Marking 20 years
of bold journalism,
reader supported.
News
Health

'There's Not Enough of Me': BC's Psychiatry Crisis

One of few psychiatrists serving the province's isolated north, Charles Brasfield is set to retire. Who can replace him?

Jesse Donaldson 20 Feb 2012TheTyee.ca

Jesse Donaldson is a journalist, photographer, playwright, and one of the founding editors of The Dependent magazine.

image atom
Charles Brasfield in his North Vancouver office. Photo by Jesse Donaldson.

Spend even a few seconds looking around Charles Brasfield's Lonsdale Quay office, and his connection to B.C.'s north is obvious. Covering the walls are works of northern First Nations art -- maps, paintings and a raven mask, given startling emotion and polished smooth by a master carver. Some were purchased. Most were gifts. As it turns out, his patients have much to thank him for; for 20 years, Brasfield has served as one of a handful of mental health professionals -- and, in some cases, the only psychiatrist -- providing much-needed outreach services to remote coastal communities such as Bella Bella, Bella Coola, and Hazelton.

"They're not well-serviced at all," he explains, referring to the isolated coastal communities that he has visited over the years. "If you assume that the full rate [of mental illness is taken into account] -- roughly 20 per cent, which is about right, that's about 4,000 people a year we should be seeing. We don't. We can't possibly."

Brasfield, 71, is bearded and soft-spoken, with a gleam in his eye that could be one of mischief, passion, or resignation. At times, his voice borders on inaudible. Six months from retirement, he maintains a patient load 120 people higher than the regional average for a psychiatrist. He is due to give psychiatric assessments on the more than 19,000 residential school claims still outstanding in Canada. He's the founder of the North Shore Stress and Anxiety Clinic, a private operation that's B.C.'s only option for the treatment of anxiety disorders. He is one of only two medical professionals in the province certified as both a psychologist and a psychiatrist. But it's his sustained passion for First Nations mental health that is the most notable aspect of his work in a close to 30-year career. 

"There is nobody else like him that we've had here," explains Carole Clark, a social worker in Bella Coola since 1991. "In Bella Coola, he is it, really. There's him and five psychologists from the clinic. Back in the '90s, we did have outreach psychiatry happening, and those were great people, but what Dr. Brasfield brings is quite an interest in native communities, and (the) problems and conditions specific to small communities with a poor socioeconomic outlook."

Growing up in the southwestern United States, Brasfield developed a connection to the Navajo culture of the region, a passion which remained throughout medical school and finally bore fruit when, in the mid-'80s, he settled in West Vancouver.

"When I got into psychiatry, the Squamish band here said: 'We haven't had a psychiatrist here for a long time. Would you come down from up the hill?'" he recalls. "That was an interesting phenomenon. My anthropologist friend said: 'They're not going to talk to you for the first year. But I went anyway, and, on day one, there were people lined up outside the door."

Living beyond the guardrail

Brasfield's relationship to B.C.'s northern coastal communities began in 1992, with a call from the Coastal Health Authority. Working through the now-defunct Anxiety Disorders Clinic at UBC, and funded by a grant from the First Nations/Inuit Health Branch, Brasfield and a small group were asked to put together a mental health workshop for the remote community of Bella Bella.

"We thought: 'Oh, we'll just do a suicide-prevention project. Everyone knows that First Nations commit suicide,'" he recalls, sheepish. "So, we proposed that, and they said: 'You cannot do that. You have to be here longer than that to know something about the community. Why don't you come here?' So, a couple of us did that."

Word travelled quickly, and, in the years to come, Brasfield became involved with outreach to other remote communities such as Bella Coola, Hazelton, Prince Rupert, and Fort Nelson, work which, partly through his efforts, led to mental health outreach work becoming built into the hospital budget in both Bella Bella and Bella Coola.

"They're completely supportive," Brasfield says of the locals. "First Nations, especially -- their first priority in terms of healthcare is mental health. Mental health and addictions. They want to talk about it."

But despite the enthusiasm of many of these communities and the financial resources made available, the general lack of support services made the early years particularly frustrating, Brasfield notes.

"There were five or six of us [mental health professionals] going around," he remembers, "and we'd see a patient for consultation, and we'd say: 'This person looks like they're depressed, anxious... they should have X/Y/Z medication and psychotherapy.' And then, we'd go away, and come back, and it would be the same person, same issues, no treatment, no follow-up, no contact."

