That's Pretty Bleak: A Conversation About Mental Health Access in Ontario

     Circlesnake’s latest show Slip starts off as a police procedural, and progresses into being a show about mental health. Circlesnake Artistic Producer Joshua Browne recently sat down with Clinical Psychology PhD student Skye Fitzpatrick to talk about the cultural mental health landscape and access to mental health care in Ontario.

J: Who are you? Why am I talking to you about this?

S: I’m a Ph.D. student in Clinical Psychology, in my fourth year of my Phd at Ryerson University. I’ve been doing Psychotherapy and psychological assessment for five years. And all of my research is devoted to the study of mental illness and treatments of mental illness.

J: Without spoiling the show at all, I can say that there’s a character in the show who has some mental health issues and fails to get help and that leads to a lot of problems for them. What are some of the barriers that people run into in getting care, and how prevalent has this issue been in your research?

S: I think some recent estimate suggests that between 70 and 80% of people with mental illness go untreated. And that’s either because they don’t want to access mental health care, they don’t know that they can, or it’s genuinely inaccessible to them at that point in time. But I actually think that the default condition for people with mental illness, or any kind of mental unwellness, is to actually not seek help. If you think about it like someone who has a little bit of a stiff back, or a pain, or some sort of chronic injury: people will go with that kind of problem in their bodies for like a decade before it even occurs to them that maybe they can live without that. So when you’re looking at someone, as an example, with low-grade depression, most people will live with that for a lot of their lives and not even consider the possibility that they could actually do something to alleviate it. I don’t think it’s until you’re out of that that you realize what a big role it’s playing in your life when you’re in it.  

J: That’s really interesting because I sort of expected you to talk more about systemic barriers, I know that’s something that gets talked about a lot. But the first thing that came out of your mouth was people’s own.  If there are these barriers, that may be economic, or  community based, or have to do with social stigma, I didn’t even think about the fact that a lot of people with these issues-- comparing it to a backache sounds super apt, like people live with chronic back pain all the time.

S:  Yeah totally. (Laughing) I mean I do, I don’t do shit about it. And I can talk about the systemic stuff at length as well, and I think they’re of course interrelated because the reason I think that happens with individuals is because we don’t really have a culture of mental wellness. The assumption in our culture is that you kind of just live with things or you kind of just “power through something,” and we essentially have really poor mental health literacy in our society. So when I say that it doesn’t occur to people that they could get better, I mean it genuinely doesn’t even occur to people that they’re not living in a mentally optimal place or that there’s a possibility of getting better. And then, if it does occur to you, and based on that awareness you decide to do something about it, then there’s all these additional barriers as well, like accessing care, which is really difficult. Standard, evidence-based psychotherapy is about $225/hr, it’s prohibitive for most everybody I know. And wait-lists at publicly-funded services are 1-2 years long sometimes. I’ve worked in clinics where it’s up to two years long, with chronically suicidal people, so even if you have the awareness to realize that you need help and then you actually get the motivation to get help which is already really difficult if you’re, for example, depressed, our society has so many barriers in place for you to access those services anyway.

J: Do you think there’s a connection between the willingness of the individual to live with problems without treatment, and the sort of macro view? Assuming that the lack of access is because these services aren’t subsidized, then our elected officials are not putting funding and money into this side of healthcare… It strikes me that if I’m an elected official living with low-grade depression, thinking “this is just the way things are,” then convincing me that other people who are relying on me to get them this funding are gonna need that kind of help….

S: It’s not gonna happen. And I think that has a really reciprocal effect because it teaches your society that this isn’t important. I’ve heard from so many people, people I know, who think “Oh maybe I should pursue mental health services” but they often really invalidate that need, and say that “I don’t really need it as much as other people do, so I’m not gonna do anything about it.” When in fact, when you actually look at that, it’s a mindset that makes no sense. If everybody in society is functioning with at least some sort of psychological problem-- and I think a really high number of people are, personally I think it extends beyond that 1 in 5 statistic-- it doesn’t make sense that we’re all engaged in this cultural process of invalidating our psychological suffering which is really taught to us by our government communicating to us, subtly and not-so-subtly, that our mental wellness is not very important. Or is not as important as, for example, pipelines. Or other things that are getting government support or funding. And what’s particularly ironic about that is that the economics of it don’t even check out. There’s such good research now that shows that if the government publicly funded mental health care it would actually save taxpayer dollars because mental illness ends up being costly in terms of people not being able to work, being more likely to be supported by the government in other ways, they have to use medical services more because they have higher incidents of different physical conditions, suicidal people end up in the emergency room more, etc. Whereas if we actually used public funds to provide psychological services, all of those associated costs go down, and it’s actually less expensive. Even if you were just looking at the dollars-- which is really sad that we have to justify this using that metric-- but even if we grant that, it’s actually cheaper to have accessible mental health care than to not.

