Real Life Psychiatry: real issues for real people

Short-Term Active Rapprochement Therapy (START)

Oct / 18 / 2015 Leave a response

What is START? It is a model of short-term psycho-dynamic psychotherapy that was developed at the McGill Mental Health Service in the years 1995 to 2006 for the treatment of emotional distress in students. It us specifically oriented towards an adolescent or young adult population, though it is effective in any age group. It was developed to foster quick change to ensure that students can succeed both academically and in life, while allowing a high number of students to be seen quickly and effectively.

The “active” part promotes the need in a student population to address issues quickly as to make it possible for students to continue functioning academically while dealing with emotional issues. The first session of START includes a detailed life and emotional history, an identification of crucial problems and core emotional issues, a discussion of these issues with the student, psycho-education about emotions, and preliminary elucidation of underlying emotional problems. While this my seem as a lot to accomplish in one session, this approach tends to lead to significant settling of the distressed student. A core underlying philosophy to START, is that students are emotional beings, and their emotional life is important and understandable. This philosophy is set in the first session.

A psycho-dynamic approach is used, as this modality has shown to be especially helpful to students. A multi-modal approach is integrated into this expert psycho-dynamic therapy, with supportive, directive, practical help and advice, and awareness of cognitions all contributing to the exploration and resolving of emotional issues. An important dimension in student distress these days has been the tendency in society and families to place achievement above emotional well-being. This makes therapy models that promote emotional suppression or distancing in the service of symptom reduction dangerous for many students as these therapies actually collude with the underlying problems. Symptom reduction usually occurs quickly with START as crucial emotional issues are addressed from the beginning of therapy, and safe space for exploring emotions is provided.

The Rapprochement aspect of this psychotherapy, refers to the work of Margaret Mahler and Peter Blos on Separation-Individuation. Rapprochement in this sense refers to the “checking in” that a young child does as the child begins to explore the world as a more individualized little human. Peter Blos has called adolescence a “second separation-individuation phase of development, where becoming an individual in a more adult sense is important, but where ambivalence between connection with parental figures and creating one’s own space and identity is obvious. The later adolescent and early adult period can be conceptualized as a second rapprochement phase, where individual identity and individuation is further developed, but where the need to re-connect to authority figures is also important. In the context of START, the rapprochement approach implies that the therapies can utilize and respect the normal phase of development that students are experiencing to allow therapy to proceed quickly. This is accomplished by not holding onto the student for too long, but to allow and encourage students to leave therapy to continue progress on their own with the invitation to come back to “check-in” as necessary. Thus one does not have a “termination” phase to the therapy. Issues are addressed quickly, work is done on these issues to elucidate and begin work on them, and as soon as the therapist and student feel sufficient progress has been made, the student is encouraged to go out, live their life, and practice emotional changes. The same approach can also be used with students with the most severe type of problems, including those diagnosed with Borderline Personality Disorder. Sometimes students with these type of problems don’t want to engage in long-term therapies, but do show substantial improvement with intermittent therapy, as long as the same therapist is available to them at times of crisis.

With START, students in a university centre tend to be seen for an average of 5-6 sessions. This includes space for about 25% of students to be seen long-term. Many students will show a major reduction in emotional distress and symptoms in just 2-3 sessions, and may choose to leave therapy at that point. Some may be satisfied with even one session. This form of therapy is often an introduction to the importance of one’s emotional life, and can set the stage for lifetime growth.

Evan Tran and the Sad State of University Services

Oct / 18 / 2015 Leave a response

The news of Evan Tran’s tragic death should give us all a pause to think. Here is another talented, well liked young man who decided to take his own life. There will undoubtedly be numerous articles written about the hardship of “mental illness” and the difficulty faced by university student services in providing help to students in distress.

One aspect that is clear: Evan Tran died of shame and not from a “mental illness”. The persona he was able to put on in public reveals that he did not have the symptoms that are associated with a diagnosis of Major Depression. While people who commit suicide are very likely to be feeling very depressed and are not mentally well, this does not mean that they fit into the neat but superficial DSM catagories. As in the case with Evan, often people receive diagnoses and medication but get little help with the underlying feelings that may lead to suicide. Labels, medication, and poor approaches focusing on symptoms and diagnoses, all to frequently increase suicidal risk rather than preventing suicide.

