Trigger warning: the following includes discussion of health care professionals, depression, anxiety and mood disorders in general.
It’s June of the year I turned 23. I have just moved across the country, from Ottawa to Vancouver, and into my mother’s house, because I am too sick to work and can’t afford to pay my rent. The only thing I really need to heal is time and safety.
My therapist suggests that I apply for employment insurance (E.I.) medical benefits (a Canadian government benefit for those too sick to work), to help with finances while I take time to recover. To do this, I need a doctor to sign a form. I go to a doctor who I haven’t seen for years, but who still treats my family members. I bring with me a letter from my therapist that explains why I can’t work.
I’m nervous through the whole appointment. The doctor chastises me for not getting better medical tests, and in my nervousness I forget to tell her that I was tested, that I was monitored by a doctor in Ottawa until I moved to Vancouver only a few weeks ago.
Finally, I burst into tears in her office and she agrees to sign the form. She charges me $20 for it and orders blood work.
I walk home. It takes 25 minutes. I cry the whole way. I call a friend who listens to me while I vent about how doctors only make things worse.
A few weeks later I hear back about the employment insurance. The instructions on the government website were incomplete, and the doctor has to re-do the form. I go back.
Mental health care is complex. When someone has a mood disorder (depression, anxiety, bipolar, or similar), there are so many different factors that can impact their health and well being.
Care means a lot of different things. One of the important ones is professional help. However, sometimes just accessing quality care can seem like an insurmountable struggle.
What follows is a list of the biggest barriers that my peers and I deal with when we try to access professional care. If you have more to add, I encourage you to comment below.
This seems basic, but it’s really important. Even here in Canada, where health care is supposed to be free, accessing mental health care costs money.
The only mental health professional that all Canadians can access free of charge is a medical doctor or a psychiatrist (i.e. a medical doctor who specializes in mental disorders). While a doctor can be helpful in some situations, there are many reasons to see someone with a different kind of training. Many very good therapists have advanced training in psychology, counselling or social work, but their services are not covered by provincial health insurance. Some cities have free clinics that offer these services, especially for children and youth, but these services are often inadequately funded and in very high demand, leaving them difficult or even impossible to access, especially in rural areas.
This problem is particularly pronounced for queer people, trans people, women, and racialized people, who are more likely to have mental health struggles, and are also are less likely to have good jobs with benefits. What this means is that the people who need mental health care the most are also the least likely to be able to access it.
2. Institutional limits
When I was a student union representative at the University of Ottawa, I was involved in advocacy work on mental health issues. Around that time, there was a significant increase in the demand for the use of the University’s free counseling services. More and more students were experiencing stress, anxiety, and depression (probably as a result of rising tuition fees, student poverty, and unhealthy academic culture) and as a result, more students were seeking counseling. Instead of hiring more counselors, the university’s response was to put a limit on how many times each individual student was allowed to see a counselor each semester.
It takes time to get to know and trust a counselor. For a counsellor to be effective, it’s important for a client to be able to connect with them. It takes time to get past the surface of symptom management and have the therapist get to know you well enough to deal with underlying trauma. If there is a limit to how many times you can see the counsellor that is available to you, there is obviously a limit to how much they can help you.
I’ve had a really great therapist for the last several years. I haven’t seen her regularly for that entire time, but I saw her when I had a major burnout, and have seen her occasionally since then when things have been bad. She works on a sliding scale, from an anti-oppressive and anti-capitalist lens. I’ve moved cities since I met her, but she continues to be accessible to me because she is willing to do sessions over Skype. This is valuable because it means that I don’t have to waste time getting to know a new counsellor each time I need to go back to one.
When I started a new job last year, I was excited that it included benefits (something that’s increasingly rare to actually find, and my expectations were low). Unfortunately, my benefits only cover counselling if I go through the counselling system that my workplace has an agreement with, or if my counsellor is a member of a specific professional association, which mine is not. On paper I have great benefits, but when I need a counsellor again, I will either have to go to a new counsellor in the system that my workplace (and start all over again with a new counsellor, wondering if they will be any good or even connect with me) or I will have to continue paying my current counsellor out of pocket. This is not prohibitive for me, but it reveals serious gaps in the system.
People who need a counsellor should be able to access one and choose the right one for them without worrying about cost and payment. The stress of figuring out the complexities of access can significantly exacerbate existing mental health problems. There is no reason that accessing good care should be this complicated.
3. Paternalism, and doctors as gatekeepers
Doctors don’t always believe their patients. In fact, almost everyone I know has had some experience of a doctor not believing in the severity of their physical or emotional pain. Doctors are even less likely to trust you if you are a woman, or if you have known mental health issues.
This can cause all kinds of problems. Like my doctor who chastised me before giving me a note, doctors are often called upon to sign off just so that we can gain access to more specialized care. Doctors are often required in order to get insurance benefits, welfare, access to psychiatrists and psychologists, even testing for learning disabilities.
