It takes remarkable ineptitude to push young people with mental health disorders to participate in activities they’ve neither chosen nor been consulted about. Peer support worker and consultant Luc Vigneault agrees. Vigneault works at the Institut universitaire en santé mentale de Québec and is well known in mental health circles for his workshops and lectures. He believes that the trauma experienced during psychiatric hospitalization scars patients and hinders the therapeutic relationship. And he would know; he struggles with a mental health disorder and once attended a treatment meeting where the staff predicted a dim future for him, in front of his family.
Once I left the hospital the stigma weighed heavy, and I became a prisoner of my medication’s iatrogenic effects, i.e., the effects they had caused. I soon grew accustomed to the revolving door effect, caught in a vicious cycle of trips back and forth to the institution. On one of my trips to the psychiatric ward, I received the following decisive prognosis: “You’re done,” then to my family, “He’s done. He’ll never be able to work or have a social life or be romantically involved.”1
Luc’s healthcare team believed that his mental illness—diagnosed as schizophrenia—was incurable. But his family and friends didn’t give up on him. They fought for the hospital to change its treatment approach. His file was transferred to another team specializing in lost causes. Their credo was “Rather than fight to eradicate the symptoms of an illness, we advocate for treatment based around a person’s life goals [...]. Only the individual is equipped to identify these goals. There’s always some part of us that’s still rational.”2
Psychiatrist Marie-Luce Quintal, head of medicine at the Centre de traitement et de réadaptation de Nemours (the Nemours treatment and re-adaptation centre) in Quebec City, and professor at Université Laval’s Faculty of Medicine considers recovery to be a personal journey.
[It is] an experience that means different things for different people [...]. Healthcare professionals must be highly adaptable as they share their knowledge with a person who arrives with a different set of knowledge. It means the individual not only has a say in the decisions made about them, but that they have knowledge no one else does. [...] They know what they like, [...] what’s important to them, what makes sense and what they absolutely cannot afford to lose. Above all, they alone can find their path to recovery.3
Let’s take the example of homelessness and mental illness. Psychiatrist Marie-Carmen Plante notes that, over the past 30 years, there has been a substantial rise in the number of people who are homeless and living with chronic psychiatric problems, chronic alcoholism and/or serious substance addictions who are in search of food and shelter, especially during winter cold snaps. They arrive at Emergency, where they are not treated specifically by psychiatric services. Inspired by the work of numerous doctors, including Leona Bachrach,4 Dr. Plante made a list of problems encountered daily by her team of clinicians and psychosocial workers:5
According to psychiatrist Georges Nauleau, staff working with individuals experiencing homelessness must adopt an individualized approach.
Despite how the many people we meet on the street and in emergency shelters show signs of numerous psychological disorders, often but not always alongside addiction (alcohol, drugs, etc.)—from psychological suffering linked to precarious living conditions to the most severe of mental disorders—it’s impossible to generalize as to the life experiences or trajectories of these individuals.7
Dr. Nauleau notes the importance of patience when working with someone experiencing homelessness, regardless of their mental health history.
We need to understand the pace and parameters of their world—this person who is asking so little—whether that world is marked by psychosis or not, and consider what kind of relational distance the person is comfortable with. Otherwise the crucial and often long work that has been undertaken to find an approach and build a connection for a strong therapeutic relationship, or simply one of support, must be redone.8
Outreach is a proactive approach that involves visiting the spaces homeless individuals occupy and taking actions based on respect for their realities and choices. Will this be the method used at the day hospital where my son is referred, after his release from the psychiatric unit? I’m hopeful. The psychiatrist who takes on Ferid’s case and the staff member who works with him are more open. I feel that I’ll be able to communicate with them. I come with Ferid to the first few appointments of the eight-week program. Ferid’s doctor urges him to continue his medication and encourages him to participate in the discussion groups and other activities aimed at reintegration.
I still have a copy of the weekly program. Looking at it now, I realize it fails to mention the group discussion topics, or the type of activities planned. Let’s think about that for a moment: in addition to having no say in the outpatient clinic programming, patients don’t even have the proper information to decide whether or not they want to attend these voluntary sessions. Would you travel to the clinic under these circumstances, when all signs point to a dead end?
It might well be that the program suits certain patients, but my son is shy. In his most difficult moments, he would rather keep to himself to avoid speaking up or causing conflict. He resists from the inside. I still encourage him to go. “Just getting out of the house and taking the metro will do you good,” I tell him. I’m unknowingly breaking my promise not to impose decisions on him. I’ve lost confidence in my judgment and in my ability to act based on my values and principles.
Eventually my son, infuriated, is direct with me. “Mom, listen. Here’s how the meetings go: someone in a white coat sits in front of me with a form that’s essentially the same as the one at Emergency. They go through a list of questions and check off my answers. Is this what recovery is supposed to be?”
Since there’s no coordination or information exchange between family members and the care team, there’s no way for me to argue for the program’s benefits. Looking back today, it’s clear to me why he didn’t want to attend. At first Ferid had had an almost unwavering confidence in his clinicians, but that was greatly diminished by the end of his stay in the psychiatric ward. We both realized that neither he nor I had a say in things. They made the decisions, in our best interest. What would break Ferid’s trust in the medical system for good was the damage his medication would cause.
1. Luc Vigneault, “Les allers-retours d’un battant,” Quintal et al., Je suis une personne, 38–39. (Translated citation).
2. Ibid., 42–44. (Translated citation).
3. Marie-Luce Quintal and Luc Vigneault, “Métissage d’expériences menant à une théorie de rétablissement,” Quintal et al., Je suis une personne, 58. (Translated citation).
4. In her 1997 article “Breaking Down the Barriers,” Dr. Leona Bachrach, citing John Talbott, M.D. and chair of the University of Maryland School of Medicine, indicates the existence of more than 200 barriers to psychiatric care that workers in the homelessness support sector encounter daily. Cited by Marie-Carmen Plante, “Les maux de la psychiatrie face à l’itinérance,” Roy and Hurtubise (eds.), L’itinérance en questions (Québec: Presses de l’université du Québec, 2007). 217–232.
5. Ibid., 217–232.
6. Comorbidity and polymorbidity are the coexistence of two or more pathologies in the same patient, which can result from an initial illness.
7. Plante, “Les maux,” 243–258. (Translated citation).
8. Ibid, 220–21. (Translated citation).