Despite continuing attempts of Toronto health and social services to accommodate persons with a concurrent disorder, the mainstream systems are not completely “there.”
In itself, concurrent disorder (co-occurring mental health and addictions) is widespread, in varying degrees of severity and among every level of society. Due to the traditional separation of mental health and addictions services, obtaining service in the Toronto area that addresses both issues is still a problem.
When concurrent disorder is combined with complex needs (homeless/ at risk, no/ low income, multiple issues), there are significant barriers to people accessing and remaining in service. This is not only highly disappointing to clients struggling to find solutions and demoralizing to practitioners trying to find competent services, but a costly, escalating problem to the health and social systems.
While an initiative such as Concurrent Disorders Support Services (CDSS) provides access to a range of knowledgeable services, it is in a beginning stage (small staff, limited catchment) and offering short-term (rather than uncapped) services.
Barriers to Access
Clients with a concurrent disorder and complex needs have difficulty complying with the traditional requirements of health and social services and either do not connect to service or withdraw prematurely. These barriers are:
Prerequisites for service:
- Need for identification
- Need for a health card
- Proof of appropriate immigration status
- Referral of a family physician
- Fees or associated costs (for example, of medication)
Criteria and wait for service:
- Exclusionary criteria
- Need for records
- Wait list
- Long assessments
- Client’s lack of a stable place to stay
Traditional agency practices:
- Attendance requirements
- Unwelcoming personal interaction
- Penalties for not meeting the requirements
- Lack of coordination and continuity between services
- Programming that does not fit with this clientele
Impact on the Client and System
As a result of these barriers, the client’s needs are not met and he/ she may continue to return in increasingly worse condition. While the issues of concurrent disorder are often long-term, the unnecessary “recycling” of clients through the (particularly, health) system takes a considerable toll:
Clients:
- Lose faith in the helping systems and may remain untreated. For example, the Mental Health Supplement of the 1990 Ontario Health Survey found that 18.6% of 10,000 respondents (general population) said that they suffered from one or more alcohol, drug or mental health problems in the past year. Approximately 75% had not sought treatment because they did not feel it would help.
- May suffer a “marked inequity” in the use of medical and mental health services, leading to higher rates of chronic disease, suicide and death (Dianne Patychuk, 2007).
- May feel justified in missing appointments or dropping out of service (see the section on “Missed Appointments”).
- May continually access new services, without regard for duplication, coordination, continuity or follow-up.
Workers:
From the CDSS experience with the workers of 20 agencies, it appears that workers:
- May feel under-educated in the field of concurrent disorder, due to training in only one field – either mental health or addictions.
- May become confused as to how to proceed with clients, as their situations (needs and services) become increasingly more complex.
- May not know how to measure the success of their interventions, as common outcome measures are based on a more stable, responsive population of clients.
- May feel overwhelmed with the ongoing nature of client need.
Health system:
- Is charged with the responsibility for addressing the knowledge/ service gap of concurrent disorder, while drawing from/ integrating existing programs.
- Must find ways to divert clients from relying on the hospital emergency room as an accessible vehicle for non-emergency care. The Toronto Street Health Report of 2007 showed that 27% of the homeless who were interviewed used the emergency room for primary health care, food and shelter.
- Must find ways to reliably transition clients out of the hospital to appropriate community services.