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: