Accessing mental health services in Canada requires the possession of at least one of three things: decent employer benefits, the ability to pay, or the ability to wait for support that is covered by public insurance. Acute psychiatric care is available in most emergency departments, and, if things are serious enough, inpatient hospital settings. But outside of emergency situations, one’s options are more or less the same: without private insurance, people in need of care must pony up or be willing to wait months — or sometimes years — for treatment.
The cold reality is that the Canadian public mental health system — which relies heavily on hospital based, physician referred, and physician provided services — can be so difficult to navigate that many people give up even trying. What’s worse, some public and not-for-profit services periodically close their waitlists altogether due to the overwhelming volume of applicants.
The failings of mental health coverage are not helped by antipsychiatry advocacy that decries medicalization, institutionalization, and even question the reality of mental illness itself. This kind of pushback stifles the intellectual contributions that leftists can make to mental health research and care. It also undermines any hope of coordinating our efforts to fight for the strong, centralized, federal support needed to create a robust mental health policy framework.
Mental Health and COVID
Unlike most other specialty services in Canada, the federal government does not mandate the tracking and reporting of wait times for psychiatry. Nevertheless, several studies have shown that they fell significantly outside of the recommended time frames well before the pandemic, which made an already dire situation much worse. Available data also suggest that timely access to care varies significantly from province to province: in Saskatchewan someone who has been referred to a psychiatrist by their family doctor can expect to wait an average of 12.8 weeks before an initial intake appointment, whereas in Nova Scotia the average wait time is 53.6 weeks.
Wait times for children and youth are particularly abysmal. A 2020 report by Children’s Mental Health Ontario found that children between ages six to eighteen with serious mental health needs might wait anywhere between two to three months to two and a half years for professional support. One doesn’t need a social science degree to appreciate the inordinate amount of stress and responsibility that parents and loved ones are left to shoulder on their own.
The personal and financial hardships emanating from the COVID-19 pandemic have greatly exacerbated the difficulties that people previously experienced when it comes to accessing mental health support. As demand for mental health services continue to soar across many Canadian provinces, it’s clear that far too many people have been pushed to untenable degrees of distress and despair. Meanwhile, our deeply fractured and underfunded mental health care systems are more strained and inaccessible than ever. One in four Canadians are thought to be experiencing moderate to severe anxiety, depression, or loneliness. Those who are most impacted include health care workers, unemployed workers, immigrants and nonpermanent residents, people with low-incomes, youth, people who use drugs, and women.
COVID relief benefits and cash transfer programs appear to have mitigated or at least delayed some of the worst-possible outcomes — remarkably, suicide rates have either decreased or remained at pre-pandemic levels in many OECD (Organisation for Economic Co-operation and Development) countries. However, there has been a sharp increase in the number of people experiencing thoughts of suicide in many of these same places, including Canada.
Although suicidology is a notoriously complex field of study, these findings lend further support to the transformative effects of robust welfare state policies. Improving the physical and mental well-being of most people will require policy efforts that meaningfully reduce income insecurity, strengthen labor protections, and legislate paid sick days. Other necessary improvements include the institution of humane drug policy; universal access to affordable short and long-term housing; and the establishment of evidence-based strategies to enhance school safety and support for children and families.
Expanding publicly insured access to psychotherapy and counseling services — including those offered by psychologists, social workers, and other regulated professionals — enjoys broad appeal, but some skepticism over whether mental health services can adequately address issues that are often political in nature is certainly warranted. Mental health clinicians and emergency services have become first responders to a structurally unjust system that they have no tools to fix. But there are some forms of mental distress that cannot be reduced to social and material adversity and that require the training and care of professionals.
Experiences like psychosis, mania, and obsessional and compulsive behaviors are exceedingly difficult to explain, let alone treat. Our best guess is that they’re rooted in a complex interplay of environmental, social, and biological factors, but clear explanations for their cause, much less their cure, remain frustratingly far from reach.
Overshooting the Mark
It is understandable that the Left is keen to spotlight experiences of mental distress that can be easily folded into our broader commitments to social and economic justice. This tendency however, becomes deeply lamentable when substantive discussions around mental health care policy and service design are deflected, avoided, or denied outright.
People with functionally impairing conditions like severe autism, developmental disabilities, or dementia need and deserve specialized care. Although this fact is readily accepted, ongoing efforts to correct for the abuses of the past have created a tolerance for denying these considerations to people suffering from various mental illnesses.
In recent years, many diagnoses have been subject to important critique. But the difficulty of organizing experiences of mental disturbance and suffering into discrete diagnostic categories doesn’t make those experiences any less real. There are people who genuinely struggle to care — or in more extreme cases to dress, bathe, or eat — for themselves or who are fundamentally unable to keep themselves safe owing to their mental state.
The failure to accept the fact that people face challenges of such magnitude is willfully stubborn and impedes our social responsibility to attend to the social isolation and material deprivation that far too many people with mental illness face. Further, it diminishes our ability to fight for a more just world where people are cared for rather than criminalized, housed rather than made homeless, and are less likely to die avoidable deaths.
The development of Canada’s medicare system routinely neglected mental health, with the result that entrenched powerful barriers exist between mental health support and associated material supports. This makes it very difficult to improve the conditions of life for individuals who either live with, or are at higher risk of developing, serious mental illness.
