I really appreciate rural colleague Dr Larsen Soles’ comments on this elephant in the room [“How do you deal with a wounded mind? [9]” BCMJ 2017;59:349]. I was a sessional, then contract GP psychiatrist for 20 years who left the system 12 years ago, but I have maintained contact with colleagues and continued to interact with the mental health system as a practising GP with special interest. I would like to add a couple of other critical elements to the conversation about how our systems have evolved.

First, in my experience, one of the most common challenges among those struggling with significant mental illness is isolation and alienation—a lack of connection with trusted others. Our system has evolved to formulaic algorithms for treatment that may be administered online, in groups, or by interchangeable and shifting functionaries. Over the last 20 years, this has often been relegated to progressively less remunerated and educated workers, and these more frequently employed casually, rather than full-time with benefits. Even the normalized term case manager is alienating and entirely framed by the system’s perspective of managing cases rather than human beings, with a clear insensitivity to what the mission needs to be. For the most vulnerable in need of support and treatment, the essential foundation for any kind of meaningful progress most often includes a continuing relationship, with an eventually trusted other. This foundation is usually necessary to empowerment, achieving self-acceptance, and trusting the system enough to genuinely participate.

The second element has to do with these algorithmic silos themselves not only in systems but including formulaic approaches to care that require employees to tick boxes, providing measureables, and the appearance of service—this without much preparation or permission to adapt treatments and resources to the complex realities on the ground: namely, personal history (e.g., trauma, financial, housing, communication, language, relationships, medical, criminal, drug and alcohol, disability, and psychiatric comorbidities including personality, a.k.a. axis II). This approach to care is alienating not only for patients, confirming that they do not matter or are defective, but also for workers within these systems, who usually start out genuinely empathetic. Just as new research into pharmacological treatment is more and more limited to patented or patentable molecules, which will in one way or another increase profits for the private sector, research even into psychotherapy is almost entirely limited to that which is manualize-able and suited to this industrial approach to saving money for private sector insurers, largely in the United States. For example, CBT is indeed very useful for those who are in the more emotionally reactive part of the personality spectrum but not necessarily so for those who are more controlled and avoid emotions, which are nonetheless operating but not conscious. Likewise, drug and alcohol use are usually about avoiding painful realizations and emotions. Arguably all dysfunctional behaviors, including within our systems, are about avoidance of that which is inconvenient.
—Andre Piver, MD
Nelson