On The Inside Looking Out

As I sat in the crowd at the Royal Ottawa Mental Health Centre to hear a special announcement there was an air of expectation from those gathered to hear the guests who were there to speak for this auspicious event. While Canada tends to not get as caught up with the idea of the “First Family” as they do in the United States, it is still something of a big deal to have the wife of a former Prime Minister attend an event, particularly when that former PM is none other than Pierre Elliot Trudeau, and the wife is none other than Margaret Trudeau, a women who has become a strong advocate for mental health while waging her own battle with bipolar disorder in a somewhat public ordeal that culminated with a public confession of her condition several years ago, after having to enter the Royal Ottawa for help after the very public loss of her son in a tragic accident. What Margaret Trudeau could not hide from the public she has turned into a vehicle for dialogue to battle the stigma associated with mental illness. She has used her own pain to heal the wounds of others.

It was that help that Margaret Trudeau spoke of when she addressed those assembled on Monday, September 28. Hearing about her past, however, was not the reason we had gathered together; everyone was there to hear about the newly christened room next to where we were all assembled: a resource centre that was named in honour of the woman that had made it possible, Ottawa philanthropist Shirley E. Greenberg. Thanks to the single largest donation (to date) to the Royal Ottawa, a donation of $1.5 Million, the hospital has been able to create a much needed resource centre specifically aimed at the unique needs of women as they face the challenges of mental illnesses from the perspective of the female physiology. The Shirley E. Greenberg Resource Centre for Women will be the focal point for new programs aimed specifically at women seeking help, women seeking the tools to deal with their illnesses and to find resources that they may not be able to find under a traditional setting.

The entire point of the event was, of course, the announcement of the donation by Shirley E. Greenberg, and her short speech was well worth hearing, but that was not what caught my attention. Then again, I am somewhat crazy. From the perspective of one sitting on the inside, looking out, as one who is referred to as a “consumer” of the “services” provided by the hospital, there was a speaker at the ceremony that struck me as having a message that was quite interesting, if more for what she did not say than for what she did say. I am referring to the Honourable Laurel Broten, Minister Responsible for Women's Issues and the Minister of Children and Youth Services. Minister Broten made the usual political “boxed” speech about how wonderful it was to be a part of such a tremendous event, but then she turned down a different route: she decided that it would be a good idea to use Shirley Greenberg as an example.

While there is an absolute incontrovertible need for the Resource Centre for Women, and for research to be aimed specifically at the way mental illnesses effect women, what Minister Broten said that made me take notice was her assertion that this donation from Shirley Greenberg was an example of how well the private sector could work with the public sector in providing the services we commonly call Health Care in Ontario. She remarked that this gift was similar to that which was being given by Bell Canada, which had provided $1 Million to the Royal Ottawa for the tele-psychiatry program. Minister Broten expressed her opinion that this was a wonderful example of how well the partnership between the private sector and the public sector was working; we had this new building, and now we had these new funds to look forward to as well. The only problem is that this only serves to provide the government with the false impression that they do not need to maintain their current level of funding, that they can continue to cut the amount that they have been spending on mental health care with the false belief that “someone else” will pick up the slack.

With all due respect, the Honourable Minister is wrong. Philanthropy is not the answer to the health care crises facing this country and believing that it can be is, to quote a phrase, magical thinking.

Mental illness has been steadily increasing as an issue, yet the level of spending has not kept up with the need. In 2008 only one Canadian province had a lower percentage of annual spending on mental health than Ontario: Saskatchewan. Saskatchewan designated 3.5% of its health care budget, or $146/person, while Ontario designated 4.3%, or $185/person. As a nation Canada also falls behind in spending when it comes to mental health as a part of the total budget. Falling short is really an understatement: when it comes to the allocation of spending on mental health Canada came in last, tied with Italy, spending nearly $6.6 Billion on this important matter, but that only represented 4.8% of our total health care budget or $197/person. On the other side of the spectrum, the nations that spent the most, as a portion of their total health care budget, were Britain (12.1%), Germany (10%), the Netherlands & Denmark (8%), the United States (7.5%), Ireland (6.8%) and Australia (6.7%).