Northern communities such as Bella Bella and Bella Coola have a unique set of needs when it comes to mental health. In addition to the usual issues that can be found in any community: anxiety, depression, and psychotic disorders, there are a number of additional problems affecting B.C.'s north in a far more pronounced and serious way. Employment is often spotty at best, and, among some, substance abuse has reached dangerous levels, with five or six joints per day "not unusual" for an individual, in Brasfield's estimation, and drinking common among children as young as 11 or 12. In addition, residents of the Bella Coola valley have a higher incident of alcohol and vehicle-related deaths than elsewhere in the province, and a life expectancy that is lower than anywhere else in B.C. But as Brasfield explains, the most common issue he faces as a psychiatrist is the spectre of Post Traumatic Stress Disorder.

"In some of these communities, between 50 and 80 per cent of women are introduced to sex before their first period," he explains. "It's rarely a single event. It's usually a relative. It's an ongoing problem, and has been for many years. For the men, it's the same kind of thing -- though it's only about a quarter of them that have been raped. And nobody wants to talk about it."

Since the 1990s, the number of mental health professionals willing to do outreach to the north has declined sharply. In fact, of Vancouver's more than 250 psychiatrists, and the province's roughly 400 clinical psychologists, Brasfield estimates that approximately 30 do any form of outreach to the north, down from 80 less than 20 years ago. That's an assessment Bella Coola's Clark agrees with.

"Sometimes," she says simply, "you go without for a long while."

So, with such a glut of patients in need of mental help, why is it that so few mental health professionals are willing to go these communities?

Brasfield shrugs.

"They're remote. You have to like mountain-flying to fly into Bella Coola. Sometimes you get in, sometimes you don't. If you don't, usually you can land at Anahim Lake, and then you have to get into a yellow school bus that will bring you down the hill. The hill is about 35 miles -- just picture that you have to go from about 6,000 feet up on the plateau, down to sea level. It's not paved, it's not graded, it's not very good for snow driving. It's usually passable. Though, not always. So sometimes, people won't do that. I always say: 'Look down there. Isn't that spectacular?' and people say, 'I'm not looking down there. There's no guardrail.' Do people ever go off? Yeah. Last year, there was a Toyota found down there. Nobody even knows when they went off the hill."

The end of isolation

In his years advocating for the north, Brasfield has tried persuading his colleagues to join him. He has convinced those doing their residency, only to have them leave once the residency was over. He says he developed the Northern & Isolation Travel Assistance Outreach Program (NITAOP), an initiative designed to give incentives to medical professionals. It covers accommodations up to $120 per night, meals up to $28 each, plus all travel and vehicle costs, and each medical professional receives an additional 20 per cent, on top of their usual fees.

"Some years ago, I suggested that those of us who live down here in the south take one per cent of our fees, and put them in a pot, and use that money for outreach, for extra funding for the north," he explains. "Every psychiatrist thought: 'That's a great idea.' They'll pay your airfare, they'll pay your hotel (up to a limit), they'll give you all your fees, plus 20 per cent, and say: 'We'd like you to go up for as long as you'll go, we'd like you to go back as often as you will,' and it's a way of encouraging doctors to go explore a community, and find out what it would be like to, say, live in Bella Coola in January... We used to go north anyway. But, it just paid regular fees, and the airfare and hotel. There was nothing extra for doing this. This was back in the early days, when there was about 80 people going, but we were beginning to lose them. So, we wanted to come up with something suitable to get more people to go north. Well, we lost them anyway."

However, developments in technology may soon make traditional outreach a thing of the past. Currently, Brasfield and five North Shore Stress and Anxiety Clinic psychologists are part of an initiative unique within B.C.: the use of videoconferencing equipment to conduct face-to-face psychotherapy sessions with patients in remote communities across the province. The initiative is known as Telehealth, and, although the hardware has existed for close to 20 years, it wasn't until recently that it was used for psychiatric purposes.

"We had the equipment back in 1998, but we didn't have anybody who would be at the other end of it until Dr. Brasfield came around," Clark notes, of the situation in Bella Coola. "In particular, he has brought us access to psychologists who are interested in our community, and that's huge. We've had the Telehealth service now since 2007, and nobody could afford this service if they had to drive out -- we're six hours from the nearest major city, where there might actually be a psychologist. Nobody could afford that."

And, as Brasfield notes, in addition to lessening the burden on patients, remote outreach can be easier on the system as a whole.

