Northern Mental Health Services Paper Draft for Comments

I've just started writing this paper, and I'd sure like to get some comments.

Lewis

Northern mental health services are perpetually problematic in Canada. Criticism exists at all levels – from funding, to training, to cultural competency of practitioners, to provision of specialists. This paper represents an intuitive inquiry into Northern, rural and remote, service delivery using the author as the main tool of inquiry.

Conventional models for mental health service delivery lean heavily on diagnosis and treatment. Public health models recognize that health promotion and disease prevention are, in many ways, as important as diagnosis and treatment (Gale & Deprez, 2003). Rural mental health systems, related to limited infrastructures, tend to focus on diagnosis and treatment at the expense of health promotion and disease prevention.

Mental health “is a state of successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and adversity (USDHHS, 1999: 4). This conceptualization is culturally based and therefore grounded in the values of an individual’s culture; it varies among individuals and communities. Mental illness, at the other extreme, is defined as a clinically significant behavior or psychological syndrome or pattern that is associated with present distress, disability (impairment in one or more areas of functioning), or a significantly increased risk of suffering, death, disability, pain, or an important loss of freedom (APA, 1994). Mental illness refers collectively to a broad range of diagnosable mental disorders that are characterized by alterations in thinking, mood, and/or behavior, in association with distress, impaired functioning, or both. Somewhere between these two poles are the many problems that afflict ordinary people that are commonly classified as “mental health problems,” which are signs and symptoms of insufficient severity or duration to qualify as mental illness (USDHHS, 1999: 5). These are the bulk of problems that affect people in both rural and urban environments and are those that are also under-addressed by diagnostic and treatment oriented systems. They include grief caused by bereavement, feelings of powerlessness caused by the loss of a job, and sadness related to a divorce. At a community level they can include the results of loss of a major employer or farm crises (Beeson, 1999; Hoyt et al, 1995; Ortega et al, 1994; Williams, 1996).

Rural communities tend to conceptualize their problems as lack of specialists, which is chronic, and not easily solved. Less commonly, rural communities work together to solve problems at a local level, often creatively, and usually without specialty resources. The absolute numbers of people suffering mental illnesses is smaller in rural areas and spread out over wider geographical areas. Weaker economic bases of these communities suggest that the development of specialty mental health services will not be financially viable (Geller et al, 2000). The constraints of rural practice also make recruitment difficult even if the economic base exists for specialty practice (Roberts et al, 1999; Beeson, 1991; Stamm, 1999). Personal stigma for mental illness or use of mental health services is greater in rural areas (Calloway et al, 1999). Mental health care ideally occurs during primary care or emergency department visits (Cunningham, 1997).

Mental health systems in rural communities are largely fragmented (Regier, et al, 1978, 1993). The unstated and often unrecognized core component of rural mental health systems is often the people who neighbors call when in crisis. These unpaid and largely unrecognized mental health workers fill the gaps existing in formal care systems, both rurally and among urban poor. Mental health must be addressed by primary health care providers, as well as social welfare, criminal justice, education, and religious and charitable organizations. Members of the clergy hold positions of trust and respect in rural communities and tend to be underappreciated as resource people by professional mental health staff (Heffernan, 1999).

In discussions of the weaknesses of rural mental health systems, the focus is too often on problems external to the community, such as the shortage of qualified providers, the lack of parity between mental and physical health, and inadequate funding levels (Gale & Deprez, 2003). Amundson (1993: 177) referred to this as the “ain’t it awful what they are doing to us” theme. This focus diverts attention away from the issues that are within community control (Gale & Deprez, 2003).

Gale & Deprez (2003) recommend a focus upon internal problems amenable to local solution, building upon the greater capacity of rural communities to develop collaborative relationships across service delivery sectors and with community members. Common languages are necessary.

Data

My involvement in Northern, rural and remote mental health service delivery began in August 2005 when I began flying on a monthly basis to the Athabascan Basin in the North of Saskatchewan, just south of the 60th parallel and the border with the Northwest Territories. I began with the usual specialist model of seeing patients on consultation and writing reports to practitioners. I quickly realized the inadequacy of this model


Fond du Lac

Our informant, Rose P., told us about the existence of an elder’s network composed of 6 people who had been to Medjugore and who were strong in the Roman Catholic faith. Apparently this group of elders ranged in age from 40 to 60. Entrance into this network required at least one pilgrimage to Medjugore, and preferably more. Rose P. had been to Medjugore twice, and planned to go again. Rose worked in tribal government, but has a second non-paying job of being a resource person for community members, who will call her at all hours of the day and night when they are in crisis. Rose (and the other elders) primarily help the person in crisis through prayer from a Roman Catholic orientation, combining teaching from the Bible with teaching of traditional Dene values and role expectations as they have come to be modified by Roman Catholicism. It was our impression from further discussions with multiple informants that the Virgin Mary is much more discussed and important in Fond du Lac than Jesus and may relate to prior conceptualizations of Mother Earth. Rose P. wanted recognition for her role in the community, and seemed to want employment and compensation for this role. She mentioned being underappreciated by the Band Councilors and Chief. She felt they dismissed what she had to contribute. She wanted to be able to do her helping work without burning out.

