BC’s mental health system has many serious problems. Here’s a big one:
Those not in acute crisis are faced with few effective treatment options, long waits, and repeated failures.
Yes, we need more resources. However, we must use resources better.
We deliver too many “interchangeable units of mental health care” that tie up clinicians but provide limited benefits.
We must deliver the right care at the right time to the right person as part of a larger evolving plan.
This document explains the problem, its causes, and how to fix it.
The crisis in acute care, or lack thereof, is a separate but connected issue. The disasters in emergency/crisis care, the abuses supported by our archaic Mental Health Act, and the human devastation that is all too visible well beyond the DTES and Pandora are huge issues.
But here I’m concerned with a problem that affects far more people yet remains invisible. Until it affects you.
Access to Mental Health Care is a Cruel Joke in BC.
All the delusions about “just ask for help and you’ll get it” don’t obscure the facts.
For most, therapy is out of reach financially or limited to a small number of visits for specific purposes. Millions have no access to primary care or 10min visits with a rotating set of providers — totally useless to provide care. This is what happens to most people:
Stumble Randomly Into Care
Have an EAP? Google a counsellor? See a doctor at a UPCC or Telus Health?
That will largely determine what care you get. It may not be what you most need. It may not even help you at all. It’s unlikely you’ll be connected to the most appropriate resource.
Of the hundreds of mental health “treatments” out there, how is anyone supposed to know what’s the right thing for them? Already vulnerable people are struggling on their own to find help and are easy prey for profit-driven quacks. The person you see is likely unable to connect you with a more appropriate resource and, at best, will usually offer very general suggestions (e.g., Google a counsellor) to pursue on your own.
Receive One Round of Care
What care you get depends on who you see.
What might that look like? Depends on where you go.
| Counsellor? | Maybe 6-10 sessions of supportive counselling. |
| Group? | Maybe 8 sessions to learn general CBT or mindfulness skills. |
| Primary care? | Maybe an antidepressant trial or a referral. Or nothing.
Mental health problems take too long for doctors at walk-ins, UPCCs, or Telus Health, who will likely never see you again. While they have the training and skills to properly treat most common forms of depression and anxiety, it’s to their advantage to either say you’re fine, write a quick prescription for a medication (that likely won’t help you), or refer you to a psychiatrist (who they know will take a year to see you). |
| Psychiatrist? | A single one-hour assessment after a year wait.
Recommendations from a single short session with an unfamiliar treatment provider are rarely sufficient. Even then, too often, those unhelpful recommendations are sent back to a nonexistent primary care provider to implement. |
When Complete, Start Over
Not better? Now what? Repeat from scratch.
When that one round of care is done, often that’s it. On your own, work up the nerve to ask for help again. Stumble into another random provider offering another random treatment.
When people can’t get the help they need for too long, they often end up in emergency rooms, the last place to deal with a long-term chronic condition. They don’t have anything to offer. Their frustration at being expected to pick up the pieces of a nonexistent system gets taken out on neglected patients with limited options and fewer legal rights.
What’s gone wrong? Look at the features of the care we’re providing.
Interchangeable
There are no “standard” mental health treatments. Everyone’s needs are different. But we funnel people into what’s available, not what they most need.
A counsellor won’t help with a metabolic deficiency. A doctor won’t help with family dynamics. A CBT group won’t help with dissociation from trauma. The ER won’t help with long-term treatment planning.
Ineffective
Even if people are in the right place, clinicians often can’t fully listen, diagnose, tailor their treatment plans, educate, and monitor responses. So treatments fail.
The time, tools, and resources aren’t often available because they don’t fit into the idealized model of care the clinician is supposed to provide. Structural constraints reduce the likelihood of getting positive results. Visits that accomplish nothing are an unnecessary drain on the system.
Isolated
Even appropriate care doesn’t always help. Then what? Likely the person starts with another clinician in the future, and anything that might have been learned is lost.
Clinical silos create an epidemic of starting from scratch. People are seen for repeated “initial” consultations. Transitions are non-existant. Clinicians are rarely able to obtain or have the necessary time to properly appreciate insights from previous care.
We Keep Doing the Same Thing
Over and Over Again
… and it’s Still Not Working!
It’s almost like we’re looking at this the wrong way.
Family doctors, psychiatrists, counsellors, psychologists, nurses, and social workers — all provide designated mental health services. They get paid (often by the government) to provide specific services.
Clinician View
People see these clinicians (chosen at random) and receive their services. From the clinician’s view, they’re done their jobs to the best of their abilities (and gotten paid), so they’re happy. All done.
Government View
From the government’s view, they’ve delivered X units of “mental health care” (think Soviet-era factory output), so they’re happy.
Patient View
Oh, right. That’s what we forgot.
We keep paying for more interchangeable units of mental health care and getting too few results.
Let’s make better use of our valuable resources.
- Psychiatrists and psychologists could assess and treat complex patients instead of repeat superficial one-time assessments.
- Emergency departments could deal with emergencies instead of people who can’t access longitudinal care.
- “Write-only” documentation can be replaced by effective communication between clinicians.
- Family doctors could take the time to listen, diagnose, educate, and treat patients rather than rush them out the door.