The University of Alberta, in response to multiple suicides on campus is planning to have a suicide prevention strategy. This will possibly make university administrators feel better, but will do nothing to stop deaths like Evan’s. Suicide prevention strategy’s often consist of anti-stigma and mental illness promotion campaigns, and sometimes even mandatory medical leaves for suicidal students. Sometimes programs to help university staff recognize symptoms of depression and possible suicidal behaviour are included. There is no evidence that programs of these types do anything, and mandatory leaves can actually make things worse for students.

The only way to help stop suicides as by providing easy access to expert treatments. This is where most universities are failing. Most counselling services have evolved from humanistic treatment philosophies, which can work well when services are under no pressure to see many students, but which fail miserably when services are swamped by students needs. Many services across North America have placed session limits on services, but without staff being properly trained in expert student oriented short-term therapy. Rather than learning expert models many counsellors either just try to use their usual approaches just in less time, or adopt simplistic short-term symptom focused models that both don’t work well and also take more time than could be necessary. Session number limits also make it unlikely that students like Evan Tran would even seek help at a university centre. If you were really struggling with long standing deep emotional issues, would you feel comfortable or hopeful going to see someone who you knew would only be available for a short period of time? Psychiatric services these days tend to mostly prescribe medication. This approach can hurt students more than help. Research indicates that psychiatric medication does not provide much benefit to adolescents, and there is little reason to believe that it helps much in the 18-21 year range. Medication can also have severe side effects that can interfere with academic ability, and that also can increase stigma. While medication can possibly play a minor role as an adjunct to expert psychotherapy, it should never be the primary modality of treatment for students.

University Student Services need to get their act together and stop playing politics with students’ lives. They need to invest in proper services and proper training. There are approaches in psychotherapy that can provide quick help to students, and result in many students feeling better quickly. Using expert modalities of treatment can allow services to have the time to treat students who have deeper levels of distress. Models, such as Short-Term Active Rapprochement Therapy (START) are specifically oriented towards student age populations, and can lead to excellent results for both students with highly distressing but acute problems and students with deeper troubles.

It is unfortunate that universities with likely just be doing more of the same in response to growing problems on campus. We’ll here the usual rhetoric about the tragedy of mental illness, and noise about some program or other. Nothing will change and tragedies will continue until crucial issues on campus are addressed and proper treatment facilities are developed.

For more information on student mental health got to: www.studentmentalhealth.ca

Umpqua shooting: When will the Violence Stop

Oct / 01 / 2015 Leave a response

It is too early to understand the details or motivation in the tragic shooting at Umpqua Community College. What we can be sure of is that there will be the usual rhetoric about mental illness and gun control. What there will not be is any solution to the growing problem of violence on campus.

It is clear that campus shootings are always related to childhood abuse and trauma. Why are colleges often targeted? It’s primarily because people who have been subjected to abuse, and who have lost hope tend to see college students as representing the hope they never had or had lost. These shootings represent rage at our society, and target those who the shooters see as benefiting from a society that has abandoned them.

We need to address the issues of social fragility, poverty, and child abuse if we want these shootings to stop. Unfortunately, this is unlikely to happen

McGill Mental Health Service Intent on Labelling and Medicating Students

Sep / 13 / 2015 Leave a response

A student waits two month for an appointment at the McGill Mental Health Service. When eventually seen, he is given a diagnosis of “bipolar 2” after just six minutes and then handed a prescription for an antipsychotic. When seen outside of McGill fro a proper assessment, it is clear that both the diagnosis and prescription are entirely inappropriate.

There are so many aspects disturbing about numerous stories like this coming out of students’ experiences at the Mental Health Service, which are evidence of poor management and negative attitudes towards students. Clearly the service has been feeling so overwhelmed that it is resorting to short cut evaluations and treatments, but the realities of what is occurring inside the service goes deeper.

