If there’s no one sufficiently reliable on hand, “we get creative….You know, ‘Where’s your cousins? Where’s your uncles? Where’s your grandma?’ Well, in the next village there’s an uncle and he’s been sober for twenty-two years and we phone over and he’s there and he’s willing to take him in for a few days.
“This is not easy work.”
Assessing the degree of danger a person poses to themselves in that moment is brutally tricky at the best of times, and Poschwatta’s team has no specialized training in how to do it. That weighs heavily on him. “I don’t know how many suicides I’ve assessed—well over a hundred, anyway. I would like to have that backup, have a hotline where there’s experts available to review what I’ve heard.” More often than not, it’s just him and his colleagues making that judgment call—will this kid be safe here, on her own, with these people who love her but who may be struggling with problems of their own, who may not be able to babysit a young adult indefinitely? Will she survive the night? “If we don’t have anyone there, then it’s just take ’em to the hospital. By hook or by crook, get ’em to the hospital.” He pauses. “But we find that’s a problem.”
You’d think taking someone in the grips of suicidality to the nearest hospital would at least get them through the crisis. Keep them safe until someone capable can figure out a plan of care. Not so much.
“All they do is ask people, ‘Are you suicidal?’ And if they say, ‘No,’ and there’s no sign—like, they don’t have rope burns around their neck or something—they let them go.”
That can be a deadly mistake.
“We’ve had situations that went sideways. We worked our butts off and we thought they were in there and we thought we had a doctor onside, they were going to hold them for an assessment or whatever, and an hour later we get a phone call: they’re back on the street. They lied to the doctor. They said, ‘I’m okay, I don’t need any help.’ So we have to run around on the street and phone the cops again,” Poschwatta says, aggravation in his voice. “We had seven in one year that suicided within one day of being in emergency….If it was non-Aboriginal people I’m pretty sure there would be a stink to high heaven. There would be inquiries and god knows what.”
And in the Lower Mainland, after Brian David Geisheimer and Sarah Louise Charles and Sebastien Pavit Abdi walked out of the psych ward and obliterated themselves, there was. That doesn’t happen in the small, largely Indigenous communities in the same province a thousand kilometres away. The inquest-spurring outcry isn’t there.
In Hazelton, a 270-person community in northwest BC, the staff at Carrier Sekani took matters into their own hands: they set up their own suicide crisis unit next door to the hospital and got clinicians with existing gigs elsewhere to commit time to staff it. Post-discharge suicides dropped almost immediately.
Once they’ve managed to get people stable, Poschwatta and his team sit them down in a group, make safety plans and start honing in on what’s driving them to want to die. Some people need to talk one-on-one with a health worker; some feel better going over their triggers of despair with others who are experiencing the same kind of thing.
There’s a lot of trauma: people who’ve been abused by parents, uncles, elders who were abused themselves. A lot of self-medication with alcohol. “It might be after two or three days working with them we decide this one needs to go to provincial alcohol and drug treatment, or this one needs a psych assessment. So we just keep working and listening until we come up with a plan for each person.”
None of this is fun. “It’s gruelling,” he says. “I’m not happy about it. I wish it would go away….It’s not a job. It’s like I’m here to do this to help them, ’cause nobody else will.”
The proactive work’s a bit less soul-destroying. The staff at Carrier Sekani have started focusing on depression screening for everyone. Apparently, the secret is not to mention the D-word while doing it. “We have some very nice people explain to the people that this is a little checkup that will let you know how you’re doing in terms of mental health.”
Also, bribery. People who get the checkup get free lanyards with their clan symbol on them and are entered in a draw for an iPad.
Then cultural liaisons go in and nudge the people who’ve been flagged toward treatment. “We’re very gentle, like right off the bat it’d be, ‘There are some things we’d like to talk to you about, would you be available to go for a cup of coffee or something like that?’ And we try to steer them to services.”
Ideally you’d get care where you live, or close to it. But it’s tough convincing clinicians to move to communities of a few dozen or a couple of hundred people in the middle of temperate rainforest wilderness. Tougher still to get outside clinicians who can actually earn the trust of the people they’re caring for.
“And then,” Henry Harder tells me when I phone him in Prince George, a 75,000-person city in northern British Columbia, “there’s the whole issue of stigma: if you’re a community of a couple hundred people, the mental health therapist arrives in town and now you’re lining up, everyone knows you’re going. So…you tend to not go.”10
I had called him to try and get my head around the gap in mental health care for Indigenous people. He figures he’s one of ten psychologists in Prince George, which is also a service hub for dozens of remote communities.
He knows you won’t get the best mental health care in every tiny community—but telepsychiatry is known to work, he says, if not as well as in-person visits at least much better than nothing, or the fumbling best efforts of someone who isn’t well-versed in psychic pain. But telepsychiatry is grossly underutilized: only 1 percent of Ontarians who need psychiatric care get it through telepsychiatry, even in remote communities where that otherwise means going without any care at all for a year or more.11 At least it can get you a diagnosis, an assessment outside of the nearest (distant) emergency department’s frantic scrum. A prescription, maybe. Or an informed opinion, with perhaps a referral to an urban centre if you need specific services, one that will ensure you get those services once you arrive.
