Health

Unwell and untreated

The mentally ill are having to cope on their own

BARBARA WICKENS August 10 1998
Health

Unwell and untreated

The mentally ill are having to cope on their own

BARBARA WICKENS August 10 1998

Unwell and untreated

Health

BARBARA WICKENS

With its purple, yellow and turquoise walls and kitschy decor, the Raging Spoon looks like any number of trendy restaurants along Toronto’s Queen Street West. The food is typical diner fare, with tasty homemade soups, sandwiches and baked goods on the lunch menu. But there is one difference: all 22 staff members have been diagnosed at some time with a serious mental illness. For them, the nonprofit restaurant and its affiliated catering business do not just offer good food to the public. They also provide real—not makework—jobs for people often deemed unemployable. “A job gives you identity as a person contributing to society,” says Dini Densmore, manager of the eatery since it opened last September. “It gives you self-esteem—and some money in your pocket.” All of which is a lot better than the alternative for many an aimless, troubleplagued life on the street.

On practically any day on the sidewalks of Canada’s largest cities, a passer-by is liable to encounter some bizarre-looking fellow humans: panhandlers who haven’t bathed in a month, individuals obliviously conducting both sides of an argument, people whose demonstrative words and actions seems wildly inappropriate. To many casual observers they seem dangerous.

And when one of them commits a violent crime, it can make international headlines. In a spectacular incident in the United States last month that played to the public’s worst fears, a paranoid schizophrenic, Russell Weston Jr., was charged with two murders after bursting into the Capitol building in Washington and firing at security guards. In Toronto, six people have been shoved off subway platforms by strangers into the path of oncoming trains in the past 12 months—killing one of them. Is that evidence that too many unstable people are being released into society without proper supervision?

Those who best know Canada’s mental-health-care system—the consumers, providers and advocates— say that when it comes to the numbers, people’s perceptions are accurate. There are more mentally unbalanced people on the streets, one result of the massive reform that has affected most provincial health-care systems. Operating under the mantra of “community care,” politicians have shut down hospital beds, admitting fewer people and getting them back out faster, and then delivering a range of services, from dressing wounds to providing meals, to people in their own neighborhoods and towns.

Unfortunately, however, community care often works better in theory than in practice. Without adequate community treatment facilities in place before the beds are closed, the effect can be devastating, says Sylvia Geist, Toronto-based president of the Schizophrenia Society of Canada. In an all-too-common scenario she describes, a patient discharged from hospital will have only a substandard or dangerous boarding house to go home to. Some may decide they are better off on the street, but without a proper address, they may not be eligible for a variety of social services, including health care. They do not get medical treatment when their symptoms are mild; instead it takes a crisis to get them back into hospital, voluntarily or involuntarily. In other cases, they are arrested, and depending on the circumstances, end up in the criminal justice system. It becomes a vicious circle. “The re-

volving door cycle is very, very high,” says Geist.

As for the perception that the mentally ill are especially prone to violence, that is just plain wrong, experts say. Studies have shown time and time again that they are no more violent—in fact, they are less likely to be violent—than members of the general public, says Steve Lurie, executive director of the Toronto branch of the Canadian Mental Health Association. The studies have shown, he adds, that the best way to predict who will be violent is to see who has a previous history of violence, not a history of mental illness. Three of Toronto’s six accused subway pushers have a history of mental illness—but three do not.

Negative stereotypes can profoundly affect the lives of the mentally ill. Lurie notes that only 25 per cent of

The mentally ill are having to cope on their own

those with a mental illness ever get treatment.

“People wouldn’t stand for it if only 25 per cent of cancer sufferers or those with heart disease received treatment,” he adds.

One of the most controversial methods for dealing with the sometimes odd behavior of the mentally ill is mandatory medication. Discharged psychiatry patients are required to show up at a designated time and place and take their prescriptions. If they fail to do so, they can be picked up by police, and be reinstitutionalized. The Saskatchewan government, for one, introduced Community Treatment Orders in 1995 and other provinces, including British Columbia and Manitoba, have been considering enacting similar provisions. There is a good rationale behind such laws, says Laura Enick, president of the Saskatchewan Schizophrenia Society. “When the brain is the organ that is ill,” says Enick,

“some people never exhibit insight into their illness and can’t decide what is best for themselves.” But opponents call the restrictions leash laws and say they are an abuse of human rights.