Rather than understanding and promoting expert models of treatment, the service is turning to bureaucratic regulations to limit services. There is apparently a twenty page document of rules for staff to follow, none of which is about clinical excellence. Now, in order for students to be treated at the service, they will have to be given a diagnosis of a mental illness. This may not sound unreasonable to bureaucrats, but the reality in student mental health is that diagnoses are usually irrelevant and often dangerous. There is considerable controversy over the DSM diagnostic system, but the most important point in the limitations of the system is that the diagnoses are not aetiologically based. In other words, the diagnoses say nothing about the underlying causes of emotional distress, so are a poor guide to treatment. Yet often these days in psychiatry, giving a diagnosis leads quickly to the prescribing of medication. While medication can at times be helpful, it has never been the best or primary modality of treatment in student mental health. In a student population, it can also cause serious side effects, including excessive sedation and impaired cognitive abilities. The inappropriate use of medication can also interfere with the resolving of crucial underlying emotional issues and can turn an acute and easily treatable problem into a chronic condition.

The McGill Mental Health Service has abandoned any sense of clinical excellence and promoting proper treatment. For decades, when the service had an excellent reputation, the weekly team meeting was considered a highlight by most clinical staff because of the high quality of the clinical case discussions. Now these discussions have been stopped. This means that there is no real top level teaching or development of expert modalities of treatment, and no way for the people supposedly in charge to have any sense of what the clinical staff is doing. I have never heard of any psychiatric service anywhere that doesn’t have in-service clinical case discussions and supervision as an integral aspect of the service. It is incomprehensible that McGill Mental Health would stop these case discussion, though given the lack of any real expertise by those in charge, perhaps it is understandable why these discussions were no longer seen as valuable.

In its present state of dysfunction, the McGill Mental Health Service can not really be seen as a true service team. It appears to be focusing primarily on symptom control modalities rather than on expert models of psychotherapy, and has no cohesive team spirit. It has become a bureaucratic student processing unit, with no real leadership, and clearly no one in charge, either within the service or in McGill administration who have a clue about how a proper service should be managed. It is using standard hospital type approaches rather than treatment orientations developed specifically for a university population. It is a “mental illness” service and not a mental health service. The type of approaches used, and the regulations being imposed, will tend to limit proper responses to treatment, and lead to students having poor results and chronic symptoms. A significant part of the turnover of student seeking help will come from the artificial limitation placed on treatment by regulations or by students leaving the service due to frustration or poor treatment. There certainly are some good people working at the service, but basically the situation now is that one just has a group of independent, unsupervised clinicians each doing their own thing, yet having to adhere to nonsensical regulations and being forced to label students. This makes no sense, and will lead to devastating results for many students.

The Law of Averages

Sep / 03 / 2015 Leave a response

In most professions in life, average implies not too bad. One isn’t getting the best, but hopefully one isn’t getting badly treated. The average car mechanic will be perfectly good at doing an oil change or general repairs. The average family doctor will be able to handle most common ailments, like high blood pressure, sore throats or colds. This is because in many fields there are manuals and protocols to follow that ensure reasonable results. The same is not true in the mental health field. There are no good manuals, the research is confusing and often misleading, and there are often outside influences that lead to practitioners having more allegiance to systems than to patients. So the average mental health practitioner is often inadequate, frequently promoting their own brand of help, rather than focusing on the patient’s needs. It is a further problem that most orientations in mental health have a way of blaming the patient when things don’t go well. Psychoanalysts often point to the patient’s “resistance” or “defences”. One often hears that the patient has to go deeper into their problems, taking significantly more time, again with the implication that if a person is not feeling better it must be something locked deeper in their mind that is the problem. While this might be true at times, it also allows the practitioner to excuse a lack of progress. Cognitive Behaviour Therapists have many blaming mechanisms, with the underlying pejorative message that a person should be able to change their feelings by learning to banish negative thoughts. If people can’t then they clearly aren’t working hard enough or doing their homework. I have been told by numerous people that they’ve been told by CBT therapists that they have to believe in the therapy for it to work, so that if they aren’t believers then they won’t work hard enough at controlling negative thoughts, and therefore won’t get better. Biological psychiatrists just blame brain chemistry. Id a person doesn’t respond to one drug, they are treatment resistant, and if they don’t respond to many, they are a complicated case. If their symptoms diminish but they don’t feel good or can’t function then they are whiners.

