Living Well Integrative Health Center

2176 Windsor Street, Halifax, Nova Scotia, Canada. (902) 406-1500

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Systemic Issues In Mental Health Care Provision published as "Mind and Body" June 2017 The Coast Letters


I would like to shed some light on some of the systemic issues that are contributing to the mental health care crisis in Nova Scotia and Canada from a professional perspective that has become an increasingly personal pursuit for rational, healthy and sustainable care. 

We appear to have departed from age-old wisdom and refer to the mind and body as if they were separate entities. As there is no duality, there technically should be no treatment of mental illness as different from physical care and as such mental health affects us all. All experiences of being human are accompanied by emotional and cognitive responses that comprise part of our mental health and wellness and similarly can be afflicted with dis-ease. We know the evidence for care in the setting of what is established “mental illness” albeit heavily medicalized so I want to speak to some of the broader considerations for “mental health” care.

At a very basic level appropriate care for patients must always consider and encompass an element of emotional or mental health care. Even in the face of what appears to be strictly physical, there are accompanying emotional and cognitive processes that require some exploration in order to ensure patients understand and feel in a healthy position to make informed decisions.

I believe that early detection and intervention is important and in the role of prevention and healthy communication around emotional health. Talking to patients while pregnant about their emotional health and well-being affects them positively. Parents are in such a powerful position to influence the way children grow and conceptualize their own health physically and emotionally. Collaborating with parents and children is key to fostering healthier lives and communities. We have the most number of elderly per capita in all of Canada. Knowing how to age well is important and protective. At the other end, compassion and emotional care are so integral to aiding our patients in being able to fare well in what is physical decline and frailty as they age. Being able to talk to our patients about their joys and fears as they face end of life issues is only kind and is a unique privilege we earn through enduring relationships based on kind care. This type of care is not valued, taught, encouraged or supported enough and needs to be.

A reductionist, mechanistic approach to research and medicine coupled with a materialistic approach to consumption and provision of medical care has contributed to a shift away from wisdom of an integrated whole and contributes to an unhealthy approach to mental health and well-being. Our current provision of care is predicated on an illness-based model. This approach aims to treat disease, not the person. It focuses on deficits and lack of capacity. It is no wonder that it does not serve mental health care needs and contributes further to the stigma that already surrounds “mental illness”.

A wellness-based model is one that considers the whole person. It is a strengths based model that embraces the bio psychosocial approach to care and places value and credibility on prevention, some medicines as well as non-medicinal approaches to care including diet, exercise, socializing, social support, one’s environment, faith, culture, sense of purpose, meaning, value and emphasizes the positive role of counseling and psychotherapy. It seeks to educate, build skills, capacity and foster resilience, which is both protective and therapeutic. It places the patient at the center of their care emphasizing choice and aligning with being patient- centered, an important pillar of the collaborative care model.

The reality is that our system is not well nor is it serving the needs

of patients or providers. This creates barriers to accessing and providing care. An over-reliance on evidence based medicine has replaced common sense and has discouraged and created artificial divisions where there should be integration and interdisciplinary collaboration. It has also contributed to a culture where there is more emphasis on numbers and outcomes rather than the whole person. There is lack of consideration for the qualitative experience of what is supposed to be a healing interaction and relationship between provider and patient. There is a growing body of evidence that demonstrates empathic exchange or compassionate care has significant positive health outcomes and this is not factored into the existing model.

Some mental health care clinics hang what is internally referenced as “the wall of shame”. Provider quotas for the day, week and quarterly are visible to those awaiting care similarly for the viewing of colleagues walking by. This fosters competition, resentment, and misunderstanding and undermines the therapeutic relationship. The visible and not so visible walls of shame are contributing to our unwell system and pose significant stress and threat to the providers within it causing alarmingly high rates of mental health issues.

Coupled with limited resources and high demands, mental health care providers are incredibly stressed and burned out. This is not a healthy place from which to care and indeed takes the joy from the job, which on all accounts is palpable and is reflected in your article. It robs patients of the healthy therapeutic relationship from which they can be cared for, learn from and heal. We are a healing profession and a numerical, quota based approach undervalues the art to our healing practices and deprives us of an essential joy through connection to what is meaningful for us; the work, the patients and each other.

