Mental health care in rural British Columbia
Issue: BCMJ,
vol. 48 , No. 4 , May 2006 ,
Pages 172-173 Clinical Articles
Mental health issues in rural BC are essentially the same as in urban BC, though patients often present for different reasons. Access to resources is minimal, which results in an increased burden to most systems of our society. Providing training in counseling for GPs and improving allowable billing would be helpful but not adequate. The addition of either salaried positions for qualified mental health workers and/or some coverage for registered psychologists would be a big step in the right direction and prove to be a cost-benefit to services as a whole.
Training GPs to provide psychotherapy and paying them for this work would help meet the province’s mental health care needs.
Most of rural British Columbia has a severe shortage of mental health services. The prevailing attitude is that people choose to live in rural areas and should therefore accept lack of funding for the provision of mental health services by qualified professionals. Furthermore, there is an erroneous belief that if one lives in the country there is less stress and therefore less mental and emotional distress. This is far from the reality of the situation. Consider some of the possible sources of stress in rural areas: the mill or mine that provides an economic base suddenly shuts down; the local school closes and children have to be bused long distances or billeted away from home; a forest fire devastates the region. Add to this the difficulties of living in an isolated area with limited medical care and hospitals long distances away.
One of the first attempts to deal with rural mental health issues on a large scale was made in the 1970s when the BC government funded a research project to look into this problem and provide recommendations (re port by A. DeVries and R.J. Maddess, Evaluation of rural British Columbia mental health needs and provision of service, submitted to the Government of British Columbia, 1977. RJM visited most of BC’s mental health centres outside of Vancouver Island and the Lower Mainland as well as communities who were requesting, but did not have, a mental health centre or satellite centre. Extensive structured interviews were held with mental health staff, local medical practitioners, and social organizations impacted by mental health issues). A detailed survey was conducted to determine how well extant mental health services were meeting the specific needs of the particular community and area. A number of small communities without mental health services were also surveyed to determine the level and type of mental health needs.
Most of the existing mental health centres were found to be providing adequate service for their local communities but were lacking in outreach services, travel being a significant problem. It was found that the need for mental health services throughout rural BC was high and access for service extremely low. The only resource in many cases was the local general practitioner.
At the same time, the allowable billing for counseling by a general practitioner was, and still is, virtually nonexistent. Currently, a general practitioner is allowed to bill four 20-minute sessions per year for any one patient, at $48.57 per session. This seldom provides adequate time even to discuss the problem.
Psychiatrists who prefer to live in rural BC have to travel a great deal with limited support and have limited access to psychiatric facilities.
Registered psychologists in private practice are faced with an additional problem in that most people in rural areas do not have any coverage (such as third-party insurance, victim’s assistance, etc.) and cannot afford to pay privately. The result is that mental health issues are not dealt with in a timely manner, and the degree of disorder and dysfunction often be comes unmanageable. The personal and societal burden—addiction, marital breakdown, chronic health problems, legal issues, and social service needs—increases in all areas.
It is time to re-evaluate the mental health needs of rural BC and for the government to fund the necessary services, including the establishment of a “GP psychotherapy” designation as exists in other provinces in Canada. Furthermore, if registered psychologists were covered by the medical plan, as psychiatrists are, the combined effort would provide a broader interdisciplinary service to a much larger population, especially the poor, the disabled, and those who live in rural areas.
Before physicians can provide psychotherapy, it will be essential to give them more training in counseling and to develop minimum qualification requirements. In an article about a general practitioner in Ontario who was found guilty of professional misconduct, Dr Doug Saunders of the Ontario Psychological Association notes that GPs can find themselves “in over their head(s)” when providing psychotherapy.[1] Physicians in Ontario currently can offer services with “just their undergraduate medical degree and residency.” On the other end of the scale, a practitioner in BC cannot bill regardless of the number of CP/APA approved continuing education credits earned.
Dr Saunders concludes that “every one loses” in such a system, wherein insufficiently trained practitioners can bill in some areas of the country, others who are qualified through continuing medical education cannot, and no funding is provided within the medical plan for qualified registered psychologists and psychological associates.
Ralph J. Maddess, PhD
Dr Maddess is a registered psychologist in private clinical practice and assistant professor (sessional, part-time) at the University of BC, Okanagan and Okanagan College. He has a practice in Vernon, BC and also works at the LabyrinthVictoria Centre for Dissociation in Victoria, BC. He has more than 30 years of experience, a portion of which has been in rural BC (North Okanagan, Revelstoke, and various communities in the Kootenays).
