Monday, October 14, 2013

BC's Mental Health System: Why it is failing & solutions to what ails it

Now, I'm no veterinarian, like the Honourable Terry Lake, Minister of Health, I'm only a lowly social worker, advocate, and now an educator.

In my career I've only worked in two different Health Authorities and several acute in-patient psychiatric units. Before that I spent several years as a child protection worker, working with clients with a wide range of mental health, and other issues. Prior to that I worked in the community, in youth detention and youth forensic settings. I also worked in numerous group homes and foster homes with children and youth with emerging mental illness. 

So, although I have no veterinary experience to fall back on, I have learned a few things over the last three decades of working in BC's social service and health care systems. 

What, no problem here, move along now

Minister Lake is disputing the claims of Mayor Gregor Robertson and Chief Jim Chu who are calling out for help from the provincial and federal governments for the mental health crisis that is occurring in Vancouver. 

Boldly, Lake asserts that he doesn’t believe building a hospital dedicated to psychiatric patients will solve Metro Vancouver’s mental health crisis. It's unclear how he came to this conclusion and whether he has bothered to come to Vancouver and taken a tour of ground zero of the crisis - the Downtown Eastside. One can only assume he hasn't, because anyone seeing the street spectacle that exists there could not fail to understand that there has been a massive failure to support and care for our most vulnerable citizens in B.C. 

How the civil mental health system fails

After working at the Forensic Psychiatric Hospital (aka Colony Farm) as a forensic psychiatric social worker, it became crystal clear to me that many individuals were not able to access the civil mental health system, both in the community and acute hospital care when needed. The outcome for some was that this led to further mental health deterioration and the increase in risk to themselves (suicide) and others (criminal acts). 

This view was strengthened after learning from my clients about the events leading up to their admission to FPH. In one sad, mad story, a young man described how he kept going to hospital trying to get admitted, telling staff that something was wrong with him. Again and again he was refused admission and put out on the street. He tried to explain to them that he was sick, and homeless. It was winter and he told me they would put him out even though he had no shoes. As a clever, desperate soul he decided to commit a crime so that he could at least get arrested and maybe get some help. He created a disturbance and caused some property damage in a restaurant. Bing, bang, boom, he was admitted to FPH and was able to get the treatment and care he required. 

In one particularly heartbreaking case, a young man who had been openly expressing suicidal and homicidal ideation for several years was not admitted to hospital, in spite of his family's advocacy for this. He ended up killing a family member. After speaking with one of his family members, whose life was ripped apart after this incident, and hearing about how the door to acute care was slammed in their faces, I promised that I would do what I could to give voice to how the civil mental health system was failing to support those who needed the care most. 

Ten days later, after I was no longer a Health Authority employee with a gag order on me, I had my first letter to the editor in The Province. I have now had five letters to the editor and Op-Eds published on the crumbling mental health system of care in BC. They all contain variations on the same message - the civil mental health system is broken, fragmented and is not adequately serving the most vulnerable people who are in need of timely, responsive assessment, stabilization and humane, dignified care. 

On Friday, Oct. 13th, 2013, I was interviewed on CBC's BC Almanac to discuss BC's mental health system and get my response to the two civil litigation cases that have been filed as a result of the alleged assaults of three women in 2012 by a man who had received care and was discharged from St. Paul's Hospital in the immediate period leading up to the brutal assaults. 

Speaking truth to power

I am one of those all-too-rare people who understands what it means to speak truth to power. I also know, all too well, what personal/professional costs occur as a result of my commitment to advocacy and speaking when others remain silent. I think it is safe to say I am probably viewed as "the enemy" to those who protect the status quo. What a sad state of affairs that truth tellers are vilified in our province, rather than listened to. 

As a social worker, I have a Code of Ethics that I live and practice by. This is what provides the foundation to my practice and my internal efforts at improving the quality of care and service when I have worked in health care and social service settings. I am proud to be part of a profession that "advocates change in the best interest of the client, and for the overall benefit of society." After working in our various systems, I became much more radical, structural and passionate about shattering the illusions that are constructed about how these systems operate. 

