There was a time society would have burnt your schizophrenic son alive, assuming he was possessed by the devil. We’ve come a long way in understanding and treating mental health, but we’re still operating out of a relic system and infrastructure that simply doesn’t work.
We’re also stuck with policy makers born back when mental health was stigmatized as an affliction of the weak or troubled. Our baby boomer generation did not learn in school that a diabetic and depressed person are really no different: the diabetic has an imbalance of insulin from a faulty pancreas, whereas the depressed person has an imbalance of serotonin in their brain. Medication can remedy both, and neither patient is more legitimately sick than the other. Nor is mental health less pervasive than physical ailments are: 1 in 5 of us will be affected by mental health this year alone.
All statistics and facts uttered in this article came from either Todd Leader, the registered psychiatrist and social worker who revolutionized Nova Scotia’s mental healthcare system, or the recently released government document produced by an All-Party Committee on Mental Health entitled, Towards Recovery. The document was mandated to conduct a full review of the provincial mental health and addictions system, to identify gaps in services and areas for improvement.
It’s Not about Us
The aforementioned Todd Leader wrote a book called It’s Not about Us, and the title is the primary point of his teachings. He argues that the politicians making decisions about mental healthcare think about the wrong things — administrative efficiencies, budgetary considerations, navigating union demands, driving political campaigns, or avoiding extra work for Joe and Joan — instead of focussing on the system itself, like the best patient-centred practices to ensure recovery of a patient, how to build a system that works for the people using it, or new programs to curb crimes associated with mental illness. This means the narrative around mental healthcare isn’t about the patients, the public, our needs, and the system. That style of management has created a clogged and inefficient system.
Things Are Getting Worse, Not Better
The number of people waiting for mental health and addictions counselling services increased 56% between September 2014 and September 2016, leaving thousands waiting for care.
More of the Same Doesn’t Give Us Different
The general public understands there’s a problem, based on wait times alone, but somehow, without research, we’ve decided a new Waterford is the answer. Arguably, all that would give us is more of the same thing that’s not working.
When the All-Party Committee consulted the Mental Health Commission of Canada on how to replace the province’s outdated psychiatric hospitals, they learned that psychiatric facilities similar to the Waterford Hospital provide in-patient treatment for only 1.5 to 3 per cent of the population with mental illness. Yes, 1.5-3%! Is the Waterford really the place to pour all our money? Can a St. John’s based hospital help a traumatized kid in small town Labrador, or a schizophrenic widow on the Northern Peninsula?
We’re at a critical, perfect moment in time to stop and think about where to spend money earmarked for mental healthcare. One building will not do for the province what a total revolution of the system itself will.
Schools Offer Infrastructure for Every NL Community
Approximately 70% of mental health problems begin in childhood or adolescence. A staggering 1.2 million Canadian children are affected by mental illness. Even more surprising is that less than 20% receive appropriate treatment. Hence suicide being a top 10 cause of death in our country.
We can’t build a hospital in every community, but we already have a school in every community, so why not avail of that infrastructure. Kids spend half their waking life there, so what better place to equip with mental health services?
Access to guidance councillors for kids in our province is 1 to 500. That’s not a great ratio, but it beats the ratio for students to psychologists or psychiatrists by a long shot. The NLTA has been pushing to expand the supports that exist in the school system, and the NL Counsellors and Psychologists Association has strongly advocated for the need to have more mental health resources in schools. Here’s a direct quote, “In the school system, we are catching grenades.”
Many teens don’t want to burden their parents with mental issues, or share the intimate details of their life … but guess who they have to ask for a ride to the doctor? Mom or Dad, who will ask, “what’s wrong,” so our children keep their struggles to themselves.
While researching for this article, I was told the story of a child who made a very public suicide attempt. The only support the school offered the kid’s mother was a promise of privacy. “Don’t worry, we’ll contain the secret of what your kid tried to do.” They did not give her a list of places to take her child, or herself, for help in preventing another suicide attempt.
When this weeping mother told her child’s doctors “he’s been saying for 2 years, ‘I don’t want to live anymore’” the doctors just said, “you’re good parents, keep up the good work, we’ll see you in 3 months.” 3 months is 90 days, 90 long stretches of 24 hour shifts spent worrying for your child. What a toll that takes on the parents.
Many of these parents don’t know about support systems out there to help them, yet an informed and concerned parent can be a solid support system for a child. And many of these parents say there are “angels” in the system, but those compassionate healthcare workers have their hands tied by our currently ineffective system.
Another Means of Reaching Past St. John’s
“You can’t be everywhere at once” used to be true. And then the internet happened. There are new treatment methods in use all over the world that go beyond traditional, office-based counselling and admission to psychiatric units. Technology as simple as Skype or web modules that make it possible to help a patient anywhere in the province.
If that seems impersonal, good! It’s been proven that patients who use e-health technology usually report better relationships with healthcare providers, and increased self-disclosure. In short: we’re less shy about interacting with people online, and disclosing our troubles online, so we’re more likely to seek help and open up online.
We should NOT replace doctors with web modules, of course not, but they could be part of the system. Cognitive behavioural therapy is great for depression and anxiety, and can be delivered online. Also, online solutions can be convenient for ill people who find it challenging to get themselves to an appointment halfway across town, or the province.
A Cluttered Chaotic System Yields Chaotic Treatment
There is no centralized process for referral to see a psychiatrist; their services are managed separately from other mental health services. Why? It is impossible to determine whether individuals who have been referred to see a psychiatrist have been referred to the most appropriate service for their level of need. Why? The system we have right now is a mess, and cleaning it up would make what we already have a better system.
Many people in need of help do not know what services are available to them, and this includes people working in healthcare who should know where to direct folks. It’s a simple communication failure. That kind of knowledge should be right up there in our public’s knowledge base with “how do I do regular blood screening” or “where can I get tested for STIs?” Drop a bit of money on advertising and education campaigns, and problem solved.
As it stands, multiple government departments or community agencies have to be accessed to receive necessary services. Such chaotic clutter needs to be untangled and streamlined. A paragraph from Towards Recovery reads, “For individuals seeking help, the current mental health and addictions system may seem like a maze, characterized by fragmented services and an overall lack of integration. People [are] being passed from one health care provider to another in hopes of receiving treatment.”
The System Should Work, Or It’s Wasting Our Time and Money
If our system is to work — and not just waste tax dollars and leave people in the cold — decisions on what to do with our mental healthcare system must focus on ensuring our system can not only let people “in” in a timely manner, but guide them to recovery too.
If someone gets into our compromised, infective, under-funded system but it doesn’t make them better, they’re still in the system, clogging it up. Picture an elevator: for someone new to get in, someone else in there already must get out. Or at least be shunted to different floors during different stages of their recovery.
We’ve over-professionalized the system at the top end (with psychiatrists). It bogs down our brain doctors, slows down waitlists, and puts patients in front of psychiatrists where a psychologist, social worker, peer support, school councillor, or someone with a 2-year counselling course, might have done it. Counselling can be as simple as support, not therapy. This would prevent everyone standing in line to see the a handful of psychiatrists in a system with hundreds of available mental health workers.
Some psychiatrists keep patients in their case load for 10 years, because they feel there’s nowhere else to direct them, or the process of doing so is too complex. Counselling or peer programs could work for many still seeing a psychiatrist, but no one has taken the time to create an efficient, diverse, tiered treatment program.
It’s called a “stepped-care approach,” and it increases easy access to services by matching mental health needs to the most appropriate level of care. Towards Recovery states, “To provide stepped care, more services are required … these services should include walk-in clinics, where people could meet with a therapist for a one-hour single session appointment, without waiting for an appointment time.” Like the recently launched Doorways program in Pleasantville.
“Your Cancer Isn’t Bad Enough Yet, Come Back in a Year”
A citizen of our province could have to wait 2 years for help. Think about it. A sixteen year old girl gets hit by a bus, her mother rushes her to hospital, and is told, “we will get to you in a year.”
Imagine showing a lump in your breast to a doctor, and your doctor saying, “Looks like cancer all right, but it’s not bad enough yet – come back when it’s crippling you and we’ll treat it then.”
It’s no wonder suicide rates are so high, it’s no wonder mentally ill citizens end up homeless and alone, it’s no wonder a significant portion of crime is driven by untreated mental illness, it’s no wonder children silently suffer when a single parent is afflicted by mental health. And it’s no wonder some people can’t get themselves to an appointment.
Speaking of appointments, one mother who lost her child to mental illness says that when she called to ask if she or at least her son could be reminded of when her son’s appointments were, the system said no. “My dentist can do that,” she says of that experience. “And I don’t have wait times at my dentist.”
Not Preventative = Not Good
Our mental health system is such that we must get to the point of being beyond help, to get help. That is the exact opposite approach to physical medicine, where we go see our doctor as soon as we’ve cut a finger, instead of waiting for it to fester with infection.
Our mental healthcare system operates this way in part because we’ve bloated the system with top-end professionals, psychiatrists, instead of building a tiered system of care offering varying services to patients of varying needs. We do very little to keep mentally healthy people mentally healthy. Our approach is to put more and more ambulances at the bottom of the cliff our people are falling off, instead of building a fence atop that cliff, with more and varied services.
We’re guilty of having built a system where you need to be bad enough to get in. The notion of “be suicidal or wait a year” leaves a person crippled by depression’s manifestation in their body (zero ambition, a flu-like sluggishness). Suicidal ideation is but one symptom, that not all people with depression feel. While being ignored by the system, a depressed person can be debilitated to the point of losing their job, their kids, their partner.
Here is a direct quote from the Provincial Mental Health and Addictions Advisory Council, “To continue to rely on crisis response systems means we will be paying the highest cost for the poorest outcomes.”
Building a New Waterford Isn’t the Fix All
The All-Party Committee report shared a confession from front-line mental healthcare staff that they want and need more education and training to learn about advances in treatment options. Who better to listen to, about what our system really needs, than the people providing treatment? They also asked for more mentoring opportunities and supervision.
The Waterford’s in-patient services are a necessary part of the whole, but having all mental health services run out of there does not appear to be the whole solution. A new facility is necessary, but what mental healthcare really needs now is more and varied services, better training, and an interconnectedness of treatment options, and a better means of penetrating every NL community with access to mental health services.
We need mental healthcare to stick its tentacles into the very fabric of our society, through centres all communities have, and to treat people at all stages of their affliction with mental health. A single hospital in St. John’s, devoted solely to the very bad off, cannot functionally do so. It’s time we find a way to ensure our tax dollars are successfully treating both physical and mental illnesses.