Rose reminded us that people never used to spend time in large groups before being forced to do so by the Canadian government. Some feuds (such as those that now exist among families in the community) were ongoing for years (as long as anyone can remember). In the past, people could more readily avoid each other by going off on their trap lines, knowing that they wouldn’t see each other for at least another year. Family feuds were more manageable in the past than when people were forced into constant close proximity.

Informant Rebecca M. had nothing positive to say about elders or the community. She was 19 years old and believed they were all hypocrites. She didn’t want to talk to old people about “stupid Catholic ideas” or hear their preaching to her to say more “Hail Mary’s” or “Our Father’s”. She didn’t think problems get resolved by prayer or focus on Roman Catholic values.

Informant Brenda F. believed that health lay in following community values and role expectations. She was in her mid-twenties and had no children. She had had some contact with Mental Health Services in the past, but no longer. She didn’t really see the need for any additional services for herself or anyone else.

Informant Kevin F., brother of Brenda F., believed similar to Brenda. He thought Mental Health could be helpful for filling out disability forms, but otherwise, had little to offer. He didn’t want any services but was glad services were available if he wished to avail himself to them. Kevin had a diagnosis of Psychotic Disorder probably induced by heavy marijuana use. He was on disability from his job in the mine.

Informant (and client) Carol P. wanted to be sure we knew that we “didn’t know shit” and “had no power to do anything helpful.” What Carol needed (in her mind) was housing and what we had offered her was counseling, which was minimally (to be kind) relevant to her situation and possibly even patronizing and insulting. She thought Mental Health services should help people find housing and solve their real life problems instead of imaginary head trips.

Black Lake

Elder Pierre R. (age 65) came forward to request a meeting. He had been a former chief and a Band Councilor for 25 years. He distrusted the younger generation who were now Chief and Band Councilor. He felt they were focused upon the mines and creating more mining, though he thought that 40 mines were enough and that more would be harmful for the environment. He thought other forms of economic development needed to be explored. He was particularly concerned about AA leaders and NNADAP workers selling alcohol and drugs to community members.

He proposed a meeting of 4 to 6 elders with me during my next trip north. His elder group spends their time on the trap line and promotes time on the trap line as healing. They are more or less Roman Catholic, but different from the Fond du Lac group in that Medjugore is not important to them. What matters to them are their own visions on the trap line and the restorative power of nature as interpreted through a somewhat R.C. lens. He felt more encouraged by the young people than he was by the generation after him. He believes that young people were coming back to an awareness of nature and natural processes, which the “in-between” generation didn’t have. He didn’t believe that current leadership had any interest in improving mental health and addictions. He said they should listen to the people rather than tell the people what to think.

Eileen X. thoughts on “Mental Health” was a person for support, someone to whom you can speak when no one else is there. There didn’t appear to be a concept of health or of mental health. She said “Mental Health/Addiction Services” is new to people so they don’t have awareness of it. It comes when people are in crisis. In the past 13 years, violence has increased in the family and among each other. She mentioned that the people don’t know about the help available to them. She used to work for the RCMP. People would phone her when she was not at work and would tell her that kids as young as 10 were being locked up for “drunk and disorderly.” They looked to her for help. People don’t know about help. It’s not advertised in the Athabasca Region. There’s no posters. There’s no awareness. There’s no public information in the way that community members can access it. She thought that there should be a committee to create awareness and public information, especially with the helpline. She said there’s no crisis unit. There should be a committee for each community. She stressed that professional support is required. The committee should have a number of people – at least four people supporting the NNADAP worker. There’s no 12-step programs and addictions treatment is not successful. She thought that all three communities should work together for public advertising and information. Regarding suicide, she mentioned that it’s not usual for their community. She talked about the suicide of last year that was so shocking, but people knew that this young person was going to commit suicide, but they thought, he tried before, he won’t do it this time, but he did. (He actually tried three times before being successful on his fourth try). She also talked about his family life. His parents were alcoholic. He was a sad child and a loner. He grew up with that. She was so clear in that. She thinks that when rumors of suicide occur, there needs to be mechanisms in place to communicate with these people and not just shrug it off. Six to 8 people should sit on the committee and meet once monthly regarding the issues in the community, especially rumors of suicide. The people who are functional and effective are too busy with their own jobs and too involved in their own life. She thinks that initially a meeting should be set with the Band Council, the Town Council, Addictions, Mental Health, the RCMP, and the elders. Another meeting should be set with the youth from 10 to 18 years old, which would include an Addictions Worker and a Mental Health worker to assist and help out.