- Services and groups could be utilized because they’re appropriate, not because they’re all that’s available.
Three Essential Ingredients For Good Care
It’s not a mystery how to provide good mental health care. Many trained professionals can do this. But it takes three things that are rarely available.
Individualized
The diversity of mental health concerns and causes is astronomical. Treatment needs to reflect that. There is no one-size-fits-all treatment. No silver bullet.
Treatment is also complex and unpredictable. Guidelines for one type of treatment for one type of illness run dozens of pages. For one illness!
Some people’s needs can be met with a short course of treatment; others require much more. The path to wellness is different for everyone and needs to consider a wide range of factors.
Sufficient Time
Listening, understanding, asking questions, building rapport, clarifying diagnoses, educating, supporting, considering a range of treatment options, trial-and-error, and evaluation — these all take time.
It’s easy to cut corners and miss out on something essential for treatment. Unlike illnesses that can be assessed by a simple test and treated with one pill a day for seven days, mental illness is complex. Effective treatment is greatly influenced by patients’ involvement in multiple aspects of their treatment plan.
Continuity
While mental health problems are sometimes short-term, they often persist for years. Treatment is, above all, a learning process that builds on what’s been learned previously.
Continuity in treatment means not repeating the same story from the beginning multiple times. It means that the lessons learned can be applied to tailor future treatment. Rather than picking a random treatment provider every time and hoping you’ll get lucky this time, continuity helps address the burden of chronic illness.
The examples of interchangeable, ineffective, and isolated care described above (a small fixed number of individual counselling sessions, a group CBT or mindfulness program, an antidepressant trial, and a one-time psychiatry consultation) fail to deliver all three of these ingredients.
We deliver mental health care as a one-size-fits-all, short-term treatment for a discrete episode of illness.
That doesn’t provide the help people with chronic mental health challenges need.
The place where continuity is supposed to exist in our system is longitudinal primary care, where patients are attached to and repeatedly see the same family doctor (or nurse practitioner).
Most mental health care needs should be met in primary care, but they aren’t. Our system keeps that from happening.
Few people have sufficient access to primary care.
In BC, over a million people aren’t attached to a primary care provider. Many of those who are cannot see them promptly or frequently enough. Many are not comfortable addressing mental health concerns.
Family doctors are penalized if they spend sufficient time.
Even with the new LFP payment model, family doctors are financially penalized if they spend the time required to do good mental health care with patients. Doctors bill 55% more if they see six patients per hour instead of two ($280 vs. $180). That’s a strong disincentive to spend sufficient time.
Under traditional fee-for-service, special codes for counselling and mental health treatment planning could be billed if more time was spent (not ideal, but something). Those aren’t available under LFP.
No access to appropriate mental health resources.
Primary care doesn’t have specialized mental health resources available to send patients when needed. Psychiatrists take one year to see and provide limited help. Counselling or psychotherapy is not offered. Mindfulness and CBT groups are available — because family doctors run them. So people get sent for generic, one-size-fits-all treatments that may not be appropriate — because that’s all that is available.
Towards a System Built for Patients
The right care at the right time to the right person
as part of a larger evolving plan.
Recognize everyone has different needs, and these needs change over time.
A lifecycle model that’s iterative and continually evaluating and learning.
Where people aren’t dropped after each step.
Collaborative, Iterative, Cohesive Treatment Plan
Goal-driven care, provided for a purpose. Constant evaluation and managed transitions. Effective navigation. Universal, cumulative, collaborative, annotated patient profiles.
Quickly get people to the right resource the first time through. When done, evaluate and transition, don’t drop. Track outcomes. Repeat failures should trigger questions, escalation, fresh eyes, and devoting more sophisticated resources. If people stall out, we need to notice and do something, not keep going in circles.
Effective Use of Resources
Sufficient clinician time and resources to deliver results. Deliver the right care, not just what’s available.
A large enough pool of resources; we make access quicker by not using them up on people who won’t benefit.
Reduce draining resources through one-size-fits-all interchangeable care.
How We Get There
What we don’t do: A high-level, committee-driven, consultative synergized integrative paradigm shift accompanied by 600 hours of meetings, executive appointments, endless PowerPoints, and glossy reports.
Instead, build from the grassroots, iteratively. Give the front lines time to address problems up front. Increase the pool of specialized supports they can access by reducing the delivery of inappropriate care. Identify, evaluate, track, and escalate chronic failures.
Who can be responsible for treatment planning? What do they need to do it?
Family Doctors
They’re skilled healers, not triage clerks. They need time to do their jobs without being penalized for it and access to the pool of available resources their patients need.
Psychiatrists
Spend more time treating patients vs. superficial assessments. Manage the full range of biopsychosocial interventions over the treatment lifecycle. Fill the gaps in care.
Psychologists
Experts in proper assessment and broad knowledge can do much more than deliver therapy to whoever walks through their door. This is an exciting opportunity to incorporate them into the public system.
Patients and Families
An untapped and under-utilized resource that’s both inexpensive and plentiful. Rather than leaving them to flail with Dr. Google, provide the right education and support. They can fill many gaps in the treatment lifecycle.