Mental Health Commission struggles to find balance in developing strategy

An article published in the October 8th edition of the National Post:

By Joseph Brean

As Senator Roméo Dallaire [pictured], Canada’s best-known traumatized soldier, launches the Lieutenant-Governor of Alberta’s Circle on Mental Health & Addiction and Queen’s University unveils its own mental health commission in response to a series of suicides, both may cast a cautionary eye on the travails of the Mental Health Commission of Canada, a 10-year, $130-million federal project.

Since a draft of its national strategy on mental health was leaked this summer, the agency has been squirming under accusations of dysfunction, anti-psychiatry bias and neglect of the most serious mental illnesses.

Critics point out the 30-page document mentions “recovery” 67 times and “support” 125 times, but there is no reference to “psychiatry.” Or “schizophrenia” or “bipolar.”

In a “letter to Canadians” last month, Louise Bradley, the agency’s chief executive, promised to “correct” the strategy before its planned release next year, because “the current draft does not sufficiently reflect the essential role neuroscience, treatment and psychiatry have to play.”

In doing so, the MHCC is trying to strike a balance between the two major ideologies of mental health: empowerment, based in social science, in which recovery is seen as a personal growth experience; and psychiatry, based in neuroscience, in which recovery sometimes must be imposed against a delusional will.

At its most extreme, this clash of ideologies turns on the question of whether the fundamental problem of mental illness lies in the brain itself, or in the stigma imposed by society.

At stake is a key part of the MHCC’s dual mandate — to develop a national strategy on mental health — which will influence the allocation of research funding and the priorities provinces set on this unique issue, spanning health care and social policy.

The other part of its mandate is to combat the stigma of mental illness through public outreach and professional advocacy, which have largely focused on health-care providers, often the first point of contact between the mentally ill and the government.

As the strategy gets revised, the ideological balance continues to elude the MHCC, although a spokesman said the flawed draft is “relatively close,” and the Commission stands by it “fundamentally.”

Focused on “recovery,” the draft strategy highlights suicide prevention, self-directed care, improvement over cure, and calls for an end to the seclusion and restraint of psychiatric patients.

However, its focus on health promotion and prevention, including the role of employers in creating healthy workplaces, has fuelled criticism that this is not a strategy about mental illness, but rather mental wellness.

“They’ve stolen the word ‘recovery,’ ” said Herschel Hardin, president of the North Shore Schizophrenia Society in B.C., whose latest bulletin accuses the commission of hiding behind upbeat euphemisms and claims “those who understand severe mental illness no longer take [the MHCC] seriously — except to regard it as a menace.”

He said the agency exaggerates the notion recovery cannot be imposed by others and must be a self-directed personal achievement.

“For the seriously ill, that’s a small part of recovery that comes after treatment for the illness itself, which is part of recovery, which requires a lot of not just support but structure, provided by others,” he said.

“Here [at the MHCC] we have a bunch of people who really haven’t done the homework that they had to do, and buried the most important considerations in bureaucratic fluff and vague wording.”

More than most health issues, vocabulary clouds this debate.

Patients are recast as “survivors,” “consumers,” or “experts by experience” on the one side, and a schizophrenic’s lack of insight medicalized into “anosognosia” on the other.

“The idea of recovery in mental illness circles has a certain meaning that is not translated well for the general public,” said Bill Honer, head of the department of psychiatry at the University of British Columbia and a clinical expert on schizophrenia.

It is not like remission in cancer, in which the disease metaphorically retreats, or recovery from a cold, in which it disappears completely. Recovery in mental health, as the MHCC describes it, is an orientation, a way of life.

The danger, Prof. Honer said, is that a strategy in which individuals must guide themselves to recovery could be unfair to those who are unable to do so, because they cannot understand their own illness.

“On a strict interpretation [of that strategy], we risk not fulfilling our social responsibilities,” he said.

At the same time, there is rampant confusion about these words and what they imply, he said. “The social constructs of labelling and diagnosis are real, but it’s not the same as what we do [in psychiatry]. Having a diagnosis is not a bad thing. That’s how we work. But labelling and stigma are, and that’s how society works.”