Helping people in emotional distress is complicated. a practitioner needs to have a strong understanding of emotional development, trauma, and family and cultural issues. One has to understand the complexity of modern society. One has to always have empathy for the other, yet also be able to see the individual from an outside perspective to be able to understand the impact of the person’s emotional life on the outside world. To help people, being average just doesn’t cut it. All practitioners need to look outside their own milieu and orientation to learn as much as we can from available resources. We constantly need to challenge ourselves, and to take responsibility when a patient is not improving.

Donald Trump, Stephen Harper and Mental Health

Aug / 30 / 2015 Leave a response

There is much that can be said about Donald Trump’s and Stephen Harper’s views on mental health. Both seem intent on labelling people and seeing “mental illness” as the root of many of society’s problems. In their approaches one can understand the real cause of emotional distress in our societies.

Both men, and to some extent the parties they claim to represent, tend to have an “us or them ” mentality. They both love to label anyone who doesn’t see the world the way they do as the “other”, with “others” not deserving any consideration or protection.

A significant cause of emotional distress in all countries is the disintegration of emotionally connected social structure. People are becoming more and more emotionally isolated. The rise in the use of mental health facilities, as well as the dumbing down of the treatment modalities in these facilities to cope with the demand, is indication of how our countries are producing people with less resilience and more emotional fragility.

Donald Trump and Stephen Harper would wish that we see all people who are suffering as inadequate, lazy or malingering. This attitude should not be tolerated. We can all hope that in up-coming elections, that people can see through the self-absorbed pontifications of these narcissistic men, and stand up for the needs of all people. It is through empathy and connection that we can build a better society. Seeing people who are struggling or have less resources as the “other” just breeds unrest and a fractured society.