The amount of money spent on a problem is obviously not the only determining factor as to the success of the programs in a nation; if it were the United States would not be experiencing the problems that they have in this area, but that has as much to do with the misallocation of funds and poor management rather than the actual available funds. In Canada, where our health care system is inexorably tied to the public money used to provide health care for everyone on an equal basis (in theory), there is an increasing inequity when it comes to the treatment and funding of mental illnesses. This inequity effects our society on two levels: first it has a direct bearing on the patients receiving treatment, making it increasingly difficult to gain access to the necessary services to maintain their health. On the second level it effects society directly as it must pay for the ramifications of a poorly maintained system that continues to allow individuals with potentially serious and, at times, life-threatening illnesses “fall through the cracks”. These individuals sometimes end up living on the streets, in a battle with more than their mental health issues, often with addictions to alcohol or illicit substances as well. The lack of appropriate primary mental health facilities – in other words, the lack of enough beds and staff that are equipped to deal with long term cases – has forced these individuals to rely on secondary health care providers such as over-extended clinics that are not prepared for transient psychiatric clients, family practitioners (if available) and emergency services when their health ultimately fails or their mental status requires a medical intervention of some sort.

The cost of mental illness to our society continues to increase yet the funding has not been keeping pace, putting a greater strain on the service providers of our society who are being forced to make due with less resources while provincial governments seek out ways to cut corners and save money by cutting funding to the mental health programs and abdicating their traditional responsibilities by partnering with businesses in order to “maximize” the profitability of the system. The problem with this mentality is that for as long as health care is considered a business, something through which profits can be generated, the people at the heart of the system – the patients – will be treated like “consumers” rather than individuals with specific needs that need to be addressed. “Consumers” purchase things; “patients” are treated for illnesses.

According to the Canadian Mental Health Association the cost of treating mental illness in Canada in 1993 was $7.331 billion. That figure rose to $7.9 billion in 1998, breaking down to $4.7 billion in actual health care costs and $3.2 billion for the cost of disability and early death. There was an additional cost of $6.3 billion spent on services that are not covered by medical insurance and for time off work for distress or depression (or other mental illnesses) that were not treated within the health care system. There are many reasons why someone would not seek treatment for mental illness, not the least of which being the stigma associated with these illnesses. Some people would rather suffer in silence rather than risk having someone know that they are suffering from something that can be treated ... unfortunately, this fear of discovery can lead to tragic endings that may be worse than anything that some stigma might bring.

In February of this year it was revealed that the Royal Ottawa was facing a $2 million shortfall in its operating fund thanks to cuts in the Ontario Provincial Budget. The brand new building that the new Shirley E. Greenberg Resource Centre for Women is in is running on less than it requires to provide the essential services needed by the patients in this community, but Minister Broten is of the impression that all is well in the battle against a group of diseases that, according to the World Health Organization, is going to cost more to the economy than cancer and HIV/AIDS combined. Psychiatry was praised for how much it helped Margaret Trudeau, but what was not mentioned was that the program that had the best tools for individuals battling affective disorders – the Psychiatric Rehabilitation Program – has been cancelled due to cutbacks. Praising that which your government is working actively at destroying is an obscenity.

While I join in thanking Shirley E. Greenberg for her generous gift to the Royal Ottawa, a gift that I am sure will help many women in desperate need of help, I must also question the climate that has necessitated such generosity. The first step in true health care reform, something that our system is unquestionably in need of, must include ending the profit-driven paradigm of our current health-care delivery system and turning instead toward a system that is truly patientcentric. We must stop thinking of those being treated for mental illnesses as “consumers” of a product but rather in realistic terms; we must return the dignity to the healing process and to individuals receiving care for illnesses as “patients” who are part of a healing process in which they play an active, informed role. When this is done we can begin to see positive change in the way mental illnesses are perceived and in so doing battle against the stigma associated with these illnesses. There is nothing wrong with the word “patient”, it is the attitude associated with the care being provided to them and with the person on the receiving end of that care that truly counts. The Shirley E. Greenberg Resource Centre for Women will go a long way in making it possible for many women to become empowered patients on the long road to recovery from mental illness. It is too bad the finances may not be there for everyone else in need in the community.

Waning Experience

A Special CrazyComposer Editorial

The news that yet another talented and highly experienced employee associated with the (dare I say “now defunct”?) Psychiatric Rehabilitation Program at the Royal Ottawa Mental Health Centre had been left with no alternative but to leave their place of employment came as little surprise, though it grieved me deeply for the loss that it represented. When I initially learned that the PSR program had been slated for the chopping block I knew it would be inevitable that many talented individuals would ultimately be leaving the hospital. Within a few weeks one of the most experienced psychiatric nurses decided to take the option of early retirement rather than have to endure any more mistreatment at the hands of the administration. Others followed shortly thereafter. Now a talented Occupational Therapist is joining their ranks and she will be followed by a Psychologist and … well, how many more will there be?