Ms. Bradley refused to be interviewed, but strategic advisor Howard Chodos, who prepared the draft strategy, said it was developed through face-to-face meetings and an online survey.

The “vast majority” of participants in consultations were “supportive of the overall thrust of the strategy,” he said, but the review process now includes “some of more public discussion that’s taken place once the draft reached a wider audience than we originally intended.”

“Was everybody included? No. Did we have the resources to do that at this time? No,” he added.

“But we felt confident that we would get the kind of feedback from that group that would enable us to strengthen the document.”

Mr. Chodos acknowledged the criticism and said the draft’s language “is not where we would like it to be, in terms of connecting with people, resonating with people in a way that will help to galvanize support for the document.”

But he rejects the notion that the focus on consensus obscures the hard cases.

“What I don’t accept is that there is a fundamental opposition between those two elements,” he said.

“We can find a way to have that balance, and we’re not sacrificing one on the altar of the other.”

jbrean@nationalpost.com

Image credit

Also see:

Mental Illness Awareness Week: Canada Stands Ready for Positive Change

Vancouver Coastal Review Sidesteps the Main Issue

An August 24th media release from the North Shore Schizophrenia Society:

Vancouver Coastal, in a review of the death by suicide of Marek Kwapiszewski, has ducked the leading question they needed to answer: Why is “dangerousness” still considered a requirement for involuntary admission rather than “to prevent the person’s... substantial mental or physical deterioration,” as spelled out in the Mental Health Act?

What was promised by CEO David Ostrow [pictured] to have been an “independent” review, moreover, turned out to be not so independent after all, with senior managers under question in the review taking part in drawing up its recommendations.

Kwapiszewski, 54, of Vancouver, who suffered from schizophrenia, jumped off the Granville Street Bridge to his death June 29, 2008. His sister, Halina Haboosheh, together with her lawyer, had made 16 different attempts to get him the treatment he needed – treatment which required involuntary admission since Kwapiszewski, like many suffering from schizophrenia, did not have insight into his own condition.

Instead of dealing with the factors leading to Kwapiszewski’s death, the review came up with three brief items in a so-called action plan, which involved no changes or improvements in practice, nor was any fault determined although it was an obvious case of clinical failure.

“The ‘action plan’ should have been called an ‘inaction plan,’” NSSS president Herschel Hardin commented. “It was as if a review had not taken place.”

The so-called action plan was presented to Haboosheh and the North Shore Schizophrenia Society, which made the original submission in the case, at a meeting July 26, in Vancouver Coastal’s boardroom.

The first item, to facilitate a discussion to consider development of an operating definition of “deterioration,” makes no commitment to ultimately do anything, and is highly questionable to begin with in any case. Nor does it apply to the Kwapiszewski case, where the deterioration was quite clear and substantial.

The second and third of the three items were bureaucratic filler, not representing anything new and showing no grasp of what the problem was.

The review also completely missed two other crucial factors in the case: the failure of Vancouver Coastal staff to involve the sister, Halina Haboosheh, as an integral member of the treatment team, following best practices, and the concomitant failure to share clinical information with her. If that had been done, Marek Kwapiszewski might well be alive today.

It was also learned that the items were not the independent work of the external lawyer and psychiatric consultant hired to undertake the review, but were a consensus arrived at with senior community mental health managers and, possibly, Vancouver Coastal’s risk management officer. In effect, they had a veto over what would be presented.

As well as forfeiting the review’s independence, this meant that a major shake-up of senior mental health management, called for in NSSS’s 2009 submission, could not even be addressed. Instead, the primary subjects of the review, as NSSS considered them, were parties to the review’s outcome.

In response to Vancouver Coastal’s items, NSSS has presented four recommendations of its own to Vancouver Coastal and has asked Ostrow and his Board for leave to speak directly to the recommendations at a Board meeting.

Attached [please click here and here] are the NSSS recommendations and the Vancouver Coastal items. The NSSS submission on the case, June 26, 2009, is available on our website at www.northshoreschizophrenia.org/marek.pdf. A brief background analysis of the Vancouver Coastal items, such as they are, is also available on the NSSS website.

Media Contact

Herschel Hardin
North Shore Schizophrenia Society President
604-922-7153
herschel@northshoreschizophrenia.org

Photo credit