Why Cognitive Behaviour Therapy is a Fraud

Aug / 04 / 2015 Leave a response

A recent study (Johnsen, Tom J.; Friborg, Oddgei 2015) titled The Effects of Cognitive Behavioral Therapy as an Anti-Depressive Treatment is Falling: A Meta-Analysis indicating that over the years studies on CBT for depression are showing progressively poorer results should come as no surprise to anyone who actively works with real people. The findings should be a red flag to the mental health industry, as one would logically think that as a therapy becomes more developed with more expertly trained therapists that the efficacy should improve and not decline. There is a saying among psychiatrists in regard to new medications on the market that one should start using them quickly before they stop working. This clearly speaks to both the enhanced placebo effects of new treatments as well as possibly the sense that repeated studies will with time show the limitations of these treatments. This saying now seems to apply to CBT as well.
Cognitive Behaviour Therapy has been highly promoted by the pharmaceutical and mental health industry as it fits well with the needs of these industries despite evidence that has always been present that it is less effective than more humanistic or emotionally based therapies. Now there is clear evidence that is nothing more than an enhanced placebo. So why is CBT a fraud? Very simply, CBT was developed to take advantage of many natural limitations and biases in psychotherapy research. Psychotherapy research has tended to be difficult to do, as in order to quantitative research on any treatment one has to standardize the treatment and simplify outcome measures. The therapy needs to be structured so that all the therapists are doing exactly the same thing, and ensure that the primary aspect of therapy that one is testing is being consistently used. For all emotionally based therapies this essentially means that one has to dumb down the therapy. For example, if one is testing a psychoanalytically based short-term therapy, all the therapists have to make regular transference interpretations, regardless of whether this makes therapeutic sense. Interpersonal Psychotherapy (IPT) which is an empirically validated psychotherapy, is one of the best known dumbed down psychodynamic therapies. Pretty much all psychotherapies that have been studied, unless one looks at naturalistic studies, are on standardized or manualized approaches, except for CBT, which is highly structured to begin with. Advanced form of schema therapy, which is in the hands of an empathetic therapist is very similar to traditional therapy may be an exception. So in most studies,s one is comparing a therapy that is actually practiced as is (CBT) to dumbed down forms of more complex therapies. Yet research has consistently shown no difference between these therapies. CBT has never been shown to be superior to other researched therapies. It has just been shown to be better than placebos.
What are the biases and limitations in psychotherapy research? As explained above, one can not just let expert therapists do what they normally do in standard quantitative research, though more qualitative “super shrink” research is attempting to analyze the practices of really good therapists. There is also significant selection bias and limitations in the populations studied. Most research eliminates potential subjects with co-morbid conditions. As any seasoned practitioner knows, very few patients ft cleanly into one diagnostic category, yet studies are almost always restricted to these type of cases. As more complex problems tend to show worse results, especially with mono-modal treatment, it is difficult to apply the results of any research to actual clinical populations. A major limitation and bias of psychotherapy research are the tools that are used to measure outcome. The most used tools are primary symptom based, and do not necessarily measure well-being or functioning. If one uses these tools, and focuses treatment primarily on symptom reduction, then one would predict that one would get some type of positive result. This certainly is true both of CBT and medication research, though psychotherapies that do not focus on symptom reduction, also show equally positive results. A major bias that should be in favour of CBT is the reality that CBT basically trains people to report less symptoms, while emotionally based therapies encourage people to express their feelings. It has been long recognized, and shown in research, that people will want to please their therapists and comply with expectations. If a therapist gives consistent positive feedback when patient reports less negative feelings, than a patient will with time report less negative feelings. If a therapist gives positive feedback whenever a patients expresses painful feelings than the patient will continue to express painful feelings. If one then gives these patients a tool that measures these feelings, the patient who was encouraged to report less feelings should show “better” response on this tool regardless of whether or not the person is doing better in life. This is the exact situation that occurs when comparing CBT to more emotionally based therapies, yet CBT, on these tools, does not show better results. This clearly indicates that CBT is an inferior therapy.
Psychotherapy research also closely controls the placebo condition to which therapies are compared. Clearly in psychotherapy research there are no real double blind studies. The therapists always know if they are doing a placebo or sham therapy. Thus the therapists who may be part of the control group are not going to have much belief or enthusiasm for their treatment. They are also forced to do really bad therapy, as they are restricted from using any of the modalities that are a part of the studied therapy, and are only allowed to make simplistic comments. Thus, if CBT is being compared to a “supportive” psychotherapy, the therapist doing the control therapy is only allowed to make “supportive” comments and not help the individual with real life problems or try to put together issues the control subject brings up. Basically, control psychotherapies are carried out by therapists who aren’t allowed to use most of their skills and are designed to frustrate both the therapist and the patient.
Research conditions also work against any psychotherapy that relies on the relationship between the therapist and the patient. In research models people do not choose their own therapist, but are randomly assigned to therapists, with the understanding from the beginning that seeing this therapist is a part of a research study, that the study is for a defined limited time, and that the person will have no access to the therapist following the study. Thus any aspect of real caring or connection is severely limited before the therapy even starts. The only aspect of any therapy that has ever shown a consistent correlation with outcome is “therapeutic alliance” despite the reality that the basic structure of psychotherapy research interferes with the therapist-patient relationship. The positive results in research of any therapy that relies strongly on the therapeutic relationship will be downgraded while the results therapies that rely more on teaching tools should not be as effected.
The reality of psychotherapy is that most expert psychotherapists, regardless of their orientation, spend a significant amount of time in therapy helping people work out real life problems and relationships. They do not only make interpretations, only make supportive statements, or only give techniques for controlling symptoms or negative thoughts. Working with distortions in cognitions has always been a part of most expert therapies. CBT theorists did not reinvent the wheel. They just put a manualized superficial structure together that allows research to be done easier and that should show better results in research by using to full advantage the limitations of quantitative research. While being able to promote this therapy by doing massive amounts of research for just about all mental health conditions, if one adjusts the apparent results of this body of research to take into account the distortions caused by the biases, the research shows no advantage over placebo for this so-called therapy. Of course, the systems that prefer that people just shut up about their symptoms and go away love this therapy. The pharmaceutical industry that wants to convince people that feelings are bad so that it’s okay to just numb people also naturally loves this therapy. The only patients that I’ve met who have claimed to have had significant benefit form CBT are all individuals that have bought into the mental illness model and have come to believe that they are inherently damaged so that all they can hope for is to control some symptoms. None of these people have shown emotional progress in life.
It is time that the mental health industry looks critically at psychotherapy research to be able to promote a balance view as to what actually helps real people. The need for naturalistic and proper qualitative studies is evident. Superficial quantitative studies cannot indicate what works best for any individual. The insistence in using research models with actual people has to stop. It should be understood that these models, and especially CBT, just indicate that therapy works, but does not indicate what works best, and certainly don’t indicate that research models are preferable to expert modes of treatment. True experts treat the person, not the symptoms, and do not buy into simplistic models. Good therapists care about their patients’ lives, and will always put patients’ well-being above any allegiance to theory.