J: Can you talk about that research a bit more?

S: So for example, in one trial, you’ll have a control group that doesn’t get the treatment. And then a group that get some kind of therapy, and it will account for all the costs of those therapists’ time, and then monitor all the other ways those participants utilize public resources. Just as an example, a study in 1999-- and these numbers would be more pronounced now-- showed that for people with Borderline Personality disorder healthcare expenditures are about $19,000/year per person when you don’t have treatment. And if you do, they’re about $8,000. 

J: Jesus.

S: Yeah, so that’s like…

J: Half.

S: Yeah, half. And that’s actually pretty conservative, I think, as an estimate. Suicide attempts alone in one year cost the US economy almost $4 billion.*see footnote* So it’s not like we have to lose all this money to support people’s wellness, even from an economic standpoint, what we’re doing isn’t very sensible. And, you shouldn’t have to use economics to justify that you want to have a happy, functioning society.

J: Sure, but what makes that argument necessary is that while I can’t picture any elected official going on TV and saying “Well, sorry folks, but it’s not our responsibility, you gotta take care of yourself,” I think the argument that does get made is “Look at our budget, look at the debt, we don’t have the money as a country, to do that.”  

S: It’s this very shortsighted way of thinking which is often what you see in economic policy. People are not thinking about prevention, which is really what we’re talking about. How do you invest on the front end to have something more viable in the long term. Right now the framework is very post-hoc: if you’re really really suicidal and unwell, maybe then you’ll get access to services, after you’ve been in the healthcare system for a decade and are functioning really really poorly at that point, then maybe there’ll be some service available to you. As opposed to, let’s actually invest in mental wellness across the board and prevent people from even finding themselves there in the first place. There are movements in other countries to put mindfulness training in schools.

J: Right, it’s happening in Chicago right now.

S: Yeah! And what a wonderful idea, we’re not teaching any kind of emotional literacy to young people right now. And I think the ideal place for psychologists would be if we could work ourselves out of jobs altogether, and not be needed. It’s an idyllic future, but it comes from broader systemic change, and a broader understanding of mental health.

J: That was actually my next question, about the future. Because you see these public campaigns like #BellLetstalk-- I can see your eyes rolling already. But that was one of the things I was really curious to get your take on. Because on the one hand you look at something like that and think and it’s maybe a step in the right direction, Because it’s bringing this conversation a little bit closer to the forefront? But the sophistication with which you’re speaking about policy and the real changes in how we view this as a culture certainly don’t seem to be happening very quickly. So I guess, first of all, do you see anything moving in that direction? How far off do you think we are?

S: I’m of two minds. On the one hand #BellLetsTalk is a good example of a positive shift that we’re seeing where talking about mental health is becoming more prominent and people are able to talk about what’s going on with them from that perspective whereas previously (and still currently) there is so much stigma operating that people couldn’t even acknowledge that, which is a huge barrier to accessing mental health care and probably also just a factor that makes someone’s mental anguish even worse. So that trend toward more public support of mental health platforms is really important and the fact that there’s a bit more of a vocal support for that is awesome. And I think #BellLetsTalk has been really successful in that way, in getting people talking.  I think the paradox of something like that is that, ya know, it’s a day a year. And one of the reasons mental health is not funded is that governments think that we’re in a culture of scarce resources, and one of the reasons I believe we’re in a culture of scarce resources is that large corporations are not effectively taxed. If large bodies that have a lot of wealth contributed more to public funds, then maybe we could fund mental health care. And it’s not just about “we don’t have the money,” but in fact the priorities are not right within the government to actually support mental health care. But sometimes it feels like a band-aid to me, like a day of activism led by a corporation is better than not having that day, and at the same time, I’d prefer that the support come from the government throughout the year.

J: Right. Do you think there might even be a sort of steam-valve effect? That everybody hashtags their mental health stories, and feels a lot better the next day about the way this is. And it can have the opposite effect of what’s desired because public outrage which is the only mechanism by which these large policy shifts happen, is when people demand that they happen, goes away. Maybe that’s too reductive, or drastic, to say that these “steam valves” become part of the problem. I don’t know.

S: I don’t know, I’m not actually sure, but I think there’s a possibility that could be happening. I also want to say that I know people who have been funded by #BellLetsTalk, organizations that are linked to some of the work that I’ve done have been funded by them. And what they’ve done with that money is really great. And it has been an important source of a lot of funds for important mental health initiatives within Toronto alone. So it’s not about Bell per se. It’s about the fact that the main work is coming from a big corporation instead of from our society as a whole, and our government speaks to a problem in how we’re thinking about this. And shows us the ways that capitalism and the under-serving of mental health are really interlinked.