"This last trip to Fort Nelson, it was $1,000 for the trip, plus $1,500 for being out of the office for that time," he muses. "That's $2,500. Plus, the 20 per cent extra fees. So it's going to cost, through the system, around $7,000. You could probably do that from here, over three or four days, for about $2,000. Take some of that money, and spend it elsewhere. That's what needs to happen."

Preliminary outcome data obtained by The Tyee -- collected by Bella Coola General Hospital's Mental Health Department for Coastal Health, and due to be released this month -- seems to indicate the success of the Telehealth approach, with 76 per cent percent of patients surveyed giving the service a five out of five (in terms of service provider competence), and an average patient score of 4.6.

"I find them very professional," a patient explains, within the report. "Non-judgmental, encouraging, but yet realistic and they seem to understand -- Dr. Brasfield and [psychologist] Kristen, they understand, they have me figured out, they have a good understanding of where I am as a client and they are able to take me and move me forward, being able to understand where I'm coming from, I don't know that all doctors are able to do that. It's not easy. I feel I'm in very competent hands."

Currently, the North Shore Stress and Anxiety Clinic performs close to 100 hours of Telehealth outreach per month, split between its psychologists. Brasfield himself does three days of Telehealth per week, in addition to keeping a traditional outreach schedule that includes seven trips north in the next eight months. Although the current telehealth equipment is expensive (roughly $30,000 per unit), Brasfield estimates that the Internet -- in particular, secure live video chat programs (similar to Skype or FaceTime) -- may one day prove a low-cost alternative in the treatment of mental illness.

"We need to do it differently," he says, of the future."We won't have physical people up there, but we will be able to provide services through electronic means. It's going to happen. We've just started in B.C."

Given that a Cognitive-Behavioural Therapy program (the traditional treatment for PTSD) typically takes roughly 48 to 72 hours to complete, there is genuine promise for the affected residents of B.C.'s north.

"What happens with the treatment of these disorders is that they get better," Brasfield explains. "Their condition improves, to the point where they're lots better, or all better, and they can pass that on to the next generation and the next generation."

'Progress is really slow'

Brasfield is set to retire at the end of August. At that point, his patients in the Lower Mainland will be referred to other psychiatrists or psychologists.

"It's just not clear yet," Carole Clark says, of Bella Coola's future. "We don't have a firm plan for what happens after the end of August."

"It's unclear," Brasfield agrees. "At this point, I'm the only psychiatrist going into Hazelton. I'm the only psychiatrist going into Bella Coola. The only one going to Bella Bella. Then there is Dr. Kotze and Dr. Jones, who go from Dawson Creek to Fort Nelson via videoconference one afternoon a month."

With Brasfield's retirement, many of these communities will be losing not only a qualified professional, but also one of the strongest advocates they have in the psychiatric community.

"There's not enough of me," he says simply. "There's not enough of any psychiatrist. So, let's expand into other professions. I've been saying this since 1963. But progress is really slow. It's been 30 years, and maybe now it's finally going to happen. They need more qualified people, whether it's psychologists, or nurses, or social workers."

Then he sits back, and considers for a moment.

"These next six months, I'm going to do as much as I can."

[Tags: Health.]  [Tyee]

Read more: Health

  • Share:

Facts matter. Get The Tyee's in-depth journalism delivered to your inbox for free

Tyee Commenting Guidelines

Comments that violate guidelines risk being deleted, and violations may result in a temporary or permanent user ban. Maintain the spirit of good conversation to stay in the discussion.
*Please note The Tyee is not a forum for spreading misinformation about COVID-19, denying its existence or minimizing its risk to public health.

Do:

  • Be thoughtful about how your words may affect the communities you are addressing. Language matters
  • Challenge arguments, not commenters
  • Flag trolls and guideline violations
  • Treat all with respect and curiosity, learn from differences of opinion
  • Verify facts, debunk rumours, point out logical fallacies
  • Add context and background
  • Note typos and reporting blind spots
  • Stay on topic

Do not:

  • Use sexist, classist, racist, homophobic or transphobic language
  • Ridicule, misgender, bully, threaten, name call, troll or wish harm on others
  • Personally attack authors or contributors
  • Spread misinformation or perpetuate conspiracies
  • Libel, defame or publish falsehoods
  • Attempt to guess other commenters’ real-life identities
  • Post links without providing context

LATEST STORIES

The Barometer

Do You Think Naheed Nenshi Will Win the Alberta NDP Leadership Race?

Take this week's poll