The philosophy that attrition is the better part of valour has become entrenched in the warped economic plans of this feckless board of directors, or so it would seem, and it is far easier on an administrator’s conscience, where one exists, when they are able to manipulate their employees into leaving – seemingly on their own volition – rather than having to hand them their pink slips in person. Of course, this hardly addresses the true cost of this situation. While the PSR program was put on the chopping block in an effort to save money in our budget-strapped health care system, it would seem as though there hasn’t been a single attempt to analyse the ramifications of the loss of so many specialised mental health care workers.

This ongoing drama made me recall a memory from my childhood, growing up in Sudbury, Ontario; on a warm summer’s day (yes, they happened) I was sitting in a playground at the end of the street we lived on, watching some older boys playing on the monkey bars, doing things that I could not do because I was too small. To be older, to have more experience, to have more … what was it that came with age, I wondered, height … intelligence … so many things that might come in handy. As I rode my bike home the thoughts that went through my head were quite simple: being young was fine, but I now knew that there was nothing to fear from growing older; with age came all of the things that made life worth living. After all, you can only play in a sandbox for so long before it begins to chafe.

What the administration at the ROMHC has failed to recognize is that they are driving away decades of accumulated experience and wisdom that cannot be replaced by five times the number of newly minted graduates – if the vacated positions are ever refilled (which is doubtful). When a psychologist with nearly 25 years experience leaves the hospital at the end of this month – for the simple reason that rehabilitation (preventative therapy!) is not a priority of our health care system – a resource that has been cultivated over a period of a quarter century will be lost to the patients and any staff that may want to call upon his considered experience and wisdom. How does this serve the community?

The loss of an Occupational Therapist with several years experience here in Ottawa, as well as a number of years in mental health care treatment centres in Toronto is another irrevocable loss of experience, wisdom, and tremendous humanity. There is no new graduate OT that can draw upon the wealth of lifetime experiences that have now been consigned to the trash heap by the visionless administration, steering this hospital like the Titanic – directly on course for the iceberg that would send it to the bottom of the ocean.

There is no value in a shiny new building if it is inhabited by shadows and incompetents; driving out the best resources you have – your employees – is not how to lay a solid foundation for any organization, let alone one that purports to serve the needs of the community. This new building, now more than a year old and still unfinished, is suffering from the deficiencies perpetrated by those whose plans are now tearing apart the heart of what the ROH represented: providing patients with the tools for recovery.

It seems an ironic note that in re-branding the Royal Ottawa Hospital the choice should fall to: ROMHC, standing for Royal Ottawa Mental Health Centre: What word is missing? Perhaps a better acronym should have been ROMHCC, for Royal Ottawa Mental Health Care Centre: You see, that is the real problem here, they have taken the Care out of the Royal – they may not care, others still do. We must stop the drain of talented, experienced individuals before it is too late.

CrazyComposer, out.

First Article

Introduction:
Welcome to the first “Psych Rehabilitation 4 You” feature article. My original intent was to post an introduction to an article that was to be published in a special edition of the “Journal of Psychiatric and Mental Health Nursing”. I had been writing a chapter for a medical textbook entitled Learning About Mental Health Practice (hardcover preorder or paperback preorder available from Amazon) when my editor invited me to submit an article to the Journal’s special edition. Unfortunately it will not be published due to the peer review process … apparently there isn’t an abundance of crazy composers writing about the creative process and how mental illness bears upon said process … but I digress).

As I said, my original intent for this “introduction” was to serve as a way to present the article to you in this forum: the article deals with creativity and bi-polar disorder and living with mental illness – from my own personal perspective. For anyone interested, there is a brief bibliography at the end of the article. However, I have decided that it is in the best interest of all who may read this to post the article separately, after this post, in order to provide an opportunity for people to have some time to reflect upon the issues raised in an “introduction” that, essentially, does not introduce the article in question.

The reason for this digression is simple enough to explain for it all centres around the recent events at the Royal Ottawa Hospital. Some of what is touched upon here shall be taken developed into a larger article (or, if necessary, articles), particularly the material regarding the economics of health-care and the importance of preventative care (especially within in the realm of mental health). Thank you for visiting. As always, your comments are welcome and encouraged! Enjoy your visit and don’t forget to tell your friends about PsychRehab4You.

My motivation for creating this blog was quite simple: the Psychiatric Rehabilitation Program that had been in operation for over two decades at the Royal Ottawa Hospital (now the Royal Ottawa Health Care Centre) had been given its notice; a date for an execution had been set. You have to understand a few things about Psychiatric Rehabilitation, or PSR as it is usually referred to by those who have come to know it and love it (or, as it were, loathe it). The only thing positive that I can think of to say about PSR is that it is a program that worked in creating a meaningful recovery process in my own life (not to mention the lives of thousands of others), without my having to become an inpatient in a psychiatric ward of an institution.

