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Steve Mathias used to throw up every morning before school. His anxiety levels were so off the charts, he couldn’t even manage phys. ed. When he went on to medical school he fell into a mild depression, and the doctor he visited just prescribed pills — not really what he needed. So these days, when yet another kid in her teens or 20s shows up at his door, another kid on the verge of being pulled under by the riptides of young adulthood, on the verge of shutting down, of giving up, he gets what she’s going through. Intimately.
There’s a great deal of anxiety in my family, a lot of anxiety around performance and not making mistakes,” says Mathias, the child of a military family whose father went on to work for the United Nations in Haiti. “It’s the same thing so many kids express to me.”
Life is very different these days for the psychiatrist and UBC assistant professor. Father to three kids under eight, with deep-set eyes and a shock of grey hair over his boyish face, he’s built an unexpectedly tranquil space for himself above the emergency entrance to St. Paul’s Hospital. One wall is covered with the ubiquitous IKEA poster of an orange bike in Amsterdam. A plastic bag of carrots and a Thermos await afternoon snack time. The bookshelf displays a copy of the positive-thinking compendium If Only I’d Said That by BC Business publisher Peter Legge.Things seem less certain, though, for tens of thousands in B.C. doing battle with all the demons of anxiety (and worse) that erupt so often in youth — everything from drug use to schizophrenia to unshakable thoughts of suicide. Despite the impression many have that we are raising a generation of extraordinarily coddled and hovered-over children, the evidence suggests the opposite.An interim report on youth mental health, delivered to the provincial government in November, disclosed discouraging numbers. Based on surveys from other countries, “As many as 12.6% of children and youth aged 4-17 years — or nearly 84,000 in British Columbia — are likely experiencing clinically significant mental disorders at any given time,” began the submission from Charlotte Waddell, who holds the Canada Research Chair for children’s health policy at SFU. “These surveys also reveal stark service shortfalls in that under one third of young people with disorders — just 31% or 26,000 in BC — are estimated to be receiving specialized mental health services.” Those numbers don’t even include those aged 18 to 24, considered by many in the mental-health world to be basically still kids in need of support. Mathias says that in 2012 172,000 people under the age of 24 visited doctors, showed up in ERs, or filled prescriptions for mental-health problems in B.C. He estimates at least as many have problems but don’t get help. Just at St. Paul’s, 1,500 young people come into emergency with mental-health or addictions concerns each year. Those concerns are the biggest health issue young people have, the heart disease and cancer of their demographic. Hence one of Mathias’s mantras: “If you’re going to have a mental illness, 75 percent of the time symptoms occur before 25.”Many kids make it through with the help of family and friends who stick by them, fight for them, and push them into treatment. There are many, though, who don’t have that, whose families are as troubled as they are, who come from foster care or get kicked out or have to leave because it’s all too unbearable. For them there’s no one to push to get an appointment with a doctor or make sure they have a place to eat and sleep or help them track down and apply for a specialized treatment program. For them it’s free fall.Steve Mathias has a vision. It’s a big, bold one: dozens of clinics around the province; one-stop shops dedicated to teens and 20-somethings enhanced with all-out social media and internet entry points; apps that provide online coaching in mindfulness and controlling anxiety; video conferencing; easy-to-do cognitive-behaviour therapies. All in a kind of franchise operation of community mental health that will make it easy, even fun, to access.
We’ve designed a system now that waits for young people to have a severe problem before they can get help,” says Mathias, in the steady, even tone he uses even when he’s making his strongest sales pitch for change. “It’s as if we told people with cancer that we would only treat them when they’re at Stage 4. And the fact that we’re not treating them now means that 20 years from now, we’ll still be having the same conversation about all these people, now living in the Downtown Eastside.”
His ambition seems mildly delusional, considering that mental-health services for young people now float unanchored between three massive, drifting bureaucracies: the health-care empire, the ministry of children and families, and the school system. Inside each are multiple actors: teachers and administrators, public-health nurses, emergency room and family doctors, private psychiatrists, addiction counsellors, mental-health counsellors, foster-care workers. Then there’s the reality that Vancouver Coastal Health just closed its one clinic dedicated to youth, the Pine Free Clinic in Kitsilano. And, of course, health-care budgets, already the largest share of public expenditure, are perpetually overstretched.What hope does Mathias have? People around him say that if anyone can alter the direction of this particularTitanic, it’s him. “He has been a very ambitious man on behalf of young people,” says Krista Thompson, Vancouver director of Covenant House, the agency that has been central in working with homeless kids. “He is a natural marketer. He has a way of producing natural sound bites.”Mining company Silver Wheaton Corp. was sufficiently impressed that it donated $1.6 million in 2012 to fund services for his mental-health program for inner-city youth, which will run until April 2016.
What we liked was the approach,” says Silver Wheaton CEO Randy Smallwood. “Steve had some pretty good numbers to back him up.”