“We’ve got to do a good job of getting them assessed and getting them out and, for god’s sake, helping them get back to their community. They’re just dumped out the front door of their hospital.”
Seriously.
He knows people who’ve been left penniless outside the Prince George hospital to fend for themselves in a city that isn’t theirs because neither level of government will take responsibility for transporting them back to their home. The federal government is responsible for health care on-reserve and the provincial government is responsible for health care off-reserve and their tussles over whose job it is to transfer someone who travelled to the city to get care back to the reserve often leaves the person—often a kid—stranded.
“People fall through the cracks pretty easily,” said Cindy Hardy, who is also a psychologist in Prince George and who I reached out to because of her work on the ways people fall through those cracks.12 Health systems fail people in the most basic ways but also in the less obvious ones. Let’s say you make an appointment to see a psychiatrist or psychologist in a big city a few hundred kilometres away. Jackpot—congratulations. Now you need to negotiate the time off work, arrange the child care, maybe figure out where you’re going to spend the night if you can’t make the six-hour drive there and back in one day. Maybe you have a car and can afford gas; maybe you get a voucher for the bus. Or maybe you can’t swing the bus schedule so you’re left hitching a ride on a highway that’s become synonymous with missing and murdered Indigenous women. Good luck making that appointment. “If they don’t show up for appointments or they don’t call, they’re off the list—that’s it. So when you’re feeling really depressed and you can’t get out of bed, that’s easy to do. They just fall off the radar.”
Indigenous people are supposed to have extended health coverage. But, guess what: you need to make a special application for psychotherapy.
�
��Isn’t that ridiculous?” she exclaims. “People are looking for help and they have to go through all these hoops. And I see this repeatedly with insurers….The paperwork is more of a barrier if your literacy is low, or if you don’t have access to a supportive physician.” Annoying paperwork can be a barrier for therapists as much as patients: busy professionals would rather not spend time filling out forms. “Especially when we have a load of other people who don’t require that much paperwork, yeah, we’re going to go with the path of least resistance, right?”
(In case you were wondering, I did email the federal government’s health department: How many requests for mental health care are made each year, and how many are granted, under Canada’s health benefits program covering Indigenous people? But they refused to say.)
Media frenzies around clusters of Indigenous youth suicides—like the one when Jolynn and Chantell and Jenera killed themselves, like when a slew of young people in Attawapiskat First Nation killed themselves the year before—drive her Prince George colleague Henry Harder nuts.
“Indigenous suicide becomes some sort of a banner call for people, and words like ‘epidemic’ and ‘crisis’ get used.” The feast-and-famine way news organizations cover Indigenous suicide makes it easier for politicians and policymakers to cast around for “a quick, hopefully easy and hopefully cheap solution to the problem.”
“When the government freaks out and they send a whole bunch of clinicians into one area, that helps for a little while. But everybody piles back out again and everything goes back to where it was before,” he says. “To me, the solution here is to provide adequate services and health care and food and opportunities into those communities long before they have a suicide issue….If I could have a big banner it would say, ‘Give that money beforehand.’” But all too often projects meant to bridge chasms end mid-air. “We seem to always go partway down a path and then the funding stops. The initiative stops. And it never fully develops.” And even when there is funding for health interventions, the execution falls flat. You’ll have half-a-dozen different pilot projects under different government umbrellas doing different things in a single place. “You could have one community approached by three or four different groups all coming to say, ‘Well, we’re here to help you with your suicide prevention.’” It doesn’t really foster trust when you feel more like an anthropological experiment than a group of humans meriting the same care as your fellow citizens.
“This sounds like a bit of a broken record, but one of the things Canadian society struggles with over and over again is the whole issue of the residential school legacy. And a great deal of the mental illness issues, especially on reserve, lead directly back to that legacy. And until we just stop pretending that never happened, or pretend like throwing money at it or making an apology in Ottawa is going to change that, then we’re going to continue having these issues. We have to help communities deal with that. There are people who were sexually abused in their residential schools who are sexual abusers on reserve. And they are in leadership positions and kids tell me they can’t go for help to the elders because they’re abusing them.
“How do you break that cycle?”
“I make presentations all over the world,” he says wearily, “and I get a better reception outside of Canada than I do in Canada. In Canada you get kind of some version of, ‘Get over it.’ I’m serious. It’s like, ‘That was a long time ago. Canada has apologized. We’ve given those Indians a hell of a lot of money. Why don’t they just get over it?’”
* * *
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MICHAEL KIRLEW—Jolynn, Chantell and Jenera’s doctor—uses the phrase “transformation” a lot when he talks about what needs to happen to make Indigenous health care anything other than a cruel joke “structured to deny care.” He believes the set-up, the people running it, the care that’s provided and the way decisions are made, all need to be wholly transformed.13 “Child mental health has to go from being considered a program to a right.”