Even those who agree that there will always be a small minority who will require prescription drugs stress that medication is not the whole answer. Adequate housing, access to 24hour-a-day crisis care, vocational rehabilitation and self-help groups should all be part of the equation, say mental health advocates. And they need those services close to home, where they can benefit from the informal support systems of family and friends.

Some jurisdictions are getting the message. In British Columbia, for instance, thenhealth minister Joy MacPhail announced a $125-million reform of the province’s mental-health-care system in January. Among a range of projects, the seven-year plan includes replacing the province’s one main psychiatric institution, Riverview Hospital in Vancouver, with 663 beds in smaller facilities throughout British Columbia. Nova Scotia is undergoing a similar regional overhaul. A 22-member steering committee established last fall is in the process of setting standards, determining how services can best be delivered and how needs vary among the four regions. ‘We are bringing decision-making closer to the community,” says Dr. John Campbell, mental-health-care planner with the Nova Scotia department of health in Halifax.

Joining Campbell, who is chairman of the steering committee, are mental-health-care providers, including psychiatrists and social workers, advocacy groups such as the CMHA and the Schizophrenia Society of Nova Scotia—and the mentally ill themselves. Their presence on the committee recognizes the once-radical notion that they can and should have a say in their care, treatment and quality of life.

That is a huge shift in attitude from the paternalism that once saw

MENTAL ILLNESS: Myth and reality

Some facts about mental diseases that will strike one in five Canadians at some point in their lives:

Cost of mental illness to Canadian taxpayers, including lost productivity, absenteeism and health-care expenditures: $4 billion

Percentage of the population with schizophrenia, the

most serious mental illness: 1; mood disorders, including depression and manic depression: 10

Percentage of Canadians who believe the mentally ill are dangerous or violent: 80

Ratio of violence among the mentally ill to that in the general population: 1:1

SOURCE: CANADIAN MENTAL HEALTH ASSOCIATION

the “mentally defective” locked away in insane asylums. Change began in the 1960s with the introduction of powerful anti-psychotic drugs. With the worst of their behavioral problems controlled by the drugs, inmates could be deinstitutionalized. From 1960 to 1976, nearly two-thirds of Canada’s institutional 47,633 beds for the mentally ill were closed (though some were added in general hospitals). “There was a good reason those places were closed,” says Lurie. “They were awful places, just warehouses, really.”

The current round of bed closings will be equally unlamented—if adequate community supports are in place. But even when politicians do announce money for such initiatives, critics are cautious. Is it really a new infusion of cash—or accounting sleight of hand? And will the money truly materialize? “Where has the money gone that was saved by closing beds?” asks Bev Gutray, executive director of the B.C. division of the CMHA “Into pavement and potholes? I’d like to know.”

What it takes to make things happen is money and political will. Gutray and others cite the positive changes in New Brunswick as an example of what can happen when those elements are in place. For instance, Sussex (population 4,293) now has 14 mental health nurses, up from just one before reform began in 1988. That has enabled the province to close its one psychiatric institution, the 1,700-bed Centracare Inc. in Saint John. Gutray notes that one reason that New Brunswick was able to implement reform was consistent government policy. The Liberal government has been in power for the past 10 years, with a strong health minister, Russell King, during most of that time. Adds a regretful-sounding Gutray: “B.C. has had five health ministers in five years.”

Not everyone is relying solely on government. The Ontario Council of Alternative Businesses, for instance, an organization of socalled survivor-run operations, gets money from the provincial and federal governments. But its 11 members—which, as well as the Raging Spoon, include courier and cleaning businesses, a woodworking company and a craft collective in several communities—pay their employees wages. And the benefits for the more than 600 workers appear to go well beyond a paycheque. According to council coordinator Diana Capponi, independent studies have shown that the people working at these projects were admitted to hospital once every two years, down from two to three times a year before they were working. “And when they did end up in hospital,” Capponi adds, “stays were shorter.”

At the Raging Spoon, such considerations do not appear to take centre stage. But those who work in the haven the restaurant provides know they are setting an example. Says cashier-waiter Kerry Cully: “We want to show the world what we can do.” Just something most people want to do. □