What, I ask you, could be positive about that? Aside from the fact that PSR works by assisting people with mental illnesses to take an active and substantive role in their progression towards recovery, it also works by providing patients with tools that can assist them in noticing the onset of troubling symptoms, allowing for the possibilities of a medical intervention that may well prevent a full-blown relapse and the subsequent need for a costly hospitalization. Again, that doesn’t indicate that there is anything worth preserving, right? Wrong. Psychiatric Rehabilitation is not, contrary to what the Board of Directors may happen to believe through their deluded sessions, some un-tested “theory” that is going to pass out of “fashion” some day. PSR has been and is being rigorously studied, and it has been established as one of the “best practices” in mental health. Obviously that must be why the Royal Ottawa has decided to move away from it … God forbid “best practices” should be something more than words on a page.

The cost of operating the PSR program ultimately became an impediment to the fulfillment of one of the singularly visionless plans that had heretofore been inflicted upon the ROH community, a plan that could be boiled down to three letters: PPP.

The decision to build a new hospital sparked a great debate over the government’s decision to enter into an unholy alliance with the private sector. While on the surface everyone was told that there would be great economic savings (read: higher costs), and the final outcome would be favorable for all involved (read: maximum suffering with minimal effort), the truth of the matter is far from the silver lined pile of dung that was served up by self serving politicians, replete with pomp and circumstance.

When the new hospital was opened there were so many problems with the building it took weeks… well, no, actually it took months … well, since it’s been a year since they moved in and there are still unresolved issues with the building, I suppose it would be more truthful to say it has been more than a year and the issues are still unresolved. As far as the “economic savings” which this business alliance was to create, that’s too has been revealed as the lie that anyone with a modicum of perception recognized it to be from the beginning. The truth of the matter is that the operating costs of this new hospital are greater than projected, adding one more element in the current $6 million shortfall currently being experienced by the budgetary bean counters at the hospital.

The failure to see that this was a bad decision from the beginning is not the point of this article, however, nor is it my role to castigate those who failed in their capacity as members of the board, for not taking the best interests of the patients to heart (or not even the best interests of the employees of the hospital). Their failure is something that will have to be dealt with at another time.

With only one year having passed since the Royal Ottawa Hospital moved into its new facilities the full ramifications of this “experiment” shall surely not be known for several years to come, but the preliminary consequences can certainly lead us to believe that we have been set upon a path of irrevocable destruction. Change, when sought after in the name of advancing and improving the quality of services provided to patients, is something that the medical community should be striving to achieve, regardless of the costs involved. Unfortunately, the changes that have been taking place at the former Royal Ottawa Hospital have little to do with the best interest of the patients and are primarily focused on the outmoded thinking that there is a price that may be attached to health care; we must change the way we view the entire health-care system, including the economic system and the way it supports the funding of the health-care services.

The recent decision of the Board to not renew the contract of the ROH’s CEO is indicative of the embattled state of affairs that the hospital is experiencing. Decisions have been made to cut programs that save lives; all for the purpose of saving money. Having made the decision to end the PSR Program is going to result in (another) major drain of extraordinarily talented personnel from the hospital who have made the decision to either retire or simply not remain working in an environment that has become overtly hostile to its employees. At the same time that these specialists in Psychiatric Rehabilitation are leaving the hospital … along with their expertise … the hospital has announced (for the second time in four years) that it would still like to have an integrated program of rehabilitation operating throughout the hospital. I suppose they are more interested in the philosophical ideal of rehabilitation rather than its actual practice; once those who are involved in the practice of PSR are no longer around to provide their expertise it will be quite an interesting trick to see to the proliferation of PSR without health-care practitioners who have been trained in its delivery.

This lackadaisical attitude towards the individual recovery process encouraged by PSR did not come as a surprise to Dr Ron Bell, a Psychologist in the PSR Program who has been with the program for over twenty years and helped to establish many of the groups that became fundamental to the success of the program. Commenting on the attitude of the ROH programs, Dr Bell said, “Most of the programs are conservative in the way they support people towards recovery.”

It was quite appropriate when Dr Bell concluded our discussion with the following comment: “You cannot be surprised when organizations make stupid choices.”

