Seeing the psychiatric patient as more than an isolated individual
Patients’ family and community ties have been crucial in 50 years of treatment at the ICFP
Since this year marks the 50th anniversary of the Institute of Community and Family Psychiatry (ICFP), the natural tendency is to focus on the building at Côte-Sainte-Catherine and Légaré that officially began welcoming patients and clients in 1969.
However, to really understand the significance of this occasion, what you need to do is look more closely at the name. After all, the building could just as easily have been called something simpler, like the JGH Institute of Psychiatry.
The name originated with Dr. Nathan Epstein, who was Chief of Psychiatry from 1959 to the mid-1960s, a period when the ICFP was still on the drawing board. It was also in the plans when Dr. Henry Kravitz took over as Chief in 1967 and shepherded the Institute to its launch and beyond.
And now it has a distinctive, five-decade legacy that encapsulates the guiding philosophy of the ICFP and the Department of Psychiatry: To view the patient not just as an individual, but as someone with a complex network of connections to family and community, against a backdrop of neighbourhood, religion, race, ethnicity and a host of other factors.
Staff at the ICFP acknowledge that this approach exists at other healthcare centres, but they say the JGH is distinguished by the unusually strong emphasis that the Department of Psychiatry places on the participation of family and community in the healing process.
And even though medication plays a key role in the treatment of certain patients, the ICFP also continues to firmly embrace a holistic approach, including psychological, social and culturally informed care.
This humanistic perspective is what attracts many talented professionals to the JGH, says Dr. Karl Looper, Chief of Psychiatry since 2014. “Unfortunately, the kind of work that we do is becoming marginalized in many places, because it’s so time-consuming and resource-intensive.”
A supportive social environment
“If the social environment is not supportive, the value of any medical intervention is going to be limited,” adds Darlene Johnstone, who coordinates the hospital’s psychiatric social workers and is a Family Therapist in Child Psychiatry.
“For example,” she continues, “if someone is depressed, and you haven’t dealt with their financial situation, their housing situation, their marital situation or their relationships with their family, spouse or children, then medication will only go so far.
“It’s often said that medication is the foundation of psychiatry, because without it, many patients would be unable to think or thrive. But nobody lives just in the foundation of a house; you need the upper floors, too.
“In social work, we take this literally by making sure that the relationships in the client’s actual house are healthy, that it’s a safe and sheltering place to live, and that there’s food on the table.”
So intrinsic is this perspective to the ICFP that active efforts have long been in place to support and treat individuals from a range of ethnic and cultural groups, and to counsel them with reference to those groups. Notable at the JGH is the Cultural and Mental Health Research Unit, founded by its current Director, Dr. Laurence Kirmayer.
Before joining hospital staff in 1981, Dr. Kirmayer developed an interest in ethno‑psychiatry, and this intensified in the late ’80s when he performed consultations and conducted research into aboriginal mental health in Nunavik in northern Quebec.
Dr. Kirmayer founded the ICFP’s Cultural Consultation Service, as well as serving as Director of the Division of Social and Transcultural Psychiatry at McGill University, the world’s oldest program devoted to culture and mental health.
Given Canada’s relative openness to immigrants and multiculturalism, he says, “you quickly recognize that culture—and the differences between cultures—is not about some special sub-group of people, but is relevant to all of us.
“This makes you well equipped to ask, for example, ‘How does an Indian family differ from a northern European family?’ Both families are important, but in each instance, it’s important to know who’s in the family and who’s out. What are the issues with regard to honour or gender roles? If you can take that general model and start plugging in the specifics, you end up with a much more powerful model.”
The JGH’s tradition of openness
While the JGH as a whole has a tradition of openness toward family and community, several factors are particularly noteworthy with regard to the Department of Psychiatry. A crucial element is the demography of residents in the hospital’s vicinity, one of the most—if not the most—multicultural and multiethnic neighbourhoods in Canada.
Decades ago, the area was largely Jewish, but as the years passed and the Jewish community shifted to other locations, succeeding waves of immigrants made the neighbourhood their home.
As a result, says Dr. Kirmayer, the Department of Psychiatry has long been accustomed to treating patients from numerous backgrounds in a family context, while taking into consideration the many cultural and ethnic influences in their lives.
Furthermore, the JGH treats a disproportionately large number of elderly patients. Early on, many of these were Jews who had arrived in Montreal after World War 2 and reached their senior years in the 1970s and ’80s.
Today, elderly parents are among the many new immigrants, and as the JGH addresses their needs—as well as those of the aging Baby Boom generation—it is fortunate to be able to draw upon a wealth of experience.
Finally, says Dr. Kirmayer, the Jewish roots and values of the JGH have shaped the hospital into an institution that has always been highly aware of the degree to which a person’s life is intertwined with and deeply affected by family, community, religious ritual and even, in some instances, discrimination.
A collaboration of experts
In providing their support, psychiatrists rely on the contribution of nurses and allied health professionals, such as social workers, psychologists, teachers and occupational therapists, who share the Department’s vision of understanding patients’ needs in the broader context of family and community.
According to an article that was published in 2001 and co-authored by Dr. Henry Kravitz, the expertise of allied health professionals was originally enlisted in the early 1960s to compensate for a shortage of psychiatrists and psychiatric residents in the Department. And as the years passed, their involvement became indispensable.