The greatest threat is to our system is the mental health of all front line health care workers and this is more pronounced in those who provide mental health care. This further contributes to the care deficit as it is accompanied by greater rates of compassion fatigue, burn out, sleep disorders, anxiety, depression, higher rates of substance abuse and suicide. It contributes to more sick days,

reduced work hours, earlier retirements, greater rates of relocation and more family conflict. We cannot provide authentic care unless we are authentically living and working our value of health.

We live in a chronically stressed society where every industry monopolizes on not being well or whole in some manner. Children are exposed to and suffer high rates of early life adverse events that are known to have significant long-term health consequences again emphasizing the limitations of a health care model that conceptualizes mental and physical health as being separate entities. Our society promotes fast foods, unhealthy sedentary lifestyles, detachment and isolation leaving many devoid of meaning and feeling undervalued. Avoidance, quick fixes, addictions, expectations and impatience grow in what is an ever expanding appeal of “on demand” culture. These circumstances contribute to the development of more mental illness and the crisis-to-crisis coping strategy is ironically mirrored in our resource-limited provision of care.

The very narrowly defined scope of collaboration has limited us and placed us in a larger deficit position. NPs, RNs and pharmacists are extremely valuable but do not comprise what is a full constitution of mental and physical health care providers. This leaves a huge gap and negates the wisdom and expertise of a large number of practitioners that could ease the burden on the institutionalized system, family doctors, patients and their families. It would also help decrease wait times. These for example include the role of certified clinical counselors, psychologists, trauma informed therapists, clinical social workers and counseling nurse practitioners, midwives, many medical sub-specialties, physical therapists, massage therapists and dieticians. Food is medicine. Exercise is medicine and so on. It takes a team and we underestimate the capacity of existing resources by devaluing the role of others.

Miscommunication and constraints lead to misunderstanding paired with quota-based deliverables contribute to a system that fosters competition not collaboration. Our stress fosters resentment and blame. That is not a healthy space from which to care. Showing compassion to other health care providers and our patients enables us to collaborative in a constructive therapeutic manner.

Collaboration does not merely require a systems review or a detailed budget. It naturally is fostered when all those involved feel heard, valued and are shown compassion and respect.

If we are open, aware, transparent and communicative we can deal with the crisis head on. What we don’t know can hurt us. Suggesting that we deny a crisis reflects the illness model by suggesting that we are deficient and lack capacity to handle the truth. This unhealthy response is a symptom of our system. Knowledge is power. The very tactics and strategies used are perpetuating and growing a catastrophe at the cost of our shared sense of humanity and at the cost of people’s lives and well-being. Hippocrates was also known to have said, “Opposites are cures for opposites”.

We all have a role and responsibility in engaging the system and contributing to a community and a society that begins to acknowledge shortcomings not as failures but as realities that through open communication, active listening and valuing what is heard we can truly collaborate and generate healthy sustainable solutions. Holding space for this new view we can begin to see possibilities, think creatively and find solutions to our growing crisis. These are the shared values that do not undermine a system and deter people from using it rather they build trust and encourage people to access care by knowing there will be value in a humanizing experience. This is at the heart of what can transform our medical system.

As someone who has both used mental health care services as well provides them, I have intimate knowledge of just how hard it can be. The difference between a human and a human being with mental illness is a degree of suffering. We are all suffering and it is time to humanize this experience and work together towards a shared vision with common values for health and well-being that should serve to attract people to work here as well to retain those of us who really believe in healthy sustainable collaborative practices.

Our center was the first formal integrative collaborative health care clinic to be established in the Maritimes. I have been privy to the gains people have made when fed from a wellness based model and have learned immensely myself. I had hoped that by being

located under one roof, barriers to care would be removed and that has proven true. I hope that our setup will aid in enabling continuity of care and help our patients sustain healthy behaviors and lifestyles. I had hoped it would improve our patient care and that we would serve as a small humble example of how others could improve their own and their patients’ experience of health care. It is not a for profit center. It has been recognized by the College of Family Physicians of Canada as a “success story” and yet we lack local support. My hope is that we become part of a larger conversation that leads to appreciable change and that people experiences are positive and humanizing.

“Wherever the art of Medicine is loved, there is also love of Humanity",

Dr. Maria Patriquin MD CCFP

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