When our children were young, we made several house exchanges with European families for our annual vacation. During one of these, my kids and I were enjoying an ice cream on a sunny day in a small Norwegian town. At the next table on the restaurant patio was a woman in her early 60’s, very well dressed, drinking a cup of coffee. She was holding an animated conversation with someone who obviously wasn’t there. No one else on the crowded patio seemed to notice her. It dawned on me: why do we inevitably associate severe mental illness with poverty and social disadvantage? It doesn’t have to be that way.
My interest in working with marginalized people has much to do with my family background. I grew up in Detroit where my father was a railroad engineer and union organizer. Lefty politics were often served at dinner. After my undergraduate years at Ann Arbor, I enrolled in the MD – PhD program at Yale. I hoped to do my doctoral studies in medical sociology, but when it dawned on me that I would be in school forever, I dropped out of the PhD program. I was accepted into the combined general and child psychiatry program at the University of Pittsburgh while doing the field research for my MD thesis in Bangladesh (on amebic dysentery!). My residency was literally all over the map: to complete a fellowship in public sector psychiatry, I did a survey of the partial hospital programs for children and adolescents in western Pennsylvania for the state government. I would drive a few hours to visit a rural program, and then race back to Pittsburgh so that my tardiness would not be interpreted as resistance by my psychoanalyst. I moonlighted at a rural mental health clinic to pay for the four times per week sessions, and when it dawned on me that my fees had paid for the analyst’s new Oldsmobile, I quit.
My tendency to be rusticated (and to find unusual work) continued at my first post residency job in the Division of Child Psychiatry at the University of Rochester. My primary clinical activity was being the psychiatrist for several rural partial hospital programs located in mainstream schools, a joint project of the university, the state office of mental health, and the local school districts. After years of Ronald Reagan and his “I’ve got mine, too bad for you” politics, the rising tide of violence, and unequal access to health care, my wife and I decided to leave the United States for Canada, something that was seen as pretty odd for a doctor in 1990. Due to licensing challenges and my wife’s refusal to live anywhere where a block heater was required, we ended up on Prince Edward Island, a welcome respite from the drive-by shootings of Rochester. As the only child psychiatrist on the island, I was happy to be part of team that moved the adolescent psychiatric beds from the 19th century provincial hospital to a brand-new group home facility, conveniently located a half a kilometer from our house!
Illness among our parents and a riot brought us back to Windsor, Ontario in 1994. The “riot” of a few conduct-disordered adolescents on the pediatric unit of Hotel Dieu Hospital made a splash in the press, and spurred calls for the development of a dedicated child and adolescent psychiatry unit. I was hired by three agencies (including the hospital) to provide care to teenagers admitted to hospital for mental health reasons, and I saw them for hospital consultation and follow-up care at a children’s mental health centre and a residential treatment centre. As was becoming usual, I was the only full time child psychiatrist in the county. These were the days of Duncan Sinclair’s Ontario Health Services Restructuring Commission, which recommended the creation of a pediatric mental health inpatient unit. However, community agencies were concerned about the medicalization of adolescent mental health care, and offered a different vision, that of a medium stay unit at the residential treatment centre that offered the young clients a large campus, fully staffed classroom, pool, and gym, all in their own clothes, not hospital gowns! I am very proud to have been part of this community effort, which is thriving today at Maryvale Adolescent and Family Services.
The Liberals’ desire to slay the federal budget deficit and Mike Harris’s cuts to welfare made my work in child psychiatry feel increasingly futile. No medication or psychotherapy would “fix” families and children crushed by poverty. This, combined with my interest in working with those with severe mental illness, led to my first Assertive Community Treatment (ACT) job at a new team in Chatham, Ontario in 1998. I really enjoyed home visiting and being out in the community, working with vulnerable yet resilient clients. In 2001, I was approached by the former head of the schizophrenia division at CAMH to help form a community outreach team as part of the division’s first episode program. We moved to Toronto, and shortly thereafter the HIP (home intervention for psychosis) team was born, and it is still very active a decade later. From there I migrated to the CAMH emergency room (where I eventually served as the medical chief for a few years) and TEGH’s ACT team. By this time, dealing with the “social determinants of health” in the community had become my biggest interest, and this led to conversations with Dr. Stergiopoulos about ICHA and my first ICHA post at Good Shepherd Non Profit Homes in 2007. I then followed her (and Dr. Soni) to the MDOT team over 4 years ago. Along the way, I’ve also worked at ICHA clinics at Seaton House, Second Base youth shelter, and the East Scarborough Storefront. I finally completely deinstitutionalized myself in 2012 when I resigned from TEGH, and began to work at ICHA’s clinic at Agincourt Community Services Association. I also joined the ICHA board and am now the treasurer.
I think ICHA offers us all a wonderful opportunity: we get to provide quality health care services to those who otherwise would never receive it. The challenges are great, but the rewards are much bigger. I feel quite lucky.