Their pro-active approach is especially evident among social workers, who often act as advocates for the patient and the family, says Alexandra Matlin, a Psychiatric Social Worker at the ICFP since the late 1990s. “Even when we’re working with individuals, we still try to work within the family system.” she explains.
Often, Ms. Matlin adds, this involves not just one-on-one counselling, but helping patients and clients with tasks such as applying for housing or welfare, arranging for schooling or vocational instruction, and finding helpful community resources.
Many social workers are also involved in the initial assessment, adds Myra Issley, who has devoted most of her JGH career to psychiatric social work since coming to the hospital in 1976.
“The psychiatrist might see the patient once a month for medication or other treatment,” she explains, “and I might continue to see the patient for six or seven months, depending on the need for social service intervention. During that time, what we do often encompasses the whole family.”
And just how do psychiatrists and other professionals become aware of the interventions that work most effectively? That’s the role of research, says Dr. Phyllis Zelkowitz, who is Director of Research at the ICFP and an Associate Professor in the Department of Psychiatry at McGill.
Even seemingly good ideas need to be subjected to careful testing, she explains, because there is no guarantee that even the most promising proposal will actually work or be any better than current practices.
For this reason, Dr. Zelkowitz says, she is gratified that in her 30 years at the JGH, the Department of Psychiatry has “consistently demonstrated a commitment to creating knowledge and empirical work.”
As might be expected, she continues, a great deal of attention over the years has been paid to research into various cultures and ethnic groups (including immigrants and aboriginal Canadians), with specific reference to such issues as their attitudes toward treatment and their compliance with it.
Another major area of research, involves psychological factors related to medical illness, Dr. Zelkowitz says. This includes finding ways to promote well-being among cancer patients, improving the mental health of individuals with medical illnesses, and determining the impact of stress and depression on medical illness (and vice versa).
Charting new directions
This thirst for charting new directions and new approaches has existed throughout the ICFP’s history, says Dr. Looper. It continues today with interest in new types of non‑pharmacological treatment, including new psychotherapies such as mindfulness, as well as contemplative practices and novel social interventions.
Dr. Looper also cites the work of Dr. Rachel Kronick, a child psychiatrist who has become a leader in gauging the mental-health repercussions on asylum seekers in detention—a major issue, given the unprecedented number of adults and children who are being held around the world.
“Her work is relevant to the growing numbers of immigrants and refugees, and is important in guiding public policy in this area,” Dr. Looper notes.
Another example, he says, is Dr. Vincent Laliberté, who is finishing his Ph.D. in anthropology and has been recruited to the Department of Psychiatry. Dr. Laliberté has begun collaborating with the Welcome Hall mission to help find housing for homeless mentally ill individuals, while taking a role in the psychiatric care that they need.
“So far the program has yielded excellent results and has been an extraordinary success for a hard-to-reach population,” Dr. Looper says.
One of the newest recruits, Dr. Zoë Thomas, who joined the department in fall 2018, is not only heading the newly launched Adult Psychiatry Day Treatment Program, but is establishing a trauma-focused therapy program for people who are suffering as a result of recent or past traumatic events—what Dr. Looper calls “the only program of its kind in Quebec, a true innovation.”
Dr. Thomas, who completed a fellowship at the University of Toronto on post-traumatic stress disorder, says the need clearly exists for a trauma program in Montreal, given the lack of such a service in the city’s university-affiliated healthcare institutions.
“We know that a high proportion of patients suffer from childhood trauma,” she explains, “and many were abused as children. The effects are so pervasive and multi‑faceted that we’re really in need of treatment that targets this condition.”
Meanwhile, Dr. Thomas’s Day Treatment Program, in a newly renovated area on the sixth floor of Pavilion B, is designed to provide patients with intensive group psychotherapy five hours a day, four days a week for eight weeks. “Its goal is to prevent or shorten hospitalization for people who are struggling with acute health concerns.
Yet another example of responding to the evolving needs of the community is the expansion of the Geriatric Psychiatry service, given the new challenges that the aging population is presenting for the mental health and psychosocial care of older adults.
Having recruited Dr. Soham Rej in 2017, the Department of Psychiatry has become a leader in geriatric psychiatry, with new clinical services, research and training opportunities for a field that is in great need of further development.
Patients play an active role
What particularly pleases Stephanie Preston, a Nurse Clinician in Psychiatry at the JGH since 2002, is that patients are not only the recipients of care, but are playing an increasingly active role in informing psychiatrists and other professionals how the Department can be improved.
“It’s wonderful to see more client representatives on committees for various projects,” Ms. Preston says, referring particularly to the Resource and Information Centre, a kiosk in the ICFP lobby that was launched after considerable input from patients, who explained their needs and helped plan the kind information the Centre would provide.
The kiosk is staffed by volunteers, many of whom have lived the experience and are able to provide support to those with mental health problems.
“When we opened the kiosk last fall,” Ms. Preston recalls, “I was really happy to see a number of clients at the ceremony. They had come for their appointments, but stopped by to have a drink and join the celebration, because this is their Centre. I thought that was great, because there we were, on an equal standing with the clientele, which is where we should always be.”
As a result, Ms. Preston describes her job as “something that I absolutely love. I’ve been doing this kind of work since 1986, and I consider it a privilege to have someone walk into my office and ask me to help with some sort of crisis or to deal with a mental illness problem. It’s an opportunity for me—and all of us—to support that person and possibly get them to see things from another angle.”