Implications for the Ontario mental health system
In Ontario, nine regional implementation task forces have adopted recovery as the guiding principle for the reform of the mental health system. While recovery literature refers repeatedly to a recovery “model,” there is currently no defined model in practice.
Recovery is not a new idea, though its recent prominence in mental health literature and policy may make it seem so. Why an idea suddenly springs into prominence has a lot to do with the nature of the idea itself, the people who support it, and the social context into which it is born.
It is also important to ask the question, what are people recovering from? Certainly, the most obvious answer is mental illness but many people state that they are also trying to overcome a history of childhood trauma. Further, immigrants and refugees, settling in ever-increasing numbers in Ontario, suffer from depression and posttraumatic stress disorder due to experiences in their war-torn homelands. Others argue that the consequences of a diagnosis of mental illness are at least as devastating as the disease itself. Consequences include iatrogenisis (harm from various psychiatric treatments), a designation of disability, helplessness and hopelessness, and discrimination – all factors in a journey of recovery.
Nonetheless, a philosophy of recovery provides a beacon of hope where, too often, people are told that mental illness means certain decline into unemployment, poverty, and disability. The promise of recovery is that it will lead to fuller lives for people with mental illness. However, recovery is not to be confused with cure. People who have recovered may still experience symptoms and struggle with the consequences of their diagnosis. For those who have experienced this journey first hand, recovery is defined as living consciously and fully despite life’s burdens.
The need for change in Ontario’s mental health system is urgent because people with mental illness are not faring well. They are over-represented among the homeless population. They are being criminalized – picked up by police and jailed rather than receiving help. They are experiencing high rates of poverty and they are vulnerable to physical and sexual assaults while living in unsafe conditions. Finally, suicide is an ever-present spectre, with 90% of suicide victims having psychiatric problems.
Recovery remains a complicated, uniquely individual process that is not well captured by mental health policy. The recovery principle’s emphasis on constructing a strong sense of self defies quantification and instead challenges policy makers, providers, and others to examine qualitative changes to how mental health services are delivered.
Adopting recovery as the overall principle for the reform of the mental health system in Ontario has real meaning for the choice of services to be funded and how they are to be delivered. Utilizing trauma literature, a well-developed body of work that focuses specifically on recovery and is associated with research showing effectiveness, we make the following recommendations aimed at building a mental health system that is truly recovery oriented.
I. A foundation for recovery: Safety
Housing and income supports:
- Housing for people with mental illness must remain with the Ministry of Health and Long Term Care and continue to be the focus of mental health policy.
- A substantial additional investment in housing for people with mental illness is crucial. There must also be an emphasis on creating a variety of models that maximize consumer choice.
- The trend to separating housing from interpersonal supports needs to continue.
- A mental health system based on recovery must actively address the administrative problems within ODSP and advocate strongly for increased benefit levels.
- The removal of the inherent barriers to the attainment of employment within ODSP is also essential to a recovery philosophy.
Freedom from violence:
- The fact that people with mental illness live with multiple threats to their physical safety requires open acknowledgment in mental health policy.
- Mental health professionals need to be able to recognize the signs and symptoms of a history of child abuse and of posttraumatic stress disorder, and develop skills to provide effective help.
- Psychoeducation must be made available to people with mental illness and their families so that they not only understand mental illness and the various treatment and community service options available, but also become aware of the dynamics of trauma re-enactment syndrome (an unconscious desire to place oneself in harm’s way due to past unresolved experiences of violence) and the known after effects of trauma, along with available helping strategies.
- Incidence levels of violence also point to the need for increased and active outreach to the homeless, the establishment of mental health programs in shelters and jails, and further expansion of a network of crisis services. Court diversion programs that ensure that people with mental illness access treatment and community services, rather than spend time in jail, continue to be important.
Access to adequate illness care:
- There must be a substantial investment in an array of community mental health services so that a balance between treatment and social supports in the mental health system is achieved. All mental health services must be integrated with the community so that they are a visible and accessible resource.
