Shortly after 12:00pm, on Friday, September 18, a woman pushed her way out the front entrance of her building in Vancouver, and collapsed in the street; she died shortly after of fatal stab wounds. The local media didn’t say much about this, except that the stabbing happened at a residential building in the Downtown East Side; that the victim had been in an altercation with her neighbour; that the assailant would be charged with second degree murder; and that this was the twelfth homicide in Vancouver for 2015.
The official news reports leave a lot to the imagination, and readers will likely pass over the incident as a drug-induced quarrel between two "crackheads," criminals, or the mentally insane—whatever is commonly understood as a typical resident of the infamous DTES. The few comments left by readers are telling, but sadly not surprising, for they evoke what is becoming a common view: that tax money is being wasted on the concentration of social services in the area; that crime is rising in the city and that solutions need to be found; and that the partial remedy is to clean up those 10 square blocks of an area often referred to as the poorest—though rapidly gentrifying— postal code in Canada. But what are we missing if we buy into this narrow perspective? A crisis of care in this country that has been going on for far too long.
The fact is that both of the people involved in this stabbing are victims: they are two of the many casualties of a system of neglect otherwise known as “community mental health care.” I am referring to the ad hoc patchwork of sub-contracted agencies, that cropped up in the 1970s and have really proliferated since the 1990s when de-institutionalisation was ramped up with little foresight. These agencies have come to be stand-ins for delivering the services and supports that were formally under provincial and federal umbrellas. And the implications for public health—and human rights—have been devastating. Unfortunately, we take the government’s hands-off approach for granted; and service providers are in a double bind.
And the purse strings are tightening again with many services getting cut, which is perhaps why no one from the community has spoken out about this double tragedy. We are all too afraid of losing our funding: so we turn a blind eye, choke down our collective sadness, and do what we can to conceal the fact that premature death—either slow and miserable, or increasingly brutal and violent—is the actual result of a mental health care system being undermined by socially irresponsible governance.
I knew both of the people involved in the stabbing. I am a mental health worker in the DTES’s only mental health drop-in, a place where both regularly spent time during the day — though less frequently as of late. As far as I can tell they were barely acquaintances, though they did both live at the same supportive housing, a building knowns as the end zone for people considered “unhouseable.” Quite a few of the people I see on a daily basis live there; people with mental illness and addictions issues, as well as autism and dementia. The workers there are dedicated bunch; but like all of us in the field, they are in over their heads.
The drop-in opened in the early 90s, to provide a safe space for those who were literally dumped onto the street when most of Riverview Hospital was closed like so many other psychiatric hospitals in the “developed” world. Some of my more senior co-workers were there when the white vans pulled up, and some of the people who were dropped off in the DTES are still around. Their issues are far more complex now though: many have fallen prey to the local drug industry as well as to the slumlords all too happy to cash in on people with very few options. The fact that some of these people are still alive—though we have a wall of pictures of the prematurely dead—is a testament to their resiliency, not to the quality care in a country that falsely prides itself on having an equitable health care system.
The drop-in is important because it is place where people can access not only food, clothing and advocacy services, but also a few leisure opportunities. But it seems that fun is even less of a right for the mentally ill than adequate food, housing, and care in this country. Leisure is increasingly unpopular among funders, despite the benefits of art and recreation which studies show.
The drop-in is also important because over the decades an invaluable (and unquantifiable) sense of community has been forged there against the odds: a community of proximity, of suffering and of survival. But sadly this sense of community is being eroded. Because the drop-in is also a space that makes one intimately acquainted with the illogical, frustrating, inhumane, effects of ever-evolving policies and glossy strategic plans that reflect a deeper respect for the bottom line than for the people we serve. The deficiencies of this system play out in more and more of our interactions and as workers we are forced to inflict surrogate violence on this community.
We clothe and feed people with donations; in other words, what is no longer usable or saleable; and increasingly, questionable corporations are handing things out and funding token projects: this gets them tax credits and kudos for social responsibility—the government welcomes the public/private partnerships and rewards those who promote them, often at the cost of peoples’ dignity. We hand out crack kits, meth pipes and syringes because “harm-reduction” is what gets funded these days—yes it saves lives, but nobody questions the quality of these lives and we’re doing harm reduction until we’re blue in the face; We also get people on wait-lists for the detox-treatment-homeless-again merry-go-round and there is nothing more frustrating than that sense of futility and contradiction; except maybe making calls to homeless shelters with revolving doors; or trying to advocate for people to get a 10 by 6 rooms in buildings that are virtual warehouses for “problem people”; To be fair, some aren’t too-infested with cockroaches, rats and bed bugs, have a working washroom on each floor and a couple of over-worked resource workers on site—those are on the better side of the human storage continuum.More times than I care to remember though, I have had to tell someone that their only option for now is the street —and sometimes that is the better option. We’re still waiting for the government’s national housing strategy by the way—in the meantime we’ll just keep telling people to be patient.
