Friday, June 11, 2021

Mental Health Reform: reflections & ideas for change

On February 1, 2020 I began work as a psychiatrist at my own private office.  

Before then I worked at a large academic institution for about 20 years, and was the leader of the psychiatric team there for 13 years. I have always loved my work very much.  I have been very privileged and lucky to have had such a job, during those 20 years.  It has been meaningful and enjoyable, for the most part, to care for my patients over the years.  And there were many wonderful colleagues and other staff at my clinic, who made our work more enjoyable, safe, and helpful.  We worked very, very hard.  There was a sense of community, like a type of family.  But I feel incredible relief to have left this position.  Now, after 15 months away from it, I feel I can have a gentle reflection upon some of the problems which developed there over the years. 

I would like to describe some instances of what I think can go wrong during a well-meaning effort to plan for change in community mental health care.  I do not want this post to be understood as a ranting complaint from a disgruntled person, but rather I would hope to simply tell the truth, from my point of view, about some events that happened, with reflections on ways to prevent such problems in the future.   I am happy and grateful for my present and my past, but I do feel there are a few things to be said.  

Mental health reform became a big issue in the community where I worked, over the last 5 years or more.  A lot of extra money appeared in the budget for this, and some care was wisely taken to plan for how to spend it. 

Many meetings took place, to discuss mental health care reform.  

A team of consultants from another country was hired, and flown over several times to assess the situation. I presume this occurred at quite considerable expense.   Their recommendations and presentations appeared to be a very polished lobbying effort.  During these presentations, which included some academic citations to support their positions, there was never actually any room for debate about the research they were citing or for the positions they were advocating, despite the presence in our academic community of many experts.  

A plan eventually developed, devoted to the idea of collaboration among different helping disciplines.  

The meetings would tend to begin with a lot of self-congratulation about progress, followed by lengthy, repetitive monologues, laden with jargon.  I was usually the only psychiatrist present in all of these meetings.  I was always very concerned that I never come across as arrogant or disrespectful of others, given my own privileged position.   I abhor professional arrogance,  so I aimed to remain quiet, to be calm, to try to listen respectfully. 

But eventually, after many hours of such meetings, I realized that major decisions were being made about health care planning, with a lot of money involved, with almost no debate or critical challenge.  These changes affected my patients, my colleagues, my morale, the group's morale, and my own philosophy of practice.    Almost none of the money was directly helping my clinic.  I personally did not have any voice in these meetings: my comments or input were not welcomed, and I think I actually was considered difficult or uncooperative because I didn't seem to go along with the plan.   On several occasions I was told, very directly, to discontinue my comments.   When I gathered feedback from professional colleagues (who otherwise had no voice in all of this), and summarized their comments in a brief written document (as was requested of me),  the document was rejected, and never submitted, because it was deemed not positive enough.  

The foundations of my own philosophy of practice are simple:  make time for patients, listen to them, be available, be gentle, be kind, build trust, be humble, try to honour a patient's wishes.  I believe that good care cannot be rushed.  Mental health care can sometimes be done with great efficiency and speed, but more often it takes a lot of time and patience.  Almost everyone I have ever seen in my career has been tired of seeing people for help who did not really have time for them.  

In terms of larger-scale, organizational philosophy, my foundation would also be simple: take care of the staff!  Everyone, including cleaning staff, clerical workers, nurses, GPs, and specialists, should feel safe, respected, cared for, and heard, in a healthy organization.  Be on the lookout for "burnout" especially when a system is strained by high demand.  Policies that seem efficient on the surface may be quite deeply harmful, if they lead to a type of "assembly line" experience for either the staff or for the people trying to access the system.    

Some tools of efficiency, such as computerized records systems, may seem efficient, and may have many uses, but they may be expensive, inconvenient, slow, prone to error, time-consuming, obstructive to rapport with patients, and very heavily marketed by software companies which are earning a lot of money, often trying to sell impressive-sounding features which are actually unnecessary (I feel very fortunate to have found a perfect electronic records system myself, called "Jane," which is far superior, and much less expensive, than the system used at my previous workplace).   

 One reason I wanted to speak out, even at risk of sounding "difficult" or uncooperative, was to advocate for my patients. I was responsible for the care of patients with the most severe, chronic mental illnesses, yet my input about mental health was not allowed, or was met with rolled eyes and even direct requests that I stay quiet.  Furthermore, none of my psychiatric colleagues were ever present or allowed to contribute to these meetings, beyond a couple of occasions in several years. These colleagues were never officially on the payroll, they always worked privately and paid overhead to be in our group. In fact, my psychiatrist colleagues were always a free service from the point of view of the institutional budget--they actually earned money for the institution by paying overhead.  They earned less money than most other psychiatrists in the community, but stuck with the group due to their love of the work.  These colleagues never had any voice in the institution's mental health care policy.  I felt that I had to speak for this group as well. 