- Rights advice and advocacy services must be available for all psychiatric inpatients in Ontario, and for those under CTOs.
- A system based on recovery must implement research on coercion, develop and implement more humane practices and, above all, focus on limiting people’s exposure to coercive measures.
- There need to be multiple sources of credible research-based information made easily available – both to meet consumer and family needs, and to help in the production of mental health policy.
- A province-wide 24/7 mental health services registry must be implemented.
- The value of first-hand consumer and family knowledge needs to be acknowledged and supported, and methods of disseminating this information, such as Web sites, must be funded.
- In Ontario, primary care reform (plans to create family health networks that reorganize how family physicians work) must address the needs of people with mental illness.
- Innovative models that include nurse practitioners as part of community mental health services need replication.
- Expanding the system of community health centres, known for their service to vulnerable populations, is also essential in ensuring appropriate and available physical health care for people with mental illness.
- Models of treatment for concurrent disorders, along with necessary community supports, need to be integrated, meaning that services must be capable of addressing both the substance abuse and the mental health problem in one program, rather than having people treated by two different teams.
- Best-practice guidelines for the treatment of concurrent disorders have been published and need to be widely resourced and implemented throughout the mental health and addictions systems.
- Recent directions within the Ministry of Health and Long Term Care that focus on uniting the mental health and addictions systems need to continue, as this approach constitutes a productive avenue for ensuring that people with concurrent disorders receive effective help.
II. Building a strong sense of self
- While it must be emphasized that counselling skills are acquired over long years of education and experience, case managers are an important group who could, if properly trained and supported, provide counselling focused on the development of self, as the recovery principle requires. The limitations of formal services must also be acknowledged. Family, friends, and community are the most important ingredients in recovery.
- Investment in the development of a vibrant self-help network is an important part of a mental health system based on the principle of recovery.
- A mental health system based on recovery must offer an array of publicly funded employment services to be developed in partnership with local employers. Some services should be professionally staffed, while others should be based on the self-help model, but all need to be focused on helping people with mental illness find and keep real jobs.
- Support for and acknowledgment of the spiritual dimension of recovery needs seamless integration into all mental health services and self-help activities.
III. Making healthier choices
- There needs to be broader implementation, and further development of, practice approaches that allow for maximum choice even when individuals are under coercive control.
- There also need to be prescribed measures designed to keep professionals safe from action against them (by co-workers, employers, or professional regulatory bodies) if they work with clients to make their own choices, taking into account the narrow parameters allowed by inpatient settings.
- Community professionals would benefit from support and supervision as they work with people in the recovery process to ensure that they have control over their own life decisions – which will include both good and not-so-good choices.
- There needs to be an ongoing forum for dialogue regarding the limits of professional responsibility so that professionals feel freer to support choices, even not-so-good ones, so long as life is not threatened.
We conclude with a few cautionary notes. Recovery must not engender a Pollyanna-like disregard for the suffering of people with mental illness. In addition, history has shown us that the introduction of new language under the guise of reform often results in things staying pretty much the same. Several questions need to be asked: How far will recovery, as a service model, proliferate when the strong countervailing trend in health care today is standardization and accountability? Will recovery become merely a way of limiting service, with providers challenged to produce recovery within a set number of visits or service units? And how does one recover from the consequences of mental illness, including such serious life burdens such as poverty and discrimination?
Recovery, as a organizing principle, has much promise but it is designed to right a wrong, rather than to prevent the wrong in the first place. Primary prevention is not part of the recovery vocabulary. Also, recovery must not become a permanent social role that leads right back to marginalization. Finally, the introduction of an all-encompassing philosophical change in how mental health services are provided cannot be left to chance. It is highly unlikely that there will be an across-the-board uptake of recovery without a provincial training strategy. Hence, our final recommendation:
- The Ministry of Health and Long Term Care, as part of mental health reform, must develop and implement a training strategy based on helping mental health professionals evolve practice approaches that support recovery.