As I now teach my students, all of these organizations and systems are socially and politically constructed. They are not inevitable. We can, and should, construct and create much better, ethical systems of care, because individuals and our whole society benefits when we do this. We have models from other countries that reinforce effective, efficient, and humane care. 

Organizational and administrative priorities in health care

One of the themes I have been trying to articulate and bring to light in my multi-media advocacy is the direct role that organizational and administrative priorities are having on the culture of practice and standards of care individuals are experiencing in BC's health care system. 

In B.C.'s acute care settings, not just psychiatry, the priority is to weed out as many people as possible at the front door. If you can prevent people from being admitted this is the first line. If admission is unavoidable, then the next stage is to try to provide emergency treatment as quickly as possible and then discharge prior to admission to an acute care ward. 

If someone requires acute care and actually makes it onto an acute unit, then the priority is to start planning for discharge from the moment the person hits that unit. Medical personnel - doctors, psychiatrists, nursing, social work, and other health care professionals work hard to assess, treat and plan for patient's discharge back into the community. They fight to provide ethical, quality care for each and every patient in overwhelmed, complex, and challenging health care environments that are tightening the budgets at every turn. 

Operational and administrative priorities for moving people through the hospital system contribute strongly to the culture of practice that is driving this process. Administrators and managerial underlings have become obsessed by Length of Stay (LOS) numbers. These are the number of days that a patient has been admitted to hospital, and to a particular unit. Medical rounds often emphasize LOS numbers and pressure is often applied to care teams to decrease LOS for patients. 

All sorts of pejorative terms now exist to describe patients, such as "bed blockers," and "door clutchers," which operate to de-humanize and objectify human beings. After working a short time in acute care, I began to see that people were not considered human beings in these systems they are "beds." The process of stripping the humanity from those we were caring for serves the systems needs and interests and justifies increasing the speed of service and discharge. 

As a social worker, me and my colleagues had to attend weekly LOS administrative meetings on our unit where we were grilled and pressured about how quickly patients could be discharged. Our attempts at advocacy and explanations about psycho-social challenges and systemic barriers fell on deaf, uncaring and uninterested ears. Although I loved working with youth and adult patients in acute psychiatric distress, I could not tolerate the culture of practice, the risks it caused to my own professional practice, and I left that work, which continues to sadden me when I think about all of the people I could have helped and served. 

Complex care needs and  psycho-social needs

As many individuals with mental health issues, and their family and friends know, it is not uncommon for people with mental illness to have co-morbid and concurrent disorders, such as addictions, and complex health conditions. This population has more than their share of strikes against them including stigma, deep poverty, and insecure social support for chronic psycho-social stressors. 

One of the points I have been trying to also emphasize through my advocacy is that it is largely the B.C. government that bears the responsibility of the mental health crisis that is occurring, not just in Vancouver, but everywhere around the province. It is the real world outcome of a structural failure. Let me explain. 

System re-design and re-organization

The BC Liberal government devolved all health care services to six different Health Authorities from direct government. Each of those Authorities spent millions carving out their own little fiefdoms, complete with layers and layers of bureaucrats and managers who all made significantly more than those who used to work in government would have. We've seen this in every different devolved entity from BC Ferries, to BC Hydro, to Translink. We, as taxpayers, are drowning in bureaucratic and managerial salaries and bloat. 

It is within those fiefdoms that decisions about funding of different types of health care services and programs are made. The net result is that a patchwork of services and programs exists throughout B.C.'s various regions, with no centralized vision, leadership, authority, responsibility, or accountability. 

Earlier this year, the Representative for Children and Youth released a report called, Still Waiting: First-hand Experiences with Youth Mental Health Services in B.C., in which she identified the fragmented and under-resourced system of mental health services that was leading to an inaccessible and inconsistent system of support for youth

She wrote “The bottom line is that youth are often not getting help when they need it, and we are missing a key chance to prevent longer-term consequences for them and their families. This is a critical age range, when getting the right mental health intervention can be life-changing. We must build an effective and approachable system.” 

This is equally true of the child, adult, and seniors systems as well. 