Walter Palmer, Narcissists, Psychopaths and Crimes Against Humanity

Jul / 29 / 2015 Leave a response

What is the difference between a narcissist and a psychopath (or Anti-Social Personality as named by the DSM)? Basically there is little difference. Both are determined by a profound lack of empathy and guilt. The main difference is that a person is considered to by a psychopath if they have been convicted of crimes, while people who show little empathy or guilt but have not been accused or convicted of crimes may be seen as narcissists. There are many people, including CEO’s and government leaders, who by normal standards are guilty of many crimes, yet are held up in high esteem by our society. Walter Palmer used to be one of these, though he is clearly guilty of immoral and criminal acts, and in insisting that he has a right to hunt and kill endangered animals he is guilty of crimes against our planet, and therefore crimes against humanity. Many countries, including the United States, tends to idealize narcissists, though insisting that criminals need to be punished. It’s time for the protection given to people who hold esteemed places in our society, yet abuse our society, be stopped. Let’s call these people by the terms they deserve: psychopaths and criminals. We don’t need people like Walter Palmer having the freedom to abuse our world. He should be in jail like any other criminal, as should others like him.

Sexual Assault on Campus

Jun / 27 / 2015 Leave a response

There has been considerable publicity about sexual assault on campus over the past while. Recently the CBC publicized a survey done in Canadian universities to try to determine the extent of the problem. Though the survey produced limited useful information due to the varying ways universities collect and report data, it does bring some issues to the forefront of discussion. Unfortunately, what has been missing form open dialogue has been inquiries into the underlying causes of “rape culture”. It is common place thee days for an issue to surface in the media, possibly leading to a publicity campaign to address the issue, without any deeper attempt to resolve fundamental causes of problems. Certainly collecting data is an important first step, though it is highly unlikely that any type of survey will come close to revealing the true extent of sexual assault on campus. This is largely because a very high proportion of campus sexual assault falls into the general categories of date and party rape. Both the perpetrators and the victims of this type of assault often don’t perceive these acts as actually being sexual assault. I have seen numerous young women who have only been able to name these occurrences as assault months or years later when talking about their sexual experiences with friends or therapists. Often the sense of shame associated with being in a vulnerable situation due to normal partying behaviour, can lead to self-blame, rather than being able to recognize the assault. When there is an aspect of alcohol or drug use, some degree of uncertainty about details of the assault may leave the person feeling confused over whether to report the incident. Beyond these aspects, incidents of sexual bullying or verbal hostility are unlikely to be reported.

