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