The primary objective is to initiate peer support. There’s no info about a kids’ allanon committee and there needs to be some type of program in place to set up such a committee [she’s talking about allateen]. What needs to be created are partnerships between the service providers and the community. The community can help the youth by more things spinning off from the primary crisis stage and moving on to create recreational activities.

She noted that elders don’t know about mental health workers and addictions workers. She’s really into pushing for awareness and making sure that these services are in your face and anyone can access them instead of waiting for the last minute. In conclusion, she said the voice has to be heard. Kids don’t know about mental health or addictions workers. She didn’t have a concept of mental health.

Carla’s notion is that it’s just something being put on them. Meetings will help integrate the services into their existing culture.

She also mentioned that she would be willing to sit in these initial meetings when they start up. She’s lived out of the community for a few years and she doesn’t like being back. She lived in P.A. for several years. When she was there, she’d see people come into treatment and be in the bar the night they were released.

Carla thinks there’s no concept of mental health, but everyone has a concept of social roles. (That’s historical).

Informant Rose M told us that having emotional problems is very stigmatized in the community. It means you are a defective person, there is something wrong with you. She is 42 years old and would not go to elders. When she did, they told her to pray harder and say the rosary more and say more “Our Fathers” and weren’t really able to address the causes of her distress (sexual abuse, physical abuse, feeling hopeless, having no escape, having an alcoholic partner, coming from an alcoholic, abusive past and home). She didn’t trust elders because they didn’t know how modern life was lived.

Informant Ray M, a Band Councilor, didn’t really trust the elders either. He trusted his children more. He seemed to emphasize a general distrust across adjacent generations. People seemed more able to trust one generation removed from their own. Ray attributed many of the community problems to alcohol and drug use and thought people drank because they felt hopeless and helpless. He believed that the marijuana problem was being minimized and was much larger than people were willing to admit. He believed that Mental Health and Addictions Services could help, but he saw the primary problem as stigma-free access. If the services were offered in the clinic, everyone saw who came and labeled these people as defective. If the services were offered elsewhere, they were harder to access. For himself personally, he never sought services in his home community for fear of being labeled and stigmatized. He went outside the community, sometimes as far as Saskatoon. He thought people needed to live a good life to set an example for their children, though he had only been sober for the past three years.

Stony Rapids

Informant Al P. said that Mental Health needed to teach people in the community how to have a work ethic. He said that he had told the Band for 10 years that they needed a day care center so that people could work, but they still hadn’t created one. When they tried, their main worker had a criminal record and the building they picked was under code, so they in essence sabotaged themselves.

Conclusions

The Canadian mainstream concept of mental health does not exist among the Northern Dene. Apparently one is having problems or one isn’t. When one is having problems, services are needed.
American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders. (4th ed.), Washington, DC: A.P.A.

Amundson B. (1993). Myth and reality in the rural health services crisis: Facing up to community responsibilities. J Rural Health, 9: 176-197.

Beeston P. (1991). The successful rural mental health practitioner: Dimensions of success, challenges, and opportunities. Rural Community Mental Health 18(4): 4-7.

Beeson P. (1999, Winter). Farm crisis and mental summit: A summary of findings. National Rural Health Association Party-Line. 7(4): 21-32. Retrieved 1 November 2000 from http://www.narmh.org/facrfrtn.htm.

Calloway M, Fried B, Johnsen M, Morrissey J. (1999). Characterizations of rural mental health services. Journal of Rural Health, 15: 296-307.

Cunningham R. (1997). Long road ahead to integration of primary and behavioral care. Medicine and Health Perspectives, 51(16): 1-4.

Gale JA, Deprez RD. A public health approach to the challenges of rural mental health service integration. In Stamm BH (ed). Rural Behavioral Health Care: An interdisciplinary guide, ISBN 1557989834, 2003, pp 95-108.

