Book review – How Can I Help?

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I was recently asked by Caitlyn Veiga at Simon & Schuster Canada to review the book How Can I Help? A Week in My Life as a Psychiatrist by David Goldbloom and Pier Bryden. David Goldbloom is a psychiatrist working at the Centre for Addiction and Mental Heath (CAMH) in Toronto and Pier Bryden is a child and adolescent psychiatrist at Toronto’s Hospital for Sick Children. In their book, we tag along with Goldbloom for a week as he meets with patients at CAMH and explores some of the current issues facing the field of psychiatry and the mental health treatment domain more generally. As we turn the pages, we also watch him identify and navigate the pitfalls of treating mental illness within the current Canadian healthcare system. We also observe some of his victories in doing the same.

My review here touches on some of the issues raised in the book and I relate these to my experiences as an early career psychologist. My principal reason for taking this approach to a review is because, on several occasions while reading this book, I noticed striking parallels between the two disciplines of psychiatry and clinical psychology – mainly with respect to the professional and ethical issues both disciplines are facing at this early stage in development in human behavioural science. My general experience while reading this book was one of resonance; each chapter was peppered with statements where, if one were to simply swap “psychiatry” with “psychology”, the underlying meaning, truth, and/or relevance of the statement wouldn’t have been altered whatsoever. These numerous parallels reinforce the possibility that, at this point in time, many mental health professions face similar problems. It also further supports my belief that tackling the problem of mental illness in Canada will take a collaborative effort in which all clinicians support and respect each other, as well as draw on each other’s knowledge and expertise.

Many folks might consider these parallels between psychiatry and clinical psychology surprising, since each discipline comes from a different philosophical direction with respect to how mental illness is treated. But these parallels exist nonetheless. One fairly humorous and benign example of such a parallel is the widespread lay belief that an encounter with a psychiatrist/psychologist will inevitably result in being “analyzed” or having one’s head “shrunk” against their will. Another example is the perception that both psychiatry and psychology are practiced somewhere away from any hospital, entirely removed, insulated, and isolated from the rest of the healthcare system. Although it is true that many psychologists (myself included) and psychiatrists practice privately as part of what they do, both disciplines have made significant strides towards greater integration and involvement with the primary healthcare system. This is much more true of psychiatry than psychology; psychiatry has been relatively established in the system for some time, whereas psychologists are still fighting for their seat at the table.

The authors note psychiatry’s growing role in the primary healthcare system has brought with it a host of new challenges and the same is true for psychology. Psychologists can occasionally find themselves in territorial disputes with other mental health professionals (e.g., psychiatrists, social workers, occupational therapists, psychiatric nurses) over who has rightful ownership over the mental healthcare domain (spoiler alert: they all do, in different ways). Within each of these disciplines, there are clinicians who believe their field should have sole ownership over this domain, and unfortunately, psychology is no exception. Perhaps it is because clinical psychologists are so extensively trained, over many, many years – in understanding and conceptualizing human behaviour, conducting and evaluation scientific research, and assessing, diagnosing, and treating mental health problems – that there emerges a sense of mastery and/or entitlement in this area. I’m not sure. But such assumed ownership by any profession is not only unhelpful to the overarching cause, it is just plain wrong. No single profession could ever possibly master the domain of mental health. Just like in areas related to physical health (no, I won’t engage in the mental-physical dualism debate here), there are countless specialists operating within their respective areas and collaborating with those in other areas. One wouldn’t expect a podiatrist to conduct neurosurgery or an ophthalmologist to clean teeth, so why would one profession assume they could solve all problems related to brain dysfunction and mental illness? These problems relating to mental illness are not one-dimensional, and rarely will they require for resolution only one type of intervention provided by a single profession. And so the story of how we ultimately slay the giant of mental illness will not be a story of David and Goliath. No one player can tackle this beast; this will be a team effort. And the team comprised of the most skilled players who each know their position and work together as a team will prevail. These are the mental health teams we need to build into today’s healthcare system.

