Waiting for those with psychosis to be dangerous before actively
intervening leads to degradation and tragedy

MHSF grant allocations and projects focus on strategic issues crucial to the well-being of those with serious mental illness.

Current priorities, as of April 2019, include:

• A more pro-active approach to treatment and post-discharge care; reducing “system failure” and averting tragedy
• Ensuring the needs of those with schizophrenia are given sufficient priority and resources
• Establishing and expanding trained family peer support
• Facilitating family involvement, with a focus on information sharing
• Strengthening community participation of those with serious mental illness and breaking their social isolation
• Research and other measures dealing with the ongoing, long-term “negative symptoms’ (post-psychotic symptoms) of schizophrenia
• Innovative projects to improve the lives of the most seriously ill

Also bearing on these priorities are the many issues the Foundation has identified as having particular importance. See Strategic Issues, below.

Family peer support

A critical element in helping those with serious mental illness is family involvement since families more often than not are key players in getting their ill relative into treatment and in monitoring their post-discharge recovery. Family peer support – support provided by a family member who has been through it – is a vital aid in helping family members manage crises, avoid tragedy, and get the best treatment and rehabilitation for their loved ones.

Understanding the Mental Health Act and involuntary admission

Even many service providers, supposedly well-trained, get the B.C. Mental Health Act wrong. They’ll tell you that a person needs to be a danger to themselves or others in order to be involuntarily admitted to hospital for treatment. That’s not, however, what the Mental Health Act says. The main criterion for involuntary admission, and it’s self-standing is “to prevent…substantial mental or physical deterioration,” provided, of course, that the person is mentally disordered. This allows clinicians to respond in a timely way to psychosis instead of waiting for the illness to do even more damage and making recovery that much more difficult. For an understanding of involuntary admission, please see an article on the subject, “Uncivil Liberties.”

A pro-active approach to treatment: reducing “system failure” and averting tragedy

The public wonders why so many seriously mentally ill people fall through the cracks. One of the main reasons: Mental health services often won’t use involuntary admission even when it’s required and appropriate, leaving ill people who are psychotic and deteriorating to fall even further into the abyss. A pro-active approach to treatment is needed instead.

Family involvement as part of the treatment team

Observations by involved family members are vital to their ill loved one’s diagnosis and to their recovery, rehabilitation, and avoidance of relapse. They’ve probably been instrumental in getting their loved one into treatment, to begin with. Their participation in the treatment process, however, is most often thought of as an add-on, if it’s requested at all. Family members should, instead, be considered bona fide members of the treatment team, with standing as part of the team and with a full understanding of what they bring to the table.

Family involvement means information sharing

Family involvement and what it brings to the treatment and recovery of the ill person is undercut when clinical information isn’t shared with family members. This is particularly the case when the ill person is psychotic and paranoid and is unlikely to give permission for such sharing, yet this is exactly the time when the sharing is most vital. The legislation governing information sharing with family members does, in fact, allow for it in such situations. Nor are other members of the treatment team, such as psychiatric nurses, denied relevant clinical information in such instances. For a discussion of the issue, please see “Family involvement means information sharing,” originally published in the NSSS Advocacy Bulletin.

Sufficient resources for helping those with schizophrenia

Schizophrenia (which affects 1 per cent of the adult population) isn’t as prevalent as bipolar disorder (2-3 per cent) or major depression (perhaps 5 per cent), yet it is the most disabling of the major mental illnesses and requires the longest stays in acute and tertiary care. Schizophrenia is also the most chronic mental illnesses, with residual but quite challenging symptoms usually lasting into a person’s old age. It’s important, then, that sufficient resources be provided for the treatment and care of those with schizophrenia, to meet their greater need.

