The promise of community care for the mentally ill: a cruel fraud

The “community care” model.

I’m going to go out on a limb and say something that will offend some fine people whom I respect. To wit: The promise of community care for the mentally ill is a cruel fraud.

Coupled with the concept of deinstitutionalization – closing institutions for the mentally ill – community treatment has never worked. It will never work. It will always – always – result in large numbers of the mentally ill being turned out into the streets to fend for themselves in increasingly desperate circumstances.

The results for the mentally ill, their families and loved ones, their friends – and sometimes just those of us who have the bad luck to sit beside them on the bus – can be catastrophic. The results for taxpayers are increased costs – spent in the justice system, instead of on health care.

Supporters of community care for the mentally ill, psychiatric professionals, government officials struggling to keep budgets under control, operators of for-profit residential “care facilities,” and many others with many motives, honorable and not so honorable, will protest that community care could work – probably work even better than institutionalization – if it received adequate resources.

Who can argue with this assertion? Certainly not those of us who are not experts in the field. But this is why the community-care model is a fraud: it will never work because it will never get the resources it needs. You don’t have to be an expert to understand this!

Come on, people! Consider what mental health care has to compete with for funding, in health care alone: multi-million-dollar MRI machines for rich people who hurt their knees skiing and their backs playing golf, just for one example.

Which do you think is going to get the big bucks from governments of the rich, by the rich and for the rich – which is all we have in North America nowadays? Something that powerful people with connections demand, now, or something that a group of people who are mostly poor, atomized and unable to speak for themselves, or even act in their own basic interests, desperately need?

And that’s just in the realm of medicine. Don’t forget that also competing for suddenly scarce government megabucks are those subsidized private businesses called P3s that build billion-dollar highways, consortiums set up to construct ritzy sports arenas, stakeholders in failing auto assembly plants and a zillion and one other enterprises that benefit people who know how to speak for themselves and grease the wheels of government.

Saying that community care for the mentally ill could work if we only devoted adequate resources to it is like saying that free love would be no problem if only we could all stop being jealous. Yeah, it’s true. And it’s never going to happen on this green earth, even with adequate supplies of penicillin.

State and provincial authorities in North America have been closing down major psychiatric institutions since the 1950s. Deinstitutionalization is always accompanied by promises that these facilities will be replaced by community care. These promises are never kept, and most mentally ill people are left to fend for themselves.

Now, as they face a financial crisis as much of their own making as caused by recession, Alberta’s prodigal Conservatives are proposing to save a few bucks by closing many beds at Alberta Hospital Edmonton, a world-class psychiatric facility. And, guess what, they’re promising us they’ll put proper community supports in place first.

What makes us think that Alberta will be different from any other Canadian or U.S. jurisdiction where these promises were made and not kept? I apologize for using bad language, but all this promising is, in the words of a psychiatrist of my acquaintance, “just bullshit!”

I believe that Dr. Stephen Duckett – the antipodean economist hired by the Alberta government to turn health care in this province on its head – is an honourable man. But he is promising something that he can’t deliver when he says, as he did in his most recent blog for Alberta Health Services employees, that “our commitment to our patients is clear: No hospital spaces will be closed unless and until community-based beds and services are in place.”

I also believe that Dr. Duckett – who is a PhD economist, not a physician, by the way – is mistaken when he calls Alberta Hospital Edmonton “a care model out of touch with contemporary best practice.” Intentionally or not, he’s conjuring up an image of the insane asylums of yore, not the world-class psychiatric treatment centre that AHE is today.

And while I don’t doubt Dr. Duckett’s word when he says “we are currently consulting with staff at Alberta Hospital Edmonton on what appropriate services might look like,” I do wonder which staff members he is talking to, because several of the institution’s psychiatrists are on record saying he’s never talked to them.

Right now, even before there have been any bed closures at AHE, Alberta has fewer acute care psychiatric care beds per capita than any other Canadian province. Waiting lists to get into AHE’s programs are long.

Without the programs at AHE and without the chimerical community supports for the mentally ill that we’ve been promised, whatever we save on funding AHE will be more than made up for by increased costs for policing, courts and jails.

And when our jails have become mental institutions of last resort, you can bet that the mentally ill they house won’t be getting the treatment they need – or once could have had at AHE.

In his blog, Dr. Duckett stated: “I recognize that there are concerns about whether or not the community spaces will be created. To that I say: Watch us.”