Smallwood says that he has a personal interest in helping improve mental-health services for young people, and his company has publicly set out that area as one it wants to support. He worried about the overlap of similar services in the DTES, but Mathias demonstrated that what he was doing was unique and that it dovetailed with others’ work there. “He’s a bit more of a collaborator,” says Smallwood. (The company is “definitely considering continuing our support,” he says.) The health ministry came onboard later with additional funding of $750,000 a year.But there are also hints — from Thompson, from others, from Mathias himself — that pushing for change, no matter how noble the cause, has set off a tussle inside the complex medical-social-service system that surrounds young people. “Sometimes he rubs people the wrong way,” says Thompson. Others murmur that he’s been lucky, crusading at a time when the political will is there to support his campaign for a different model of services. Thompson’s colleague at Covenant House, program-services director John Harvey, puts it more bluntly. “There is no new money, so how are we going to pay for this? As Steve started to be successful, more resources were being applied to his program. Someone in the system lost out.”Changing the system seemed just as hopeless in 2006. Back then, kids who were on the street, or about to be, would cross paths with the medical system in some way. They’d show up in an emergency room or at a clinic talking about a different problem — inability to sleep, weight loss, a drug habit, drinking — and someone would recommend they see a psychiatrist or some other mental-health service. That person would make an appointment, and four times out of five the kid wouldn’t show. “It was a revolving door in the emergency room,” says Thompson.At St. Paul’s a cluster of psychiatrists decided to try something different. Chief among them were Bill MacEwan, Megan Sherwood, and Mathias, the young doctor who had just come back from a fellowship in Melbourne where the national government had created a comprehensive system for treating young people with psychiatric problems.All three noticed the obvious problems with the homeless they were seeing at Covenant House down on Drake: the kids didn’t even bother trying to get help; they’d get appointments to see specialists, then not show up; they’d keep the appointments but refuse to take the pills prescribed. Mathias had been one of several medical students who started a clinic in 1999 in the Downtown Eastside, where they saw that forming a real bond with the people they were trying to help (not just treating them like patients) made a difference. Could the same approach succeed with youth in peril?“They had this idea that they would move closer to the kids,” says Thompson. The trio started hanging out at Covenant House, meeting kids there, covering the costs of their work through sessional billings that hacked the unbreachable limitations of the Medical Services Plan. The kids responded. The rate of kept appointments climbed from 20 percent to 80. Covenant and the doctors started wondering how to go beyond just their own drop-in efforts. Sherwood and MacEwan moved on (Sherwood to adult psychiatry at VGH; MacEwan to run psychiatry at St. Paul’s), but Mathias stayed put. “Bill was the mentor, but Steve really picked up the ball and ran with it. He was the driving force,” says Harvey.From those on-site meetings at Covenant House, Mathias created the Inner City Youth Mental Health Program, now with a team that includes seven psychiatrists, two social workers, an occupational therapist, and a psychiatric nurse. That team serves about 160 kids at six sites — the new Kettle Friendship Society social-housing building on Burrard and the new Renfrew House project in East Vancouver among them — as well as at services run by Atira, Raincity, Coast Mental Health, and Covenant House. The doctors run group sessions, meet one-on-one, and carve out time just to play with their clients. One doctor has pickup basketball sessions. Mathias goes out snowboarding with them when he can.The time has come for the next step, Mathias believes — the first in his plan for a provincial network, a brand for youth mental health. This month, a storefront on Granville Street becomes that one-stop shop he’s been talking about, a place (not yet named) where teens and young adults can come for basic physical health, for help with addictions, for mental-health treatment, for whatever they need. Just above the clinic, which is a couple blocks north of the bridge, the Career Zone already runs services aimed to help young adults access education and training.Mathias figures that the new storefront will end up serving about 1,600 young people a year, a number that he admits scares people in other parts of the mental-health network who fear he is opening the floodgates to a demand for services there’s no way to meet. So part of his work now involves just trying to calm everyone down. “We can’t be scared as a system that if we brand health services for young people we’ll be overrun. That fear is standing in the way of a couple hundred thousand people in this province getting help.”He also gets resistance from those who think this new system is going to mean giving every teenager in the province a mental-health diagnosis, pathologizing every one of them into becoming a client. He counters that the problem isn’t getting too many kids into treatment; it’s helping too few. “Men in North America are especially reluctant to get help, and it impacts productivity for our young men.”For the next decade, Mathias is going to be out making these arguments over and over. They’re going to be hard for some to accept — especially the idea that there’s enough money to do everything he believes should be done. (Mathias also thinks the province should pay young people minimum-wage salaries to finish school.) There will be those who fight against his ambitious plans and those who encourage them. John Harvey, who has spent hours hashing out Mathias’s ideas with him, says, in the end: “I trust his ambition. I trust what he’s trying to do.”For his part, Mathias insists the money is there. All he’s asking for is $100 million for child and youth mental health, almost a rounding error in the province’s health-care budget of $17 billion (and rising). It makes more sense, he argues, to spend the money early than to wait until the problems become far more entrenched. As people get older and they’ve been addicted or struggling unsuccessfully with building a life for themselves for more than a decade, “their belief in what’s possible is really diminished,” he says. He points instead to the resilience of youth. “There’s a lot more hope. They themselves still have hope for their future.”