered woman, an issue he had only begun to address in therapy. The prognosis for Paul, an articulate, severely depressed and therefore motivated client, is quite positive in psychotherapy.
Yet a medically controlled health system in collaboration with the insurance industry would direct Paul’s treatment in opposition to Paul’s expressed wishes into a Procrustean bed. To do as he is told when the evidence basis for his treatment by psychotropic medication is at best highly questionable.
There you have it, a single instance of a dance which repeats itself over and over, again. Dare we, the psychologists, the social workers and other mental health professionals extensively trained and available to address the many problems which are generally and inappropriately presented to busy, less psychologically trained physicians, dare we not speak out for fear of the elephant in the room?
* Identifying details have been changed
Albert Silver is a privately practicing psychologist with more than 35 years experience in treating individuals, couples and families. He has had a long-standing involvement in seeking to provide mental health services to the underserved poor, children, adolescents, seniors, minorities and rural dwellers. Currently, he heads the task force on mental health accessibility of the Ontario Psychological Association.