Will I be watching? You bet I will! If Dr. Duckett somehow manages to pull off this promise, I’m going to make a fortune … selling umbrellas to pedestrians to protect them from flying pig droppings!

7 Comments on "The promise of community care for the mentally ill: a cruel fraud"

  1. Anonymous says:

    You could not have said it any better. We'll all be watching.

  2. Anonymous says:

    Well said. So they want to de-institutionalize? Perhaps they should actually check out the population in our jails first. I could not agree with you more.

  3. Anonymous says:

    Brainstorm with me for a minute Dave. What would you need to see in a "community care plan" that would sastify you ?

    BTW, am not Mr. Dr. Duckett looking for ideas.

  4. David J. Climenhaga says:

    What would satisfy me in a community care plan? Evidence it worked; confidence adequate funding could be sustained. Neither is very likely, in my view. I'm not a mental health professional, so I can't prescribe treatments or approaches that I think would work. I can see what goes on around me, and I see nothing to make me confident North American governments will ever be committed to community care for the mentally ill, at least for very long. Beyond that, as a layperson with an interest in the topic, I suspect strongly that the institutional approach has been unfairly maligned by both the left and the right. The right, of course, is quite happy to seem to agree with an obsolete and questionable "human rights abuse" interpretation of the activities of mental health institutions in order to push the business objectives of companies and individuals who want to operate community care settings for profit.

  5. Anonymous says:

    Absolutely, the government will leave it all up to for profit community group homes and facilities to house the mentally ill. But, who will actually treat them? Are the psychiatrists and therapists and nurses going to make house calls? Who will pay for those?

  6. Anonymous says:

    Thanks for speaking out. There are some good community supports available, i.e. assertive outreach, psychiatric day programs, supportive housing,collaboration with GP's and urban hospitals, (many provided by AHE), but no where near enough.
    It is not about community versus inpatient beds, it is that the community supports are meaningless without acute care backup and vice versa. So to gut in-patient care to support community is as useless as supporting inpatient to the neglect of community supports.
    The bottom line is that our government has neglected mental health for years. AHE as an example has had redevelopment plans made 6 times. The most recent time, a sign went up saying redevelopment is underway. The sign remains, but the message has been painted out.
    Enough is enough, we need everyone to speak out!

  7. Anonymous says:

    I think your pieces on mental health are informative, hit a cord that is balanced, refreshing. Although no answers are given, your entries still speak to many.
    I have an autism spectrum disorder, some neurological issues, and 2 genetic disorders. 2 years ago I experienced a breakdown my psychologist said was a development of psychosis. Whethr it's chronic or just brief/situational psychosis brought on by anxiety nobody knows.

    According to the diagnostic models and seperation of psychiatry from the from the medical field, I have experienced many invalidating situations at the ER. So I know how it feels for a system to neglect somebody and Im not even on the streets.

    Right now I am unfortunatley stuck b/c if police come to my place I may be kicked out of my place. Sure my dad might find me another palce but where am I going to go. My friend on the autism spectrum was kicked out of a housing program for PDD and was lucky to be admitted to the hospital.

    Now Im scared to go back to the hosptial or urgent care facilities because they ignore me, call me a liar, it's painful and my reacting is consistent to PTSD.

    It is very scary and I feel for the people with more severe mental health issues than me or struggle with homelessness. I volunteer at a homeless drop-in because at any moment I know it could be me on the streets.

    A lot of people mention I have a lot of good ideas. I think the insitution model was antiquated and abused but the idea is purely about help and support. What would insitutions look like today…? Well we have Alberta Edmonton Hospital and it's world class. On the FB page supporting the retention of psych beds, a few people posted their recovery stories of AEH.

    Maybe we need to create a in-patient facility that has the ability to keep patients from a low-to moderate timed stay with an accelerated assessment process. If they don't meet a threshold, they can be followed up at a community mental health center every 2 years.
    Then create a few more long-term facilities for that segment of mental health patients and/or with medical needs.

    And some individual's will never be matched up with the correct services, if their even are ones. My friend has BPD but the friend also may be on the autism spectrum.

    So now what do you do with somebody that has ASD and BPD 9mental health issue) or ASD and psychosis….? Pretty much all services are thrown into the trash. Although some services may benefit like DBT or psychotherapy.

    Thanks for listening to this opinion…!


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