This went on for years. Patient care suffered.  I was the only person in all of these meetings able to do psychiatric consultations for people with severe illness who had been waiting for months, yet I was sitting in redundant, lengthy policy meetings in which I was not even allowed to contribute.  I thought of my patients, which led me to try to speak up, even at risk of sounding "difficult."  

One of the themes of the new policy was "collaboration."  But ironically, because of the policy meetings, the actual collaboration meetings which I and my counselor colleagues had enjoyed for years, in which we would discuss mental health care in general, as well as immediate, serious clinical issues about specific students, were cancelled.

One summer, there was a series of meetings devoted to drafting a formal care algorithm for treating depression.  This was yet another absurd journey.  The subject was the foundation of what most of the counselors in the group had studied for years, in graduate school.  The subject was arguably the focus of my entire 20-year career.  Yet, once again, I and other experienced professional colleagues were mostly silenced, and assigned into small groups to prepare some kind of treatment "algorithm" in an essay-like form. I thought of all the patients who were not seen while we were doing this.  

This was especially troubling, as I found the whole process more and more ethically objectionable.  We should begin by ensuring that people are assessed well, are respected, are heard, and their wishes about their own care honoured to the best of our ability.  Many algorithmic branches should be negotiated by a well-educated caregiver and the patient or client, not dictated by a flow chart.  Good care requires deep attention to building a trusting, caring relationship, empathy, understanding, and a therapeutic alliance.  Furthermore, restricting any "algorithm" to only consider depression is inappropriate, since most people coming for help have various other problems other than depression, which would all have to be considered together. 

During another meeting the entire group of 100 or so people was asked in advance to fill out a Myers-Briggs questionnaire.   The entire group was subdivided according to their Myers-Briggs personality type, and made to sit at separate tables.  Some Myers-Briggs types are more rare, while others are more common.  Many tables were full.  A few tables had only one person.   

The Myers-Briggs personality assessment has very limited validity.  It can lead to fallacious polarization of traits which actually lie on a continuum.   But in any case, personal testing data about psychological traits or symptoms is intimate:  it is arguably in a similar league as any other medical test.    It is inappropriate to have to share such information in a group setting.  There were a few people in the less common personality categories who ended up sitting alone.   To divide the group up like this was an example of what NOT to do with mental health labeling: to actually separate people on the basis of differences, leaving some people alone.  It was introducing new labels, stigma, and separation, needlessly.  To top things off, it surely would have cost money, going to a company making large profits,  to purchase these tests.  In addition to the cost of paying everyone's salary for this, there was also the cost of room reservation and catering.  Most importantly, there was once again the cost of severely ill patients who were not being seen.  

Another meeting featured a visiting expert, who had some national fame.   I would once again love to know how much his travel expenses and speaking fees were.    He was a charismatic speaker, with remarkable orational skills.  Everyone loved his presentation.  But one thing stood out for of his opinions had to do with what he thought were excessive mental health resources being offered to people with what he considered minor problems.  In a hushed tone, he summarized the problem as being "narcissistic entitlement" on the part of the people seeking mental health care.  I have no doubt that there is a lot of narcissistic entitlement out there, but to dismiss an entire category of people, and to advocate for major policy change in mental health, based on this assumption, is prejudicial.  I have to wonder how often some famous policy-makers actually work with patients in a therapy setting.   Once again, there was no actual debate on this, just discussion groups affirming what had already been said.  

Another meeting was entitled "Stepped Care Anxiety."  It was a presentation led by a local research psychiatrist with a lot of experience in community programs, though someone who spent little time actually seeing or caring for patients at this point in his career.  Once again, clinical care of patients was cancelled in order for staff to attend this presentation.  Initially I thought the meeting would literally be about "stepped care anxiety"-- that is, anxiety induced in caregivers upon being presented with another tiresome trendy catchphrase.   But the title was actually just a product of some difficulties with English, and the meeting was about "stepped care FOR anxiety."  Basically, the idea of stepped care is to offer more care to people who have more severe problems, and less care to people with less severe problems.  As people improve, start to reduce their level of care.  This is a statement of the obvious, of course, and is what all of us would naturally do anyway.  There seemed to be an implicit assumption that psychiatrists in particular would be seeing patients unnecessarily, even if they were well or not in need of further care, and that we needed guidance to step away from this wasteful practice.   I was asked to be well-prepared for this meeting, by reviewing the materials in advance.  But once again there was no real meaningful discussion about this, aside from a review of obvious principles.  A deeper discussion of care would have allowed for the idea of actually spending time to know patients over a longer period of time, regardless of symptom severity, so as to prevent severe recurrences of mental illness, rather than saving our clinical attention only for emergencies.   Stepped care, when applied dogmatically, is yet another ideological system which leads to superficiality of care, a type of fast-food equivalent in mental health provision.  