Orwellian government speak

Minister Lake erroneously suggests that the issues need to be studied further. He couldn't be further from the truth. This is Orwellian government speak for lets pretend we're interested in doing something, without actually doing anything. 

Unlike his predecessor, Margaret MacDiarmid, who at least met with parents who were advocating for systemic improvements to the child and youth mental health system, Lake doesn't even seem willing to consider that the Mayor and police chief of Vancouver, might have some valid concerns. Instead, he denies the severity of the problems and plays the media game. 

Strategy and plan to improve BC's mental health system

Let me set the record straight. No more studies or research are required. For free, here is the plan the B.C. government can use to improve the mental health system and ensure that people with mental health issues in BC can have the same type of human rights and dignity most of us take for granted in accessing health care. 

1. Create a provincial role to take leadership of BC's mental health system of care - This is key to identifying and determining what mental health services exist around the province. Create a strategic plan that has a vision of strengthening and improving community, tertiary and acute care. A special emphasis must shift from a reactive, crisis-driven approach to a prevention, early intervention and consistency of care approach. 

This plan entails wide consultation with a wide range of stakeholders including individuals with mental illness, family and friends, health care professionals, advocates and others, including First Nations and various cultural, and immigrant communities and service providers. 

This plan must include and integrate best-practice and evidence-based research from other jurisdictions which have seen marked improvements and success in outcomes for people with mental illness and for communities. This will need to be translated into training and helping to change cultures of practice within the different Health Authorities. 

The goal of this is to create a consistent, accessible and humane mental health system of care for children, youth, adults, and seniors in B.C. 

2. Auditing and assessing how Health Authorities are funding mental health services - From community-based programs to acute hospital care to funding for community and tertiary and other forms of housing. 

This analysis must look at whether the number of front line professionals is adequate and what the impacts of under-staffing and resourcing is having in driving the ongoing mental health crisis for so many. 

In several Health Authorities, community prevention, early intervention and stabilization services have had their funding cut. These decisions will have downstream costs. If the police thought they were busy before, they will soon be receiving even more calls related to people who are sick and in need of care that used to be provided in the community. 

The predictable and inevitable outcome of these short-sighted funding decisions will be an increase in much more expensive emergency, hospital and acute care. 

3. Audit and increase funding for a continuum of housing - At this point, there should be some effort made by the BC government to audit and assess what housing resources are available to those with mental illness and determine whether an increase in funding needs to dedicated to this population around the province. 

Due to the complexity of living with mental illness and other conditions, a wide range of housing is required. This includes independent living, supportive housing, mental health boarding homes, locked specialized units, tertiary and long-term beds, as well as and low barrier housing and shelter beds. 

A community like Vancouver should have dramatically improved emergency and acute care services because police officers should not be de facto mental health workers and mentally ill people should not be locked up in jail for being sick and requiring treatment. 

I am not in favour of Riverview being re-opened because we need to get away from the idea that people with mental illness need to be locked up and out of sight. Institutional care has caused a significant degree of harm to previous generations. 

People with mental health issues deserve to live in communities and they do better and remain stable if they can receive the care, support and protection they require. 

Realistic and achievable plans

These suggestions are not the ramblings of an idealistic, naive, starry-eyed person. These are strategic, realistic and achievable plans. What is necessary to improve BC's mental health system of care for children, youth, adults, and seniors is strategic vision, and strong, ethical leadership. 

The B.C. government created this mess and they are the only ones who can fix it. This takes political will. 

When people with mental health issues receive the services and supports they require, they are able to lead healthy, stable lives where they are able to participate in meaningful activities and contribute to the community. This is the vision we should all share for every last citizen in B.C. because we become a richer, stronger province when everyone is able to participate and be included in our society. 

Additional sources

More BC Psychiatrists For Children Demanded By Parents' Petition

Dirk Meissner, The Canadian Press, 04/02/2013. 

The Representative's  report on youth mental health services in B.C., with focus on 16 to 18 year olds.
To view the report, click here.
To view the news release, click here.

‘We now have a mental health crisis on our streets’ says Vancouver police chief, urging action



Desperate Families of B.C.