The Need for Centralized Care
Although health care falls largely under provincial jurisdiction, the federal government — because of its broad fiscal capacity and the redistributive mechanisms at its disposal — has played an important role in both financing and standardizing care across all provinces. Early cost-sharing agreements between the federal and provincial governments — the Hospital Insurance and Diagnostic Services Act (HIDS, 1957) and the Medical Care Act (MCA, 1966) — focused chiefly on hospital-based care but excluded psychiatric hospitals. Unfortunately, because psychiatric hospitals have long been the provenance of provincial governments, they were the only place where publicly funded mental health care was offered. Cost was certainly a factor — these increasingly decrepit, overpopulated, and grim institutions were incredibly expensive to run.
When the Canada Health Act (CHA) passed in 1984, the federal government missed a significant opportunity to shape a more extensive and efficient system of health care provision and design. Despite contemporaneous shifts toward community-based care — the deinstitutionalization movement being a notable one — the CHA commits the federal government to a fairly blinkered cost-sharing formula focused on “medically necessary” hospital services and “medically required” physician services. What’s worse, the CHA fails to formally define what these terms even mean, making them, paradoxically, both too narrow and too vague to be all that useful.
Legal scholars have highlighted how, absent any rigorous process for evaluating which goods and services ought to be covered, Canada’s governance mechanisms for defining the medicare basket is “passive, opaque, and only tenuously evidence-driven.” As things stand, the great majority of mental health services — along with dentistry, optometry, prescription medication, and others — currently fall outside medicare’s ambit and remain largely inaccessible. Over time, the federal government’s slow retreat from health care — from covering 50 percent of costs in 1966 to 22 percent in 2019 — has only made these matters worse.
The funding priorities outlined in medicare’s legislative framework produced powerful financial incentives to close psychiatric hospitals throughout the 1970s and 1980s and transition to an idealized vision of community-based care that failed to ever materialize. This process shifted mental health care away from institutions and toward outpatient and short-stay treatments within general hospitals.
Deinstitutionalization sought to transform the lives of many people facing potential abuse in institutionalized exile by allowing them to live and seek care in their communities. But by many accounts, it was a complete disaster. The task of transferring the comprehensive suite of health and social services that was once packaged together within psychiatric hospitals would have required participation from all levels of government. To make the change effectively would have required collaborative efforts from a variety of departments and agencies, including housing, social and welfare services, and health care. A project of this size and jurisdictional complexity could have only been coordinated at a federal level. Thus far, the necessary steps have not been taken.
Over the course of several decades, mental health care and “wellness” services for people with comparatively less complex needs has flourished into a consumer-driven industry — one semiprivate facility in Ontario boasts a Red Seal Chef for its luxury guests. Meanwhile, local governments have paired an increasingly anemic public health care system with not-for-profit charities to produce a deeply fractured network of services incapable of tending to those with the greatest needs.
Toward a Politics of Robust Care
Egalitarian social and economic policies are good mental health policies. But when acute mental health needs arise in the context of situational stressors, targeted social services and health care programs are also necessary. So too is the need to improve quality of life and functional outcomes for people with severe and persistent mental illness.
The basic components of comprehensive care already exist, but public funding and administration will be required to expand provision such that they’re available to anyone when needed. The recent expansion of public coverage for certain psychotherapy services in the United Kingdom and Australia offer important lessons that the Canadian system can draw from. While mental health crisis beds fill an important gap between care in the community and in hospital, they can be incredibly hard to come by when they’re needed most.
Long-term case management and supportive mental health housing have proven to minimize rates of hospitalization, but people wait months, sometimes years, to be connected to them. With adequate public support, innovative peer-run support programs could achieve even more.
The Italian city of Trieste — which offers one of the most internationally celebrated approaches to community-based care — pairs comprehensive clinical services (including twenty-four-hour crisis response teams) with the basic resources people need through supportive housing, home care and meal preparation assistance, and social-recreational programming. By making sure essential needs are met, people are better able to focus on their psychological well-being, explore their interests, and forge meaningful relationships with others — at minimum, their suffering can be better managed.
Of course, not everyone who struggles with their mental health requires this level of support — in fact very few people do. But making such programs available when people need them will give emergency departments and inpatient units increased capacity to offer timely care to people and ensure much shorter and more clinically focused interventions. Such improvements will redound to the benefit of all patients — both those who require high-intensity care and those who do not.
Trieste’s model of care has been successfully adapted elsewhere and has proven itself capable of minimizing hospitalization, coercion, and contact with the criminal system. But the model could also offer positive freedoms, such as a chance to live a more dignified life in light of one’s illness, not despite it.
In Canada’s highly decentralized federation there will be significant legislative and political challenges to coordinating a sufficiently robust and humane approach to care. Without strong leadership and funding commitments from the federal government, very little is likely to change.
We must expand access to a wide array of mental health care services so that they are universally available to everyone who needs them, when they need them. In order to reduce our reliance on crude and paternalistic treatments, we also need to achieve a better understanding of mental illness through massive public research programs. These programs must be held to a higher standard of academic rigor and public transparency than is currently permitted by the pharmaceutical companies which dominate the field.
If we hope to accomplish any of this, the Left must first acknowledge the complicated nature of mental suffering. Even under socialism, robust health care systems will be needed to address the complex nature of mental illness and suffering. We must engage with, not retreat from, the difficult task of providing thorough and compassionate mental health care and service.