After a lull in these meetings, the next chapter began with new hiring in the institution.  This time even more money was spent on expensive administrative positions, instead of on badly-needed direct health care.    Some of the administrative positions were filled by clinicians, so in addition to the cost of paying these administrative salaries, an extra cost to the community was of an expert clinician paid to do office work and attend meetings instead of using desperately needed skills to help patients directly.  I think of how many hundreds of thousands of dollars per year were spent on this increase in administrative funding, while actual clinical care languished.  Our clinical unit had barely grown in decades, despite serving a community which had rapidly expanded, perhaps even doubled in size.  Encounters with the administration were negative and morale-depleting.  I dreaded them.  I really just wanted to see and take care of my patients.  My other priority was to take care of my coworkers and colleagues.  But I felt powerless to do anything for them.    

One of the meetings--again arranged by cancelling our actual work with patients--was with a visiting specialist who had invented a new way to see more patients more quickly.  A psychiatrist would join a GP for a 30-minute "mini-assessment."  That way, more people could have psychiatry assessments, there would be shorter wait lists, and the primary care doctors would feel more supported.  Once again, there was no opportunity for any critical discussion, during or after this presentation.    The thing is, such assessments are pretty much the opposite of what I consider to be good psychiatric practice.  Assessments cannot be rushed.   Imagine if you had to see someone for a difficult, very personal problem or issue, and had to discuss it in 30 minutes, with two people in the room, one of whom a stranger, with the understanding that your future care would be guided by the new expert's opinion during this fragmentary discussion.    It is arrogant on the part of psychiatrists to assume that extremely brief visits could lead to diagnostic or therapeutic insights that the other caregivers had not already thought of.    Such brief assessments, and other schemes in mental health care similar to them, tend to bias the conclusions towards medication management, since this is the easiest type of thing to construe in a short assessment, without knowing a patient well.    Assessments and good care take time--there is no avoiding this!  Relationships cannot be rushed.  

Satisfaction surveys following such changes could also be quite biased and misleading, in the same way that taking a survey of people leaving a fast-food restaurant could give a biased view of food services quality in a community.  Many people might be quite pleased to have convenient fast food, but those who would suffer the most from such policy would not be included in the survey, since they would not be using the services.   

I am deeply relieved to have left that place!  But I miss my colleagues, I know they are good people and skilled professionals.   My decades of work there, despite the frustrations at the end, were a labour of love, for which I am deeply grateful.  While I have voiced some complaints above, the years at my previous position helped make me a better person, and taught me a lot about how to be a good doctor. 

Here are some basic ideas, based on my experience, for organizing a program of mental health care reform: 

1) the expenses involved in the reform program should always be transparent, especially in a public institution.   If consultants or experts are brought in to give presentations to the group, it should be clear to everyone, including the public, how much money was spent on their travel expenses and any other compensations.   Catering and room costs should be made clear.  And most importantly of all, if there are 100 helping professionals who spend 3 hours at a meeting, it should be made very clear that this represents a cost of 300 person-hours of  care.  That is, 300 people could have had a 1-hour therapy session or evaluation.  30 people could have had a basic 10-session treatment for depression or an anxiety disorder, which could possibly have saved lives.  

2) critical debate should always be welcomed.  If there are experts in the group, their expertise and experience should be shared.    If a visiting expert is flown in, the group's responsibility is not to simply compliment the visitor, listen politely, and clap -- at a major academic institution, or anywhere else in society, there is a responsibility, a duty even, to engage in vigorous, intelligent debate, especially when there are critical issues about health, well-being, and morality, being discussed.  

3) it should be absolutely unacceptable for anyone working in the system to feel that their voice or opinion would ever be suppressed. 

4) consideration should be given, at a very high priority, to the morale and well-being of the workers, not just to the efficiency of the work.  

5) if there are to be catered lunches and time off given to staff for collaborative meetings, or to bolster group cohesion, then ALL the staff should be included, including the cleaning staff.   Most of us don't even know who the cleaning staff are.  

6) I have a very specific idea about the economics of care provision.  There are many underemployed counselors in the community, who often have to spend a lot of money renting private office space.  Many can't make it, and end up working in some other field.   But there is a lot of office space vacant in large institutions or campuses during evenings and weekends.  This space could be offered at a very low or free lease rate, to increase the number of hours of care available for people in the community.   This would be a win-win situation for underemployed counselors as well as for the community of people in need of more care.   Clinical office space should be provided with a much higher priority than administrative office space, particularly when there is a severe shortage of clinical care.  

For salaried care workers, I think that a blended payment model (that is, baseline salary plus some component of "fee for service") would be very efficient to increase care provision.  Some workers (counselors or doctors) might want to work longer, or less typical,  hours, and I am quite certain that there would be a high demand in the community for these extra hours.  But there would have to be a fair and convenient model of compensation.    Current salary schemes do not allow such flexibility.  

If you are interested in mental health policy, I encourage you to use your voice,  to be aware of changes going on in your community, and to get involved in the reform process. 

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