I want to help promote a new project that Gary Mauris and his family are starting to increase awareness of the impacts of BC's mental health system. 

Desperate Families of B.C. is encouraging any family who has struggled to help a loved one with mental illness to email their story to:

Friday, March 15, 2013

BC's Collapsing Mental Health System for Children, Youth & Adults

My Op-ed on the failures of the BC government to properly fund, monitor and take leadership on the collapsing mental health system for children, youth and adults. 

Tracey Young: How many must suffer, die, before action?

The Province, February 8, 2013.

How many children have to hurt themselves or take their own lives before there is action? How many people have to be critically injured or murdered by individuals who are acutely mentally ill and in urgent need of psychiatric care before the B.C. government takes responsibility for the fact that the child, youth and adult civil mental-health systems are failing an increasing number of people?

The names in the media articles change, but the stories remain the same: mentally ill people, some of whom are openly aggressive and violent toward others, often family members, or those who express suicidal and homicidal ideation to mental-health professionals, deteriorate to the point where they hurt themselves, harm or kill others. These incidents are not random and we must connect the dots to see why this is happening in B.C.

When family members see tragedy bearing down like a runaway freight train, why do they have to struggle alone and powerless to get their loved ones help from the only systems set up to provide it — the community mental-health system and the acute-care psychiatric services in hospitals?

Having worked as a psychiatric social worker in the youth and adult forensic psychiatric and civil mental systems I am unequivocal in stating that mental-health assessment and treatment has never been more difficult to access for children, youth and adults. The system of care from community mental health to acute psychiatric-care units, to long-term tertiary care, to supportive community housing is vastly underfunded and understaffed.

Many professionals working in this area of practice also do not have adequate training and ongoing professional development to ensure they are working together to provide the most competent, ethical and evidence-based care possible.

If someone has a broken arm, an acute heart condition or any other serious physical condition we would not dream of denying them access to health care. This is radically different for mental-health injury and illness for people of all ages. Mental illness continues to be stigmatized, just like those who suffer from mental health issues, who face extraordinary discrimination in daily life.

The B.C. government, in their 2010 report, Healthy Minds, Healthy People, stated that “over any 12-month period, about one in five individuals in the province will experience significant mental-health and/or substance-use problems leading to personal suffering and interference with life goals.” So they have at least recognized the immensity of the problems that occur for individuals, often starting in childhood.

The report goes on to state that a “recent Canadian study has suggested that mental illness costs the Canadian economy $51 billion annually in lost productivity — B.C.’s proportional share of this burden would be more than $6.6 billion each year.” In spite of creating these lofty reports, which lack concrete plans, something is going horribly wrong in the process of designing, implementing and carrying out services around B.C.

Thankfully, the office of the Representative for Children and Youth is studying the child and youth mental-health system, but the entirety of B.C.’s mental-health system of care from cradle to grave must be put under the microscope. Mental-health services are fragmented and regionalized across six different health authorities and the Ministry of Children & Family Development for children and youth.

All of these organizations have created their own bureaucratic infrastructures and administrative cultures, which has led to a serious lack of oversight, monitoring and accountability and no cohesion, sometimes even within the same organizations.

The B.C. government must take strong, decisive leadership to create a comprehensive, accountable plan that includes measurable goals for mental-health services across the province to ensure timely access to care and best practices in assessment and treatment are occurring within the system, within all program areas and organizations providing services.

Efforts must also be made to change the structure and culture of practice within the mental-health system of care. As many families find there are complex barriers to accessing both community and acute psychiatric hospital care for children, youth and adults. If individuals make it into acute-care units, structural and administrative priorities of moving people out of acute-care beds as fast as possible have replaced client-centred care, treatment and effective discharge planning to ensure that gains made in hospital are maintained as people transition back into the community.

There must also be increased training for clinicians working in the system in assessing risk of self-harm and violence toward others as it has become all too clear that the civil mental-health system is often failing to adequately assess these risks.

In media story after story we learn that individuals were given cursory assessment and “treatment” in the civil system and then went on to commit violent crimes, often later being found Not Criminally Responsible on account of Mental Disorder.