Geller J, Beeson P, Rodenhiser R. (2000). Frontier mental health strategies: Integrating, reaching out, building up, and connecting: Letter to the field No. 6. Frontier Mental Health Services Resource Network, Western Interstate Commission for Higher Education, Denver, CO. Retrieved 11 August 2000, from http://www.wiche.edu.mentalhealth/frontier/letter6.html.

Heffernan J. (1999, Winter). Mental health and ministry: The vital connection.National Rural Health Association Party-Line, 7(4), 16-18, Retrieved 11 August 2000, from http://www.narmh.org/facrtwel.htm.

Hoyt D, O’Donnell D, Mack K. (1995). Psychological distress and size of place: The epidemiology of rural economic stress. Rural Sociology 60: 707-720.

Ortega S, Johnson D, Beeson P, Craft B. (1994). The farm crisis and mental health: A longitudinal study of the 1980’s. Rural Sociology 59:598-619.

Regier D, Goldberg I, Taube C. (1978). The de facto U.S. mental health services system. Archives of General Psychiatry, 35: 685-693.

Regier D, Narrow W, Rae D, Manderschied R, Locke B, Goodwin F. (1993). The de facto U.S. mental health and addictive disorders service system: Epidemiology Catchment Area prospective 1-year prevalence rates. Archives of General Psychiatry 50: 85-94.

Roberts L, Battaglia J, Epstein R. (1999). Frontier Ethics: Mental health care needs and ethical dilemmas in rural communities. Psychiatric Services 50: 497-503.

Stamm BH. (1999). Creating virtual community: Telehealth and self-care updated. In B.H. Stamm (ed.). Secondary traumatic stress: Self-care issues for clinicians, researchers, and educators. (2nd ed., pp. 179-210). Lutherville, MD: Sidran Press.

U,S, Department of Health and Human Services (1999). Mental Health: A report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, Retrieved 11 August 2000, from http://www.surgeongnenral.gov/library.

Williams R. (1996). The on-going farm crisis: Extension leadership in rural communities. Journal of Extension, 34(1), Retrieved 11 August 2000, from http;//www.joe.org/1996february/a3.html.

Community and Special Needs Children

Here's a presentation I made on community and special needs children:

Conventional medicine and psychology typically ignore the surrounding social> environment in their assessment and treatment of children with disabilities > or special needs. Whether the child suffers from fetal alcohol effects, > autistic spectrum disorders, attention disorders, or learning disabilities> --> indeed for all children -- the community is important. Multiple streams of > research from different disciplines have shown that the expectations of > others> for how children will develop and behave are often more important than the> biomedical or psychological diagnosis. In this workshop, we will consider > how to> involve community in our work with children. We will explore how community > members can be a source of support and therapy and how to change community> expectations for children at risk. Examples of strategies include talking > circles, community meetings, ho-oponopono in traditional Hawai'ian > structure,> sweat lodge ceremonies and other rituals for Plains First Nations and more.> Through these approaches, people are already doing what has been called > naturalistic behavior therapy (shaping expectations for child development > and> behavior toward the positive with rewards inherent in the environment of the> child> accruing for small steps toward the goal with progressive expansion of the > goal as it is met). We will explore how to implement naturalistic behavior > therapy (which has been more effective than the more standard discrete> trials> approach) within communities using parents, grandparents, and others as > "therapists." These approaches are especially useful in rural and remote > communities> where trained professionals are lacking. They have even been shown superior> to "therapy" by professionals when the work is done by community members. > Finally, we will explore the importance of belonging to a community and the > support that comes from community involvement as was demonstrated in the WHO> studies on schizophrenia in Third World countries (better outcomes than > developed countries) and will consider how to support communities maintain > "ownership" of members who are different, thereby avoiding institutional> care.

Transformation

Transformation has been defined as a profound change in the core ways in which we function, view ourselves, and relate to others. Transformation can occur in any or all aspects of a life and is an ongoing process of development. It can involve paradoxical movements between dialectics -- such as surrender and will and even the uncovering and reconciliation of opposites and conflicts. It usually involves increasing awareness of the spiritual dimension (less identification with an individual self and a greater sense of overall connectedness). It may move us toward a greater sense of presence, openness, and inner freedom.

Recovery from Illness

What if recovery from illness could be unrelated to how illness arises?

A basic hypothesis of a narrative approach to illness is that the conditions of a person's life are more or less conducive to illness or to recovery. This differs from previous mind-body approaches or psychosomatic medicine that locate the source for illness within an individual and his or her intrapersonal dynamics. In a narrative approach, it is the entire story that must be considered. The story includes all aspects of the context as well as all involved individuals. Through a narrative approach, we enter a larger model than our science has previously been able to grasp. The model is confusing. It defies simple statistics. It resists linear cause and effect. It proposes that illness arises as an emergent, dynamic condition supported and maintained by all aspects of the situation. This new model both reduces human agency and increases human freedom. It is distinctly similar to aboriginal models of health and disease. Mathematically it requires complex systems methods rather than simple statistical formulae.

Illness has the potential to serve as a stimulus for personal transformation. It can also transform a social network. One of the most profound changing experiences of my life came from being part of a network ofpeople connected to a young woman who died of adrenal cancer. Though she died, those of us who were ostensibly helping her, were irrevocably transformed.

A narrative approach also has the power to move us beyond the defective people model toward an optimizing systems model.

Illness can awaken us to previously undeveloped qualities, perceptions, sensibilities, and abilities. It may be the catalyst toward emotional healing. It can allow us to emerge into greater sense of meaning and purpose. Illness can serve as a call to spiritual practice, or, in the West, become a spiritual practice in and of itself. It can become an antidote to modern Western visions of growth based on developing personal ego power. Jonathan Kabat-Zinn (1993) and Deena Metzger (2004) compare the illness experience to excruciating physical endeavors which ancient spiritual seekers willingly undertook for the sake of their own spiritual development.

Narratives exist of people who have been able to "wake up" through their illness, who tranform through the real life experience of illness.

What is healing and how does one do it?

Today I am at the New York Open Center. It's so busy on the streets of Soho. Christmas has come to New York City! Everyone is bustling. And there are so many workshops and practitioner trainings to attend. Everyone has a technique or a theory. I feel a bit daunted, since I have a non-theory, more or less. My theory is that healing emerges through dialogue and that anyone can do it. That's a hard sell for a workshop. It's easier to pick a technique -- heal yourself through reiki, core shamanic practice, reflexology, numerology, iridology, ayurveda, etc. I'm doing some of that myself when I teach Cherokee bodywork, though I try to teach it as a non-technique, a way of following energy and not a strict set of procedures that one does. My sense is that we are upside down in North America. We need to develop our own abilities to follow energy and to sense spirit and listen to spirit more than we need to learn algorithms. We need to form communities of like-minded healers, start healing circles, dialogue with each other and let the emergent properties of systems hold forth. I think about John Charles, a Cree healer in Saskatchewan, who has never attended one of these workshops and who is a man you would definitely want praying for you. We'll see what happens tonight in my workshop on Native American healing amidst the cacophany and excitement that is New York, so different from Sturgeon Lake First Nation.

High dose Vitamins

Just a note about some of my non-aboriginal related research, though, in some ways, it is, because aboriginal people have some of the worst nutrition in the world, thanks to being starved and then fed government commodity food.

I'm talking about high dose micronutrient therapy for psychiatric conditions. I thought to make this post today, because a local psychiatrist called me who wanted to get started in this area because I had seen one of her patients on call and had suggested Empower Plus and it had worked so well when medications hadn't, that she wanted to know more. So word is spreading thanks to patients who are doing well.

I'm starting a study on the use of Empower-Plus for mood disorders in January, and will appreciate referrals.

The logic behind this approach comes from a paper written by Bruce Ames, Ilan Elson-Schwab, and Eli Silver, called High-dose vitamin therapy stimulates variant enzymes with decreased coenzyme binding affinity (increased Km): relevance to genetic disease and polymorphisms , from the American Journal of Clinical Nutrition, 2002; 75: 616-58.

Also see the research section of True Hope's web site at www.truehope.com.

Mental Health for Northern Peoples

Today I attended a gathering to discuss mental health for Northern peoples in Saskatchewan. I continue to be amazed by how much money can be thrown at a problem instead of doing actual community development which is so much cheapter. I am drawn to the World Health Organization studies of how much better outcomes India has for serious mental illness than the United States. What India has are intact communities and social networks, sorely lacking in North America. India lacks the money to invest in chronic medication for serious mental illness, so medications are only used for acute episodes. Indian patients must be cared for by their families, even in hospital, since money doesn't exist for nurses. Of course it's not magic, but social relationhip is important and it is so much more compatible with aboriginal ideas about mental health in which self is social and not individual. Identity is seen as the story we tell ourselves to make sense of all the stories that have ever been told about us. People's behavior is determined more by context, environment, and expectation than internal psychodynamics or psychic structures, or psychic apparatuses. When we focus on that, we realize people can change without ever coming to treatment if the community changes around them.