Does Ontario need a treatment advocate?

CrossCurrents

The Last Word

Editorials do not necessarily reflect the views of CAMH. We welcome submissions from our readers. For information, contact the Editor, CrossCurrents,33 Russell St., Toronto, Ontario M5S 2S1,tel 416 595-6714, e-mail hema_zbogar@camh.net.

David is 27 and has schizophrenia. He has had several past admissions to hospital when distressed by voices and delusions. On Saturday night, David is brought to the emergency room of his local hospital by staff from the hostel where he is staying. He has not been taking medication for several months and is agitated by voices that criticize and insult him. The assessing psychiatrist believes David would be safer and more likely to take medication if hospitalized. But there are no available beds, so she sends David back to the hostel with a prescription for an antipsychotic. On Monday morning, David leaves the hostel, convinced that staff are conspiring against him. He roams the streets, increasingly distraught. One week later he kills himself by jumping from a bridge.

David is a fictional character, but his experience in the ER is played out in cities across Ontario many times each week. While most cases do not end as tragically as David's, the failure to provide necessary treatment robs many of our most vulnerable citizens of their health and condemns them to prolonged suffering.

Let's try to understand what went wrong in David's case. Who was ultimately responsible for ensuring that David got the care and treatment he needed? Could David himself have insisted that he be admitted and receive treatment in hospital? To the latter question, the answer is no, because like many people with serious mental illness, David did not recognize he had an illness and needed treatment. This lack of insight is a cognitive deficit called anosognosia. But even if David had understood that he was ill, he may have had other common symptoms of schizophrenia, such as reduced motivation, poverty of thought and social withdrawal, that prevent people with schizophrenia from effectively advocating for themselves.

For other disorders that impair people's ability to recognize their need for care and treatment, such as Alzheimer's disease or mental handicap, relatives play a leading role in ensuring the person's needs are meet. Why did family not advocate for David's needs? Well, as often happens, David and his family had drifted apart. Perhaps David had incorporated the relatives into his delusions, or maybe the family had become frustrated trying to get him to stay on his medication. Stigma may also prevent family from stepping into the spotlight to advocate for appropriate services.

What about the hospital and the doctors? Was it not their job to ensure that David's needs were met? Alas, Ontario's hospitals are debt-ridden and in serious trouble. They are increasingly preoccupied with preventing admissions (medical as well as psychiatric) to save money. Doctors have been co-opted to the role of the system's gatekeeper. Indeed, psychiatrists often fail to admit individuals who meet the criteria for civil commitment and who, like David, would greatly benefit from admission.

Isn't there a psychiatric patients' advocate? Yes, but the role of the Psychiatric Patients' Advocate Office (PPAO) is to provide rights advice for individuals committed to hospital or on a community treatment order. The PPAO also provides some systemic advocacy, but the advocacy is primarily "rights-based," and the PPAO would find itself in an impossible quandary if it were expected to argue that an individual should have been committed to hospital.

Thus, in Ontario, individuals like David are often left to deal with their own demons. You may believe the situation is not as bad as I have portrayed it. I happily acknowledge that many relatives, psychiatrists and other mental health workers are effective advocates - but many others are not. The evidence that we are failing to provide a basic level of care is all around us. Large numbers of people with mental illness are in jails rather than hospitals; others remain untreated for months (sometimes years) if they do get admitted to hospital or are forced to live on the streets.

When vulnerable individuals lack a clear and consistent voice, society has a responsibility to ensure that someone can speak for their needs. The time has come to establish a position of treatment advocate for Ontario - someone who could intervene directly in individual cases and respond to systemic failures. Most of this work could be done on a semi-formal basis. Let's say that David did not kill himself, but that hostel staff alerted the advocate's office that the hospital had failed to admit a very disturbed individual. With David's permission, the advocate could approach the psychiatrist to find out why this happened. An unsatisfactory response would take the question to the hospital administration. It is remarkable how differently we behave when we know that our work is being monitored! The advocate would maintain the prerogative of reporting a "serially offending" hospital to the minister or of drawing the media's attention to repeated problems at a particular hospital. Concerns could be directed to the advocate 's office from patients and their relatives or from agencies like the Schizophrenia Society of Ontario. The advocate could not attempt to resolve every case; rather he or she would strategically select cases. Where problems are due to inadequate resources, the advocate would offer to work with the hospital to ensure the required resources are provided.

The position of treatment advocate is necessary to provide balance in our system - to ensure that in addition to protecting legal rights, we also provide treatment when it is needed. A treatment advocate position would not solve all the woes of the mental health system, but it would, at a minimal cost, help many of our most needy citizens receive the care and treatment they require.

Dr. Richard O'Reilly is a professor of psychiatry at the University of Western Ontario and the psychiatrist for a rural assertive community treatment team.

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