A provincewide acute psychiatric care system that prioritizes getting people out of beds over a slower, measured process of assessment and treatment is leading to a normalization and minimization of risk factors that put individuals at risk.

Albert Einstein said the definition of insanity is doing the same thing over and over again and expecting different results. I am labelling the current B.C. government as the ones who are insane for sitting on their hands, year after and year, ignoring the tragic failures, impacts and loss of dignity and human life that is resulting from the failures of the mental-health system of care that they have created.

With the provincial election occurring on May 14, it is time for all political parties to get real, get concrete and to stop twiddling their thumbs and inform voters what their strategic plans are to improve the mental-health system of care for children, youth and adults.

Individuals with mental illness, family members, professionals working in the field and concerned citizens have surely run out of patience waiting for the B.C. government to improve accessibility to the entire range of mental health services needed, improving outcomes and enabling people to live with the dignity and rights that everyone else takes for granted.

Tracey Young is a registered social worker, a consultant and counsellor in private practice, a writer and an advocate.


Wednesday, January 30, 2013

Community Living stories in the new again

Campbell River mom, daughter one of first to test new Community Living B.C. waters

Sian Thomson, Times Colonist, January 29, 2013. 


A Campbell River mother and her special needs adult daughter are one of the first families to test the waters of the new revamped services from Community Living B.C. 


Victoria Allen and her special needs adult daughter Becky have become one of the first two "test cases" according to David Hurford, Director of Communications for Community Living BC (CLBC).


Allen had to stop working to care for her daughter 24/7 and repeated and exhaustive attempts to get this corrected fell on deaf ears, she said. 


"It was one meeting after another, one email after another, one phone call after another, all with no answers , just more delays, more "no's" more frustration, mixed messages," she says.


Allen was getting desperate because she had a permanent job offer and did not think she could take it unless CLBC put services back in place for her daughter so she could work.


Allen's Becky has multiple disabilities and requires daily care and supervision. When she turned 19, the responsibility for her care shifted from the Ministry of Children and Family Development (MCFD) to CLBC which funds support services for adults and youth who have developmental delays and learning disabilities.


Up to October 2012, Allen received support through a funding agreement with CLBC. While Allen used to work while Becky was in a day program and respite care, "as of Nov. 23 everything was gone" she said.
"CLBC wanted to move Becky out of my home and into a home share," said Victoria.
"For the past year and a half everything was great," said Allen. "Becky has been having less seizures, hardly needs to use her walker anymore, and is so happy, very affectionate with me. It is the happiest and most at peace she has been in a long time. Then they told me her only options under CLBC funding were home share or a staffed home. So they wanted to move her out of her home with me and into a situation that would cause her stress and set-backs."

Through a series of failed attempts after being placed in living situations away from home while Becky was growing up, her mother says that her health and safety were neglected and put at risk.

"She had been physically and verbally abused, isolated, and stressed," said Allen. "And again they wanted to take her out of our home and move her into a home share where it would cost a lot more than what it does not to keep her with me."

The funding she received paid for the trained caregivers required to keep Becky living at home, and attending a day program part time, while her mother worked. Funding also paid for a respite care provider to take Becky two weekends a month. The funding was paid directly to the care providers.

"Without the funds CLBC was paying to Becky's care providers, I have to drive her where she needs to go, pick her up, supervise her, take her to the doctors, I am with her 24/7. I cannot work under these conditions," said Allen.

But instead of renewing the agreement that was already in place and working, Allen says she was told to take out a personal loan to pay for her daughter's care.

Hurford says that the Allen case is one of the first to test the waters since the new and improved quality service measures have been implemented but Allen continues to feel the stress of being set adrift by CLBC and waiting for help to come.

Allen reports that currently there have been some services put in place since the Courier Islander contacted CLBC, but said Becky had already been injured from a fall when she had a seizure on the first day she left her with a caregiver and went to work. "I still have nothing in writing, they tell me everything takes time, everything is complicated. I am working for now, but I don't know how this is going to end up."

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