HEALTH INSURANCE. A new ordinance on the refunding of psychotherapies, currently in consultation, causes fears in the profession.

"They want to put the psychiatrists under supervision." Suspected on the faith of some small sentences launched June last to want to remove the refunding of psychotherapies, Pascal Couchepin is on the point of adopting a new regulation, less radical but nevertheless constraining. The project of new ordinance has circulated for a few days in the mediums concerned. And like Pierre Vallon, president of the group of the psychiatrists of Vaud, many of them express their concern.

"This project falls under the climate of permanent suspicion which one is installing around the people suffering from psychic disorders", is indignant Nathalie Narbel, secretary-general of Pro Mente Sana association.

In question: a reinforced monitoring. Today, the basic insurance refunds the psychotherapies "used successfully in psychiatric institutions recognized" at a rate of two meetings per week during two years, then of a meeting per week during three years additional.At the end of the first sixty meetings, however, a green light of the medical officer of the case is necessary.

The project obliges the doctor who carries out or supervises a psychotherapy to announce to the insurance all the cases where it envisages more than ten meetings.The obligation to subject the continuation of the therapy to the downstream of the medical officer of the case intervenes after forty meetings.The new provisions should come into effect at the beginning of July and be the subject of an evaluation by the end of 2010.

The first control - after ten meetings - has strong chances, everyone seems to be appropriate about it, to be especially formal.It worries however Pierre Vallon:"In practice, more significant data will circulate between the doctor and the case, and like the latter is likely to be overflowed, the danger is real that the access to this information is not limited to the medical advisor."

The second control would have, in theory, to hardly differ from that which currently intervenes after sixty meetings.And it is thus especially on the subliminal message - but nevertheless very Net - which accompanies this tightening by the deadlines that concerns concentrate."One risks, estimates Nathalie Narbel, to see called into question of the assumptions of responsibility long however necessary."A all the more strong fear as the medical officers of the cases are only exceptionally psychiatrists of formation.The risk thus exists that they are not very sensitive for the particular benefits of the assumptions of responsibility to the long course of the analytical type - or psychodynamic.

The project of ordinance envisages to refund the therapies "whose effectiveness can be proven scientifically".In theory, this change of formulation should hardly modify the range of the refunded therapeutic approaches.The psychodynamic, systemic and cognitivo-behavioral therapies (TCC) currently practised "in the recognized psychiatric institutions" can be based on scientific work establishing their utility.The new version opens even the door, always in theory, with new approaches whose effectiveness could be proven scientifically.

But, there still, it is the under-text which worries.Behind the obligation to align scientific evidence takes shape that to privilege the least expensive solution systematically.This request - not formulated explicitly at this stage - supports the approaches aiming at eliminating a determined symptom quickly, like the TCC. These last, which currently have the wind in poop, raise the mistrust of the psychoanalysts for whom any symptom is only one screen behind which the true suffering of the patient is hiding place.

Currently, the utility of the assumptions of responsibility to the long course is recognized vis-a-vis certain heavy and persistent pathologies like certain depressions.But in certain cases, their benefit is measured above all with the complications which they avoid.It is in particular the case, underlines Francisco Palacio Espasa, doctor head of the service of psychiatry of the child and the teenager in Geneva, of the treatment of some disturb serious of the child."By making a significant effort to this moment, one can avoid pathologies which cause, later, the greatest number of social problems:personality disorders."Who comprise, in bulk, the abuses substance, the behaviors impulsive, violent ones and/or suicidal.

The risk exists there to see tomorrow sacrificing this significant future benefit for an immediate economy?Spokesman of the federal Office of the public health, Daniel Dauwalder will not answer this question.Nor with others."We cannot express us on an administrative process in progress", ensures it.Silence shared by santésuisse, the ridge association of the insurers, which did not fix its final position yet.

Side of the psys, one does not blame the need for a control nor even the risks of abuse."There exists, considers professor Genevese Thierry de Saussure, a risk of confusion between certain forms of psychotherapies and the psychoanalyses with the clean direction of the term which does not have to be refunded."Between the psychic effort of refitting which concerns the personal development and that required by a symptom, the limit is not always frank, the more so as in both cases, the starting point of the step can be consisted a suffering.

In theory, the definition of the margin is business of competence and ethics of the therapeutist.To define the methods of an external control is more difficult.The more so as, raises Jacques Besson, Community professor of psychiatry in Lausanne, "one tackles the problem by the bad end.For defining the methods of refunding, it would be necessary to know which policy of mental health one intends to follow.However, on this point, it is the vacuum."A concern which Jacques de Haller, chair FMH, adds a sociological fear of order:"In oneself, the requirement of additional controls is legitimate.But it should be remembered that one applies to particularly fragile and not very capable populations to defend oneself. Vigilance is thus of setting."