Contributing to this problem of territoriality among mental health clinicians within primary healthcare settings is that many of these professionals are not adequately trained or oriented to the interdisciplinary nature of these treatment settings. With respect to psychologists not being fully trained to work in hospitals, part of the responsibility goes to, surprise surprise, the psychology training programs themselves. I think my clinical training program was incredibly strong and I owe a huge debt of gratitude to my very experienced and knowledgeable supervisors for facilitating my development as a clinician. With that being said, most of my learning about how to effectively operate as a psychologist within the healthcare system came from working with psychologists and non-psychologists working in hospitals, and these learning experiences themselves were ones I intentionally sought out. In other words, my learning about how to operate as a part of a multidisciplinary team (which is still ongoing, I might add) didn’t come from the mandatory training curriculum. Perhaps this kind of training needs to be embedded in our training curriculum as a means of readying psychologists for work in these primary healthcare settings, where their expertise is currently needed.

Yet another issue compounding the territoriality problem is that many healthcare professionals, such as family physicians, do not have a clear idea about what psychiatrists and psychologists actually do in practice, when to refer to them, and/or when one should refer a patient to one instead of the other. One frequently cited criterion distinguishing psychiatrists from clinical psychologists is that psychiatrists generally prescribe medication whereas psychologists do not. Alternatively, psychologists reply primarily on cognitive and behavioural interventions for treatment, and psychiatrists do not. But even with respect to this criterion, the line distinguishing the two professions isn’t clear. Case in point, there are psychologists in the military that prescribe medication, and there are some psychiatrists who choose to deliver more psychological interventions than prescriptions in their practice. Given this lack of clarity, how could other professionals and the public be expected to know when to seek one profession over the other? Thus, establishing a clear professional identity with equally clear boundaries is another target psychologists must aim for. (As an aside, there is currently a debate within psychology about whether psychologists should be able to prescribe medication…with some additional training, of course. My impression is the vast majority of psychologists don’t want this privilege.)

I have digressed in my review, but my point is that the current lack of clarity about which disciplines are responsible for what practices within the mental health domain is doubtless contributing to both real and perceived professional encroachment, territoriality, and “silos”. This bickering and confusion, in turn, is likely negatively impacting our collective capacity to provide patients with optimal mental health treatment. I have been personally very fortunate to work in places that were highly collegial and where other disciplines were, more often than not, perceived with respect and curiosity rather than hostility. However, I know this is not the case throughout the healthcare system. Yes, we have more work to do here.

Back to the book. Another issue raised by the authors is the problem of how to ethically and effectively treat mental illness when our knowledge of the brain and human behaviour is so utterly incomplete. The clinical practice of psychiatry hinges heavily on research related to the myriad physical and chemical mechanisms associated with mental disorders, as well as to relevant neuropsychopharmacological tools, and how those tools might adjust these mechanisms so that they function more adaptively. Psychologists are also interested in these mechanisms, but psychologists focus more on research that informs them of how to train the brain to fix itself. This is usually accomplished by using the brain’s own mechanisms to actively reshape itself neurologically, by forming and practicing new thought and behavioural patterns. Psychologists do this this by capitalizing on the incredible adaptability and flexibility of the brain – a characteristic referred to as “neuroplasticity”. As you might imagine, treatments in both psychiatry and psychology are incredibly complicated processes, because so much remains to be discovered about so many facets of how the brain operates. With all that being said, the authors contend that despite such gaps in our knowledge, we do indeed know a lot about the brain already and about which treatments are effective. They also point out the well-established fact that treatment is currently much more beneficial for clients than no treatment at all. I share the authors’ views in these areas without qualification.

