Montreal’s Douglas Mental Health University Institute offers an array of services based on patients’ specific needs, the severity of their illness, and their diagnosis. A variety of Post-hospitalization treatments are also offered – a team approach or a one-on-one program, in which patients are matched with a case manager. Evangeline Smith, who has worked at the Douglas for 30 years, explained that after hospitalization, the Douglas matches patients with an outpatient team or refers them to specialized services or treatment centres. “We do what we need to do make sure that a patient can live in the community adequately,” Smith said.
Smith is now the manager of the ambulatory services department, part of the psychosis program, so her expertise refers most accurately to patients receiving care for psychosis, particularly schizophrenia. Post-treatment services focus on reintegrating patients back into their communities and focus on psycho-social issues, and more logistical matters: balancing a budget, finding housing, and ensuring that patients take medication. The Daily quizzed Smith last week, curious about a growing trend of shorter hospitalization stays for the mentally ill and obstacles former patients face when transitioning from in-patient care to independent living.
McGill Daily: Have you noticed that patients are being discharged earlier than they have been in past years, that they’re staying for shorter times?
Evangeline Smith: They are staying for shorter times. That is definitely the case. It is a progressive trend. It is a trend that destigmatizes. We feel that that person can be treated for the more acute stage of an illness in the hospital, and then be discharged very quickly in order to reintegrate back into community living. It makes the transition easier than [staying for a long period of time does]…. Patients were hospitalized for many months in the past partly because we did not have resources in place to accommodate their return back to the community. Those resources are something that we are now more sensitive to. There are a lot more housing alternatives, and a lot more community resources; we have many more partnerships with the community organizations, and they step in and collaborate with outsource teams.
MD: What criteria are used to decide when a patient should be released?
ES: We have traditionally been very hospital-centred and we always feel that a hospital is the best environment in which to treat a patient. If you look at methods in other countries, hospitalization is a lot shorter. But patients can be treated in the community; they do not need institutionalization to get better or in order to continue treatment…. We’re good at providing that. We now have so many different levels of case management and such strong team support with exactly that mandate: to support transition into the community.
MD: What sort of living situations can patients enter when they return to the community from treatment?
ES: It depends very much on the level of care that patients need and their desires. We have numerous types of housing alternatives, so a client may go to a family care home if they need a kind of structure where they can have meals offered to them and have care 24 hours a day. Some will go to their own apartments and will then need some support in terms of daily living skills – their capacity to shop and cook and clean. Some will go to group homes. We certainly want to encourage autonomy as much as possible. It is something that we promote and encourage in order to empower the patients to make a transition not just into the community, but into society.
MD: Do you think there is something particularly risky about returning, say to the apartment that a patient was living in beforehand. Could something like the environment trigger a relapse?
ES: This would have been evaluated before the patient returns to that setting…but there is the issue of stigmatization. There can be issues of going back to an apartment building where your neighbours or your landlord know that you were recently hospitalized, when already you are feeling insecure and feeling that other people are perhaps judging you, or you are feeling suspicious of other people – the way they look at you or if they’re whispering, you think they’re saying things about you. There is also an isolation issue, although that is getting better. We try to link [patients] to different social organizations and activities…. There are programs in place but sometimes it’s not always that easy to reintegrate. Budgeting is also very difficult. They have a very minimal amount of money, because they’re on welfare and receive only about $850 a month.
MD: Have you observed any variation in a patient’s recovery process in relation to the length of in-patient care they received?
ES: There are certainly a lot of patients who don’t want to stay in the hospital very long. They have perhaps a healthier attitude about returning to the community. We do also have a lot of patients who have become very comfortable over the years, very comfortable with being inside the hospital and being looked after. They have a very secure feeling about being connected to the hospital…. It’s mostly our older patients who are undergoing feelings of dependency and insecurity, and so on. With them it’s a little bit harder [to leave], and I suppose that’s the system’s fault.
We have been very protective and maternalistic, and we recognize that in the long run that may not have been the most healthy way to help our patients. We’ve fed dependency to some degree – and as I said that is more with our older patients – and now with our younger patients we’re trying to let them see that they have a role in society and that they can have a good quality of life, and a stable life in the community, despite their limitations. There is a gradual trend in the recovery, where we like to promote their autonomy, give them choices, allow them to explore what they want in terms of their goals and their life. Sometimes those choices come with risks – the same way that these choices come with risks for everybody in society. We allow them to go through these choices, but at the same time help them make decisions that are more healthy.