J: So it seems like the problem is not #BellLetsTalk, but if anything, that #BellLetsTalk is one of the only things that’s happening in this sphere.

S: Yeah. And I think the other problem is that Psychologists (and I’m biased as a psychologist-in-training) but really some of the most informed, evidence-based, comprehensive providers of mental health support are not OHIP covered. So in order to access us, you basically need to be able to pay out of pocket, have private insurance coverage, or see somebody in a hospital clinic which is increasingly difficult. So what happens is either a lot of the kind of mental health support that is accessed by people is that which is more accessible, which is often a more medical approach, meaning prescription-based medication. Which is not necessarily a bad thing, there’s nothing wrong with doing that, but we have a lot of evidence that there are other interventions that are equally effective and in many cases more effective and perhaps with less side-effects.  Or people are going to practitioners who are maybe more affordable and more accessible, but have less training. And I think the problem with that is that a lot of people have had ineffective treatment, and are walking around saying that they’ve tried therapy, they’ve tried cognitive behavioural therapy for example, and it didn’t work for them. And they’re not gonna access it again. But in fact they’ve never had the treatment to begin with, they had some piecemeal, diluted version, that was accessible to them.

J: Are you talking about student therapists and things like that?

S: Anybody. There’s not a specific genre that’s problematic. There are a lot of people out there with very little training doing therapy in a way that’s not necessarily bad, but it’s not the most rigorous application of the therapy. And I think sometimes the side effect of that is almost making people more resistant to therapy when they actually do get it at some point in their life.  For example, the population I work with, people with Borderline Personality Disorder who are very suicidal; if someone is telling them that they got the most evidence-based therapy for their problem, and they didn’t actually got that, they got some random application of it by someone with little training, now that person is going to be even more hopeless, even more suicidal, because they feel like they got the best treatment and it just didn’t work for them when actually, there are amazing resources out there that they just can’t access because it’s really hard for psychologists to get the good treatments to people in this kind of system. So…

J: That’s pretty bleak.

S: Yeah…. But! I think there’s an easy remedy to that, which is that we really need to lobby our government to include mental health providers as OHIP-covered practitioners. They got left out of that in, I think, the early 90s but I think that would be a shift that would be relatively simple to push for. The solution is very clear, we need to be covered by public funds, and I think that would make a huge difference in terms of the access to services.

J: **stunned silence**

S: Should I say something hopeful?

J: (Laughing) No, I think that was honest, I mean--

S: Well I actually do have one hopeful thing to say.

J: Okay, shoot.

S: Okay, so the good news is that even if we’re not publicly funded right now, our research is really sophisticated, and it’s only getting better. We’re understanding better and better how to treat these problems. What I can say is that for most people with psychological problems there is a good treatment that really does work. The problem is how do we get it to you, how do we get it to people. But the treatments exist, and are only getting better, so we have to figure out how to deliver it and I think that’s what our current responsibility is. To figure out how to get this to people. But I think we’ve got a lot of solutions and answers, already, so that’s half good news.

J: Yeah, well to leave it on a positive note, what would you say people can do?

S: To make change or to get help?

J: Both! You mentioned lobbying the government--

S: Yeah, write your MP. Demand that mental health care become a publicly-funded service. And include information on why that’s an economically prudent choice, put that on the radar. #BellLetsTalk in a Facebook status is great, but emailing your MP I think will be more effective. And in terms of getting help, just go to therapy. And I know the cost can be prohibitive, but there are lower cost options out there, they just take a lot more motivation and rigour than people should have to put into this, but if you contact enough people you can find someone with a sliding-scale option. I know someone who found a good therapist who was a social worker for $5/hr.  Try and pay attention to their credentials, do they have a degree in social work or psychology or something related? Often you can find family doctors who have some training in psychotherapy, that can be good. Sometimes you can find a psychiatrist who does psychotherapy as well, it just takes some searching, but it’s out there. Psychology Today is a great database, a great place to start. Talking to a GP is a great start, because lots of places that are publicly funded, like CAMH for example, you need a referral. So talking to a GP and requesting a referral is a good step. You can also go to the website for the College of Physicians and Surgeons, and look up Psychiatrists, and you’ll get a huge list. And one thing you can do is just call them up, call five people a day, and ask them if they see clients for psychotherapy only, if that’s what you’re looking for, as opposed to medication if that’s not what you want. And they will be covered.  

*Skye emailed me later to let me know that that $4 billion statistic was outdated, it’s actually $93.5 billion.