Kori Doty recently wrote about how the process of proving their disability in order to receive benefits actually made them more unhealthy. The problem is, in order for people to believe you are sick, one actually has to look sick. If the doctor can’t see the symptoms by looking at the patient for only five minutes, the doctor may only have the patient’s word to go on.
Doctors, who are accustomed to being in authority and relying on scientific evidence, don’t like having to rely on trust. Add that to the stigma surrounding mental health, and what you get is many doctors who hesitate to believe that their patients are actually sick or deserving of treatment.
Activists like Julie Devaney have brought attention to how paternalism manifests in physical health care. When doctors don’t listen to their patient’s knowledge of themselves, it can result in more pain for the patient. The results of sexism in health care can be very serious. And when a patient is mentally ill, caregivers are even less likely to respect a patient’s agency and knowledge of themselves.
Those of us with mental illness usually know exactly what we need, if we are given a chance to think about it and explain. Many of us have been dealing with our issues for much of our lives, and we know our own bodies and cycles. Whether we need a hug, medication, financial help, or a note to get out of class, we know what’s best and what will help us heal. If those things are inaccessible except through a professional and the professional doesn’t respect our agency, it’s going to be a lot harder for us to take care of ourselves.
It’s a mark of the paternalism of the system that in almost all cases, a doctor is the gatekeeper to accessing mental health benefits. It’s not unlike the maternal health care system historically, where for many years it was illegal to give birth anywhere outside of a hospital in the care of male doctors. Even in the last twenty years, the maternal health care system has opened up quite a lot, where now parents have many different options for caregivers (like midwives and doulas) and in many cases can give birth at home or in a birthing centre instead of a hospital.
While still far from perfect, the maternal health care model has shifted to one where doctors are present for care and support, but parents increasingly have the agency to decide the way they want to give birth. It not only is good for parents, but also relieves the medical system, because fewer people need to access it. The mental health care system is lacking this kind of move towards trusting the patient to being the ultimate authority on their health.
Paternalism drives many people to avoid going to the doctor. They might wait until it is worse, or they might have to search around for a doctor who will believe them. In the meantime, their situation is likely getting worse.
4. The definition of “success”
Remember the university counsellors I was talking about earlier? In addition to the restrictions on how many times a student could see a counsellor, the university had a directive for the counsellors: get the kids back to class. The department operated on the problematic premise that the main problem with mental health issues was that it was a common, or even acceptable, hurdle to academia and the counsellors’ primary goal was to guide the students through the hurdles so they can get back to class.
The problem with this philosophy is that not only does it normalize stress, depression, and anxiety, it also means that successfully treating a client is usually only defined as the student finishing their studies. Even if the student is not healthy or does not feel well, so long as they complete their semester, they are seen as a success.
This means that counsellors are only treating symptoms and are potentially disinterested in going into more depth about what is underlying students’ challenges. It also means that counsellors are not acknowledging the ways in which school might actually be the cause of a number of health issues. It also could be that some students are staying in school when it is making them unhealthy.
This is the problem when health care workers are funded by institutions like universities, schools, and private workplaces, rather than by the public health care system. Their jobs are tied to the success and public image of the institution, rather than to the health of their clients.
5. A narrow view of mental health
We have a narrow vision of what it means to be mentally healthy. A mood disorder is not a fever that can be taken away with ibuprofen, or a cut that can be cleaned with an alcoholic wipe. It cannot even be likened to a cancer that can be removed with surgery.
It is all-encompassing and often chronic. If you have a mood disorder, it can stretch deep into the fabric of your being, and can define your life. It is complex, and to deal with it, to really heal, a person has to deal with their traumas.
We have to look at mental health concerns differently from other types of illness. Mental illnesses are illnesses, but the healing process can be incredibly complex and it is always different for every person. Each person needs to be given the agency to figure out what they need in order to heal, and their needs need to be respected.
Depression, ultimately, is caused by genetic susceptibility plus stress. That’s it. (And if you don’t believe it’s really that simple, watch this video). But where does that stress come from? That question needs to be addressed.
Doctors are willing to dole out prescriptions and referrals, but rarely are willing to question the systems that made their patients sick. We don’t hear enough counsellors advocating for a shorter work week or returning to the earth for the sake our health.
We need more health care workers that are trained in anti-oppression. We need to be willing to think of work, stress, and colonialism as sources of illness. We need to realize how those things cause trauma and contribute to illness.
Who is the health care system for?
When you’re healthy, it’s easy to think that the health care system is easy to access. When someone mentions how they are feeling, it’s easy for a healthy person to say “have you seen a doctor?” and assume that if the person hasn’t, that means they aren’t taking care of themselves.
The health care system can help. While it can’t help everyone, and it is certainly not the only solution, it is an important one.
We need to ask, who is our health care system for? Is it only for the rich who can afford it? Is it only for those whose illness is so severe that they need to be hospitalized? Is it only for workers, to get them back to work? Or is it for the people who are actually just sick, so they can become healthy, and live their lives?
The system needs to respond to the needs of those who need it most.