I am not surprised … I am deeply grieved. May I point out, for those of you who may only now be gaining consciousness and haven’t been following the simplicity of this chain of thought, that it becomes exponentially difficult to recreate something – say a model of something – when you have thrown out the instructions as to how that “thing” works. Imagine, if you will, a scene at the “Antiques Road Show” … the experts are appraising an extremely beautiful, hand-made, model ship that someone has brought in to be assessed.

The expert is amazed at the quality of the model, by the wonderful details of the rigging, by the detailed carvings along the forecastle and the beautifully preserved painting that hasn’t chipped or peeled after many years. Oddly enough, the appraiser doesn’t seem to mind that there aren’t any instructions along with the model … the reason? The person that made the ship didn’t make it from a “kit”; he made it from “scratch”, without a plan.

We now have the model, and it is beautiful. When the hospital decided that they wanted to spread the beauty of the model throughout the hospital they took the model out of the single unit that it existed in and turned the employees into the PSR “team”, to act as PSR “evangelists” for the entire hospital. At the same time they dismantled the boat. They made the instructions, but dismantled what had been working brilliantly … they didn’t even take a picture of the boat (forgetting it had been a ship).

After a time, by the time the “new” building was ready to be moved into, it became apparent that the instructions weren’t quite good enough … they weren’t clear enough for some people: without a clear picture of what psychiatric rehabilitation is able to accomplish the bean counters found something to be eliminated. This time the instructions were destroyed leaving only a shadow of what there once was; something that only exists in memory, longed for and desired, but in all likelihood gone because they would rather pay for an acute crisis than preventative care.

When the people who leave are gone, taking with them decades of experience working in PSR, we will have lost a resource that cannot be replaced by a dozen newly graduated doctors. It is time to reverse the decisions that are destroying the largest mental health care facility in Eastern Ontario. Future articles shall (attempt to) explore solutions to these issues.

The next article will be: Creativity and Bi-Polar Disorder: Living With Mental Illness

Article and original fractals Copyright © 2007, by Peter Amsel (SOCAN)

First Post - Welcome

Welcome to my newest blog, a blog created out of an urgent need for a dying thing: psychiatric rehabilitation in the city of Ottawa. This blog shall be dedicated entirely to issues surrounding mental health and, in particular, to the issues of "Psych Rehab", which is a short way of saying psychiatric rehabilitation.

Psych Rehab is an important element in the health care hierarchy for the simple reason that it treats mental illnesses conjunctively with medications, using groups, therapists and other diverse treatment plans in combination as a way to help an individual living with a mental illness take control over their treatment and become a partner in their care. Psych Rehab saves the economy money by preventing expensive hospital stays, allowing costly beds to be kept for those in extreme crisis while those who are able to manage their illnesses in other ways try to, with the support of those trained in the Psych Rehab model.

Most of all, Psych Rehab is a tool that offers mental health consumers a choice when it comes to their treatment: instead of relying entirely upon the treatment protocols prescribed by a physician it is possible for an individual to take personal responsibility for their course of treatment, and for the direction of their recovery, by using the tools provided by an effective Psych Rehab program.

This blog shall deal extensively with the tools of psychiatric rehabilitation, symptom self-management, goal-setting, and all of the other things that go into the "big picture" of Psych Rehab, tools that anyone with a mental illness - or anyone who knows someone with a mental illness - can use to recognize warning signs and other clarion calls for help.

We are always told that "Cancer can be beaten", and we must believe this to be true - but are we ever told that "mental illnesses" can be beaten with the same vehemence? There are mental health care practitioners in the field today who do hold this position, who advocate that these illnesses can be "lived with", "managed" and "coped with" in ways that allow an individual to experience as much of a "normal" life as anyone else, quite often without anyone even knowing of the presence of an illness without the disclosure from the individual themselves.

This site is dedicated to all who struggle to live with illnesses that are misunderstood, misrepresented and maligned by the press on a regular basis; their ongoing vilification of individuals with mental illnesses perpetuates the stigma surrounding the disease, making it difficult - in this day and age - for people to feel comfortable to seek treatment because they may be criticized by the likes of a movie star who doesn't "believe" in psychiatry.

Psychiatric Rehabilitation 4 You shall be a place to come for links to mental health sites, psych rehab resources and other tools for those seeking that first step (or beyond) down the road towards recovery. It will also be a place to share stories of inspiration, to encourage others in their walk. Please, if you have something to contribute, send it in and I shall consider posting it as soon as possible.

In closing, this site is also dedicated to my dear friend - an Angel - who felt the burdens of that dark beast overwhelm her last year. Her loss is still felt, the pain of her passing still present.

Remember: Mental Illnesses Can be Beaten.