Another issue raised by the authors, somewhat in passing, is how misguided treatments for mental illness in the past have effectively scarred society, rendering members of the public highly suspicious of such treatments and making them more reluctant to seek it. Historically, treatments for mental illness have ranged from absurd (e.g., phrenology or the interpretation of the skull’s topographical features) to sexually abusive (e.g., treatment for female “hysteria”), to ethically despicable (e.g., conversion therapy), to downright horrific (e.g., trepanation, lobotomy, bloodletting). Understandably, this sordid history has created a lack of trust by the public in mental health practitioners. However, this perspective, while understandable, is outdated and the mistrust undeserved. Thankfully, times have changed (we generally try not to drill holes in people’s heads anymore). Modern mental health treatments are highly effective, ethical, voluntary (except in extreme circumstances), and most practitioners strive to give patients as much agency as possible in choosing their course of treatment. As in many other areas, we still have a ways to go on this front, particularly with respect to giving people the option to have the costs or either (or both) medication and psychological treatment covered.

Goldbloom and Bryden also highlight the staggering costs of mental health on the Canadian economy. Estimates of cost vary but usually center around $50 billion annually when one accounts for factors like work absenteeism and “presenteeism” (i.e., attending work while ill). This amount of economic damage is roughly proportional to that of a Category 4 hurricane hitting a major metropolitan area in Canada…every year. And this is because people aren’t getting the treatment they need and want. Stigma around mental illness is indeed a problem and is frequently cited as the main reason why people don’t receive treatment for mental health problems. However (and this might be surprising to some), the data clearly identifies a bigger problem: the lack of access to services. The current lack of access problem itself boils down to two factors: (1) the fees for service aren’t covered by public healthcare plans and (2) the wait times for treatment through the public system are too long. In a 2013 report written by health economists for the Canadian Psychological Association, the coverage of mental health treatment in Canada was described as “fragmented, at best, and, frequently, non-existent” (p. 2), resulting in a “silent crisis” (p. 3). Obviously, the problem of access requires serious attention by politicians, and the public should be demanding more from their government to meet this need.

Most healthcare professionals would agree the problem of lack of access represents a massive crisis that delivers heavy blows to both human quality of life and the economy. But can we economically afford to invest in these treatments? The answer is clearly yes. Current data shows that every $1 invested in mental health and addiction treatment yields a $2 to $7 return on investment (ROI) to the economy, depending on the treatment and the health target. Given these numbers, even the most diehard, rightwing conservatives should be frantically scrambling to fund mental health services. Thus, positions of wavering, passivity, and/or willful ignorance on the issue of whether or not to fund mental health services are no longer ethically or economically defensible ones (were they ever?), regardless of one’s political orientation.

In the end, Goldbloom and Bryden do a nice job of carefully discussing some of the myriad problems currently faced by mental health clinicians, as well as unique problems specifically faced by psychiatrists. The authors strike a nice balance between exercising caution that some magic bullet for mental health problems will emerge, and instilling confidence in us that many current evidence-based treatments we are using are doing a lot of good. If you’re interested in learning more about the trials and tribulations of knowledgeable and experiences psychiatrists operating within the Canadian healthcare system, and about the system itself, I would certainly recommend giving this book a read.

It is certainly true that our current understanding of the brain is incomplete, as is our understanding of how best to optimize the brain’s functioning, but we do know a lot. In fact, we are learning a staggering amount about the brain every day and at a rate faster than we ever have. And with this progress comes incredible potential. Modern day mental health practitioners are doing a substantial amount of good for the lives of others. And yet, we are fallible.

Clinicians, like anyone, make mistakes. We all struggle. We all fail. We all learn from our experiences (hopefully) and we move forward. Regardless of whether one is a clinician or a patient, we are all human. And as humans, we do our best with what we have to work with at the time. As the authors note about their patients, “they are us”. We are no different than the patients we treat. In a sense, we are all patients; we all need help from those around us. And at the same time, we are all clinicians; we all need to help those around us. And in these uncertain times, now more than ever, we need to do everything we can to take care of and support each other.

Caelin

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