Whether it is possible or not to get accurate statistics, it is clear that sexual assault on campus is a real problem. It is crucial to understand the many roots that lead to sexual assault. Apart from many aspects in our general society that can lead to violence, there are particular conditions and attitudes on campus that can promote violence. Any type of power imbalance in society can have an effect on how people treat other people. There has been a growing trend in universities to emulate corporate values rather than academic values. Ideally, universities should be places which primarily encourage intellectual and emotional growth, and where healthy relationships with mentors can be fostered. Yet universities have been moving away from this type of model, with administrations seeming less open to students, and with competition between students being encouraged. Universities are become more and more bureaucratic, seeing students as products more than as people. This emulates a growing trend in society where people are seen by the corporate world as disposable cogs in the wheel, and children are being raised in families where achievement and competition are more important than emotional growth. The problem of sexual assault on campus will never be solved unless universities begin taking seriously the fundamental emotional needs of individuals and communities. One can’t treat employees badly, foster extreme competition, idealize sport teams, all for the purpose of marketing the university, and then just have a few anti-assault programs or events and expect that all will be okay. Attitudes, empathy and fair treatment for all has to come from the top, and be evident to every person on campus. Without this, students will be immersed in an atmosphere where using other people is justified.

Report to Kirby Commision 2005

Jun / 26 / 2015 Leave a response

Report for the Senate Committee Study on Mental Health

Norman Hoffman, M.D., F.R.C.P.C.

Over the past twenty years, university mental health and counselling across North America have experienced a dramatic rise in the need for services. At McGill University, the number of students we treat has doubled every four years. The severity of mental health problems also appears to be increasing. Of the 1920 students treated this past year 50% had serious longstanding psychological difficulties. In a recent survey of university counselling services across Canada, 75% of service directors reported an increase in the severity of problems seen. There has been some suggestion in the U.S. that the increase in demand is due to better, earlier treatment that is allowing students with mental health problems to attend university. From our experience this appears to be totally erroneous. The service has seen little increase in specific major mental illnesses. The increase is mostly due to increased long-term psychological distress. Our major concern, though, is not primarily for the university population. Certainly, this is a population that holds great promise for our society. Fortunately, universities have the ability to provide proper mental health resources for their population, though at the present time in Canada, only McGill and University of Toronto provide full services. While psychiatric services across Canada have become increasingly system centred over the past twenty years, McGill Student Mental Health has remained strongly patient centred. Each patient has a primary therapist who works with the individual to ensure personalized care. We are working to keep up with the increased demand to be able to maintain a full service model. In surveying university services across North America, it is apparent that one mental health provider per every thousand students is the minimum number necessary to have adequate patient centred care. Universities in Canada fortunately do have the ability to provide this level of service. The same is unlikely to be true for the rest of Canada.

I do have two major concerns for the mental health of our country. The first concerns the roots of our mental health situation. It appears that the mental health of our society is deteriorating. Reports from educational institutions across the country indicate increased behaviour problems and emotional difficulties in students at all ages. Mental health systems are unable to keep pace with growing demands. Secondly, I am concerned about the responses of our society and mental health systems. As demands have been increasing, we have moved towards a system centred, symptom based approach, that often provides only minimal care.

A disturbing and evolving social condition over the past twenty years has been the weakening of relationships between parental figures, authorities and children. The solid presence of families, extended families, teachers and other mentoring figures in the lives of our young has been dramatically eroded in recent times. At the same time, the power of the media, and of peer groups has been heightened. In order to have a positive impact on the mental health of our whole society, it is imperative that we strengthen the role all adult figures in the lives of our youth. We need to provide increased support for all families, and we need to improve our education systems so that every teacher can be an aware and involved mentor for our children. Programs such as therapeutic day care and after-school care for high-risk kids and could have a major impact on our children’s development. Strong counselling services in schools are essential.