When we notice that one of our regulars is really not doing well, we call the Community Mental Health Team, which consists of a handful of dedicated psychiatrists, psyche nurses, social workers and mental health workers, whose caseload is well over 1400—translating into over 125 visits a day. There is also the ACT team now: Acute Community Treatment—which is composed of small pods of similar workers, and these meet clients out of office. But again, these teams of mobile professionals are few, and have an ever growing caseload. So our best bet is the police, who can apprehend people under the Mental Health Act—which is often our only recourse when someone is so mentally unwell that they don’t sleep or feed themselves; or have become so anaemic that they’ve collapsed, or when we know they are very likely going to get beat up—or maybe killed—because of their erratic behaviour (or shot by the police, which happened 3 times in the greater-Vancouver area in 2014, though I doubt that was included in the homicide stats.9).
So the best solution for day-to-day management of mental illness is the default to medicalization. And often this is in the form of a prescribed and mandatory injection (monthly, or bi-monthly), the main purview of the mental health team: it’s efficient, and cost effective and If someone misses their appointment, they will be sought out. Non-compliance means apprehension by the police, involving what comes very close to a SWAT team. This sends quite the message to the community: that they best behave, and that they have no rights.
The person is generally removed with little fight, and a fear in their eyes that is indescribable. The process is quite traumatic for everyone involved including the workers who had to make that call and get to feel complicit. Usually the apprehended are taken to the psych ward at St. Paul’s hospital (where there is a total of 69 psychiatric beds, and last year there were 7345 mental health related visits). After a short stint there they are usually released to their “community”—back to the poverty and instability of their day to day lives
This is community care, and it has not fulfilled its promise of providing more humane mental health care or any semblance of quality of life. The rhetoric merely masked the real priority of cutting back on expenditures— but at what cost? Emergency rooms are full, the police only show up 1 out of 3 calls, while the prisons are filling with people with mental illness who face solitary confinement. Meanwhile we have experienced continued program cuts, little commitment from federal and provincial governments to improve a historically deficient mental health system, and the constant undermining of some of the more valuable services that have managed despite the odds.
Vancouver Coastal Health—one of the main bodies that allocates government funds in Vancouver— has recently introduced its “Second Generation” report, ostensibly in response to the deficiencies I have described. Their plan speaks of collaboration, a more comprehensive system of community care, with services that are more health-related and accessible to clients, and with more "peer support" to remove barriers—lofty intentions that sound very familiar, which is why we should be scared for those whose lives are always at the whims of expertise.
At the dawn of this new generation, the DTES mental health team is facing cuts. The Network, got slashed after 20 years of doing real peer-based support. Gallery Gachet a therapeutic, peer-cased art collective for mental health survivors has lost it's funding too—this was announced the week of the stabbing and I don’t think it’s a stretch to make a symbolic connection between the two. At the same time, invaluable advocates, those that dare speak out for the mentally ill, are being laid off from some of the only programs specifically for people with mental health issues: first the Kettle society and MPA, now perhaps the drop in, where we have been told that we must now compete for funding with 5 other services, some that have addiction as their mandate.
If we “win” the funding, they will close, and our focus will likely no longer be mental health but addictions, to make up for this loss. While the two are very much related now, thanks in large part to policies dolled out with little foresight—they should not always be conflated. But we have no choice but to try and sell ourselves, focusing on raising narrowly defined health statistics which do not really measure quality of life; and focusing more on putting clients back in the workforce—as if everyone is fit to work—with "peer support” now implicating cuts to trained staff. We are running with fewer workers, longer hours and a growing clientele—which puts us all at risk. Our advocacy services are being faded out. Our recreational programming is being gutted. But “if the funder wants fruit salad, we will give them fruit salad,” so we’ve been told by the consultant hired to make us more efficient.
Competition is the opposite of collaboration, and reflects how the values of business-minded governments continue to penetrate the realm of human care. Not surprisingly, there is a move within non-profits in Greater Vancouver to amalgamate and expand to gain leverage over others. With this comes the tendency to organize around a corporate structure and value system that undermines community ideals and alienates the people who rely on our support. And as workers, forced to compete within the bind of public/private partnerships now, we have become afraid: to speak out within our organisation, afraid to speak out for the casualties of this system—or risk losing our jobs. We have little say now in how our organisation is run, and even less say about the government policies which dictate its social mandate. We can’t risk offending the wrong people, because then our clients will suffer the fallout.
And where would people go to get away from the street or their 10 by 6 dwellings if places like the drop-in close? What will become of their lives if our sole purpose as service providers is to feed, and clothes poorly, and medicate blindly? What happens to people who have been coming to our centre for over 20 years, to people like the woman who was stabbed, and her assailant who found his way to one of our last remaining institutions. Of course the onus is on us lowly workers, while the government is off the hook again.