Dealing with the “negative symptoms” of schizophrenia

Most people associate schizophrenia with the psychotic symptoms of its acute phase, such as delusions, hallucinations, paranoia, thought disorder, and catatonia. These are called, ironically, “positive symptoms,” because they add to what was there before the illness struck. There are also, however, “negative symptoms,” so-called because they involve deficiencies – losses to what was there before. Negative symptoms include an often profound loss of motivation, (“avolition” in clinical language), lethargy, poor social interaction, dampened feelings and responsiveness, trouble with rhythm and clarity of speech, slowed movement, and cognitive deficits. Unlike antipsychotics for psychotic symptoms, however, there’s currently no effective medication for them.  Also, unlike acute-care treatment which is relatively brief, these challenges may last for the rest of people’s lives. Dealing with these negative symptoms, in research and programs, demands the same degree of attention given to acute care.

Metabolic syndrome

Related to negative symptoms is a metabolic syndrome, a cluster of conditions that includes excess body fat around the waist, high blood sugar, high triglycerides and abnormal cholesterol (low HDL). Those with schizophrenia are particularly vulnerable because of lethargy, the physiological burden of their illness, the sedation effect of many anti-psychotic medications, and weight gain produced by the medication in many cases and poor diet. This means a greater vulnerability, in turn, to diabetes, heart attack and stroke.

Engaging those with schizophrenia in the community

Because of negative symptoms, and because many of those with schizophrenia were hit by the illness in their late teens and early adulthood when social skills are developed, those suffering from schizophrenia can end up isolated and languish, with limited activities and seemingly bleak futures. They are said to be “in the community,” which sounds nice, but they’re not “of the community.” As long as they don’t cause trouble, we may in fact not have any contact with them at all. Their quality of life and the joy of meaningful relationships with others is greatly diminished. Engaging those with schizophrenia in the community, with a circle of friends and acquaintances to which they feel they really belong, is one of the greatest, yet seldom talked about, challenges in the struggle to help the seriously mentally ill.

Avoiding mission creep; keeping our focus on serious mental illness

“Mission creep” is a quasi-political development where the resources that should be going to help the seriously mentally ill are misallocated to, or just plain frittered away on, those less seriously affected who don’t need the same level of help. It happens by talking about mental health generally (rather than mental illness), or running mental-health campaigns that apply to those with moderate conditions (e.g. mild depression), the “worried well,” and those who simply can benefit from social programs. Those cohorts, at the same time, because they don’t suffer from serious mental illness, are more active and articulate, and have a louder voice. Serious mental illness, in this framework, slowly but inevitably becomes marginalized and misunderstood, with the flow of resources allocated to helping the seriously mentally ill decreasing accordingly. This “mission creep” is particularly a problem in the United States, but is also a factor in Canada.

Recognizing “the reality of serious mental illness”

Mental health service providers often overlook just how rooted psychosis can be and its continuing effects.  They may be slow to act or decline to intervene even though, because of the underlying psychosis, the person’s life is sliding into degradation and misery. They’ll rationalize their lack of action, in such cases, with stock clichés like “Well, he’s an adult, you know,” even if the person’s thinking is driven by delusions. Absent on the service provider’s part is any realistic assessment of the patient’s competence to make critical decisions, as if the patient, because they’re not floridly raving, can process information and make decisions just like anyone else. The degree of impact of the illness goes unrecognized. Another stock cliché for inaction by professionals is an ostensible need to “show respect.” However, not addressing the workings of the person’s illness is the opposite of showing respect. The consequences, for the ill person, can be disastrous.

Addressing physical deterioration and harm

One of those disastrous consequences is physical harm and deterioration, sometimes leading to death. This is aside from suicide. The B.C. Mental Health Act specifically allows physicians to use involuntary admission and treatment in cases where a mental disorder, interfering with understanding, threatens physical health, say from cancer or an untreated infection. The applicable clause in the Act for such involuntary admission is quite clear: “To prevent…substantial mental or physical deterioration [italics ours].” Yet all too often the physician ignores this provision and the corresponding duty to act, with predictably devastating results.