He sees young kids with developmental disabilities that never get treated because the federal government won’t cover the cost of travel to a city with specialists capable of assessing their needs. He’s had travel requests to see a doctor denied because a patient saw the doctor eight months earlier. So kids grow up lacking necessary care, struggling to cope at home and in school, where as students they receive less funding, per capita, than their non-Indigenous counterparts. If, like a huge proportion of Indigenous kids, they’re in foster care, they can have been through dozens of homes by the time they hit puberty, which means that what care they get is truncated. “It becomes a recipe for disaster.”
Worse than all this, though, is the way a system that undervalues you in the most literal way reinforces the suicidal sense that you don’t matter.
“Colonization really works to take away your hope—hope in justice, hope in fairness, hope in health equity….Youth might lose hope because of all the different things that have happened in their lives, because of all this trauma, but, as well, because they interface with a system that has told them that they are hopeless and they have no value.”
What do you tell a suicidal twelve-year-old?
“I tell every single one of those youths that their life is valuable—that [their] life has purpose….They may have never heard that before.”
23
Race as Barrier
Mental illness is expert at compounding existing marginalizations—taking aspects of your life that make you vulnerable and using them to screw you further.
So it is with race. Not being white can make you not only less likely to get in the door to get care, but less likely to get good care and less likely to stick around long enough for that care to work. Things that might otherwise be protective—a close-knit community, family ties, a commitment to stoic strength—can work against you. Even the most basic need to be seen by the people providing your care can prove elusive, shafting your shot at help that makes a positive difference.
Let’s be clear: I am not a person of colour and I don’t live with the burdens, don’t face the barriers that entails. I’ve tried to read as much and talk to as many people as I could to rectify my own innate ignorance, because frankly this barrier to adequate, effective mental health care—ranging from systemic racism to therapeutic incongruence—is too urgent, too deadly not to address head-on.
A 2010 National Institute of Mental Health study found that while only one-fifth of Americans with depression got the right kind of care for their condition, African Americans, Caribbean Black and Mexican Americans were half as likely to get good care. And while health insurance may enable better access to depression care, it does not ensure better care.1 Latinx Americans in need of mental health care are less likely to get it, less likely to see a specialist, more likely to experience delays and, when they do get care, less likely to get anything congruent with guidelines and less likely to be satisfied with the care they get.2
An American study of Medicaid enrollees found the most marginalized or seriously ill people were least likely to get minimally adequate care. Black people and those who began depression treatment with an inpatient psychiatric stay for depression were less likely to receive minimally adequate psychotherapy and more likely to receive inadequate treatment.3
When it comes to accessing health care, poverty and geography can screw you in terms of getting in the door; race can keep screwing you once you’re there. There are insidious hurdles—a health practitioner treats you a certain way, makes assumptions about you and what you need, fails to see you for you because of the way you look. You’re made to feel unwelcome, uncared for.
A nurse almost gave eighteen-year-old Rudayna Bahubeshi someone else’s medication when she confused her with the only other Black woman in the mood disorder inpatient unit. She had been enveloped in a depressive vortex that yanked her out of her life, out of her final weeks of high school and into a psych hospital. What may seem like a minor, malice-less slip on the nurse’s pa
rt made her feel shut out of an ostensibly universal health care system. “After several weeks of feeling increasingly hopeless in the hospital, I checked myself out. For many years, I didn’t seek mental health support,” she wrote in a 2017 opinion piece for the CBC. “I can’t say those who were negligent in overseeing my care had malicious intentions or made conscious assumptions related to my identity. But at the end of the day, do intentions matter when the ways in which I was vulnerable were overlooked and unacknowledged?”4
Interventions won’t work if you can’t connect. Clinicians are trying to fix your brain, not your bike.
An effective therapist doesn’t need to be their patient’s demographic twin. They just need to be cognizant of what people different from them are going through.
The newbie psychologists Rheeda Walker advises look at her askance when she tells them to ask new patients about the role race and culture play in their lives. In their first session, even. In a written questionnaire, if they’d rather. It’s key to understanding where a person is coming from, she tells me. And it’s often something people won’t bring up on their own, “because you don’t want to make other people feel uncomfortable.”5 I’d called her up—a psychologist and head (and founder) of the University of Houston’s Culture, Risk, and Resilience Lab—to help shed some light on psychological racial disparities. She speaks with the patient authority of an expert who breaks down her expertise to the clueless for a living. (Our phone conversation took place on November 9, 2016, the day after the US election, a day when much of the world was reeling and, she noted, a day when cultural sensitivity would be a must if you’re a health practitioner.)
It’s often tempting to hope that not mentioning race neutralizes it as an issue. But if race or cultural background is a key part of your identity, if it affects the way you experience the world and your own psychological pain, ignoring it can doom a therapeutic relationship. “So you can see how termination might happen prematurely. It’s like, ‘I don’t even know why I’m talking to them. I should just go somewhere else.’ Or they don’t go anywhere.”
Hello I Want to Die Please Fix Me Page 23