The manner in which our youths’ emotional problems are presently being addressed is also a major concern. There has been a trend over the past ten years towards hasty diagnosis and simplistic treatments. The DSM is a manual of descriptive diagnoses that is meant to be used as a guide, and does not, for the most part, indicate actual disease entities. In its introduction the DSM states “The specific diagnostic criteria included are meant to serve as guidelines to be informed by clinical judgment and are not meant to be used in a cookbook fashion”. Unfortunately, in most medical schools across Canada, psychiatry is presently being taught by a predominantly biological approach that assumes DSM diagnoses to be actual biological disease entities. The misuse by the DSM is leading to a medical disaster for our youth. At McGill 15% of first year students are on psychiatric medication. In many universities in the United States, up to 30% of students are on psychiatric drugs. 90% of the students that we see from the U.S. who are on medication have been inappropriately diagnosed and treated. This trend is now moving into Canada. It is imperative that, especially for our young people, we move away from a simplistic diagnosis based model to a problem based model. While it may be fine to increase awareness of mental illness, programs such as depression screening using inexact tools tend to lead to misinformation rather than the addressing of problems. The most widely used depression screening tool is a commercial product, highly financed by the pharmaceutical industry, that has been poorly validated in a general population, and not validated in a young population. Screening programs in mental health are contrary to the patient centred approach this committee is recommending, as these programs tend to categorize individuals according to system needs. If we do not have adequate assessment and treatment facilities in place, screening programs, while appealing for their optics, can do more harm than good. Twenty years ago, students would come in to see us, saying “I feel down”. Now they are far more likely to say “I think I have depression”. The concept of depression as a singular biological entity is being highly promoted by the pharmaceutical industry, but has no support either in research or in clinical practice. We need to stop labelling, and to start addressing the real issues. Across our nation, people are becoming increasingly out of touch with their emotional lives. Relationships are becoming more superficial with significant attachments waning.

One concern about this committee’s interim report is that it focuses too strongly on mental illness rather than on mental health. With the growing needs in our country, there is no way we would ever have the resources to properly attend to the emotional problems of our nation. Placing our resources mostly in aiding those who we have labelled as mentally ill is not going to stem the tide of increasing psychological distress. More emphasis should be placed on prevention by addressing the issues that lead to the development of psychological difficulties. We need to strengthen institutions from families to education to care providers that will help children grow up to be emotionally healthy adults. Helping disadvantaged youth should be a priority. I would recommend setting up a countrywide, government-sponsored system of “Outward Bound” type summer programs for young people, with continuing after school mentoring programs throughout the year. Let every child in our nation grow up with positive feelings and memories of a strong mentoring figure. We cannot afford to wait for troubled children in our society to turn into mentally ill adult.

The impact of marketing by the pharmaceutical industry is also a major concern. It is in the pharmaceutical industry’s interest to have the maximum number of people on medication for the greatest amount of time. The industry has been highly promoting the idea that medication should be prescribed to all people with depressive symptoms, as well as constantly coming up with new indications for medication usage. A ban on direct marketing by the pharmaceutical industry to doctors would encourage proper prescribing habits. Drug companies presently spend more on marketing than on research. Over the past five years, the two classes of drugs that the pharmaceutical industry has spent the most marketing have been modern anti-depressants and Cox-2 inhibitors. This marketing has led to an over-prescription of these medications. These medications, while useful, often are no superior in the majority of patients than older, better established and less costly drugs. Especially as the government is looking at universal drug care, the cost of pharmaceuticals is going to be a major factor in the spending of our health care dollars. I would recommend the establishment of an industry financed government board to review drug literature and provide appropriate recommendations to the medical profession. This could lower drug costs, and put the emphasis on the pharmaceutical industry to produce more effective drugs rather than more marketable drugs.

Ultimately, the value of this commission will be determined by how its recommendations are implemented. Most frequently, administrations will often pick out aspects of recommendations that have high media visibility, and will tend to ignore those aspects, that may be more difficult to implement but will have higher impact. It is likely that the majority of suggested actions of this commission will be shelved, while a few simplistic actions may be taken. This would be just a further example of the “disease” of superficiality that we are facing in our families and our country. A national strategy on Mental Health sounds good, but will be empty words without proper resources and determination. The Mental Health systems in Canada are partially driven by research coming out of the United States that highly promotes symptom based treatments. These treatment modalities frequently fail to address the most crucial issues affecting a real life patient population. It will take more than rhetoric or policies to change the way medical students and psychiatric residents are taught, and the way hospitals are run. A national suicide strategy is good politics, but may have no impact. In Quebec, we do have a provincial suicide strategy, but the most important element in suicide prevention; access to services is absent. It is imperative that your final report contains practical and feasible direction and does not simply promote empty jargon.

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