Heather is a social worker who is studying a new way to provide mental health and addiction services to youth. It involves help with the daily tasks that can seem overwhelming – and a lot of texting.
“Is it hard sometimes to connect with youth?”
“When they tell me that getting five texts a week is as a meaningful to them as having a one-hour, face-to-face visit per week, I think ‘Hmmm, that’s not how I experience the world!’”
When someone shares that they feel suicidal after seeing a Facebook post, that’s not my world. Someone saying that they are feeling unsafe or suicidal by text, that’s not my world either.
“But we need to reach people in their worlds. Now we are making youth go to an office where they may not feel safe. I was talking to a young person who said service providers have to figure out how to leverage technology better. She said that when she is at her computer, she feels in control and safe.”
“Our staff, on average, send out 2,500 texts to their clients each month. They are texting constantly. And our young people say over and over again that’s what they love about our service.”
“How do you maintain privacy and quality when interacting with patients through text?”
“We have put in as many mitigation strategies as we can. We have a policy that outlines that only our agency’s phones can be used for work-related texts. That means I can see the texts and audit them to make sure the responses from staff are appropriate. We talk with staff about the use of emoticons, which can easily be misinterpreted or might be too informal for the situation. If a phone is misplaced, we can shut down that phone remotely. The phones are password protected. Our staff members are only allowed to text during work hours; they shut off their phones at other times.”
If you’re going to text clients, you need to have some sort of 24/7 number that clients can call or text if they’re in crisis, and we have that.
“Our clients sign an agreement that says this is not private communication, and there are risks. We talk to our clients about how to mitigate the risks. We’ll say, for example, ‘What will happen if I text you, and your abusive partner sees the text?’ We explain, ‘If I don’t respond right away, it’s not that I don’t care about you; I may be with someone else who needs service.’ So we outline all that, and they sign on. It’s a big process for us.”
We have an amazing group of peer mentors. Young people say they want to talk to someone who’s been there; they want someone with lived experience.
“Clients are saying they want young people with lived experience with them in the emergency department. Young people who are on methadone themselves will accompany other young people to their methadone appointments. We have had really positive experiences with our peer support workers.”
“In social work school, I was always trained never to share anything about myself – to have strong boundaries around personal information and disclosure. Yet we hire peer mentors to do exactly the opposite, to open up and tell their stories. That can be a very hard thing to do so we want to make sure they have training and a lot of support themselves. A question for the leadership in many institutions is how you supervise this newer and very specific discipline. If someone’s a nurse, they need to be supervised by someone with that scope of practice. I think people need to be very careful to ensure that peer support workers are recognized for the discipline they have, and get supervised by someone who has that expertise.”
“Our agency is also involved in a randomized trial in 14- to 18-year-olds with mental health or substance use challenges. Several hospitals in Toronto are part of the project. If they participate in the study, kids who present to hospital who have mental health issues but aren’t in crisis will either receive treatment as usual in the hospital or be referred to receive treatment in the community. Over three years, we will be comparing the two approaches by looking at the severity of the clients’ symptoms, whether they have stayed in school, whether they have been able to keep their housing, and their relationship with their families. We’ll also be doing a cost-benefit analysis.”
“For the community-based intervention, we have pulled together something awesome that young people have said over and over that they want. We feel like we’ve made the Cadillac model. Initially, we will determine whether a couple of solution-focused counselling sessions is what clients need, or whether they need a more intensive service. Clients will be offered a care navigator who will take them to their first appointment if they want. They will get psychiatric care if required, access to a family health team and a nurse practitioner. They will have access to one social worker who will help them with everything. That’s because we’ve heard from young people that coordinating all the aspects of their care and their life tasks is really exhausting for them.”
“‘You need help going to school? You have challenges with anxiety? We will come and take you to school. You need to get income security, you need to get on Ontario Works? We will help you with that. You need ID? You need help with bed bugs in your home because it’s overwhelming?’ Our workers will do that.”
What’s so exciting to me is that this research project is investing in community capacity.
“That’s really amazing. I have not heard of that happening before.”
“Are you concerned that half the people you are randomizing aren’t going to get the Cadillac model?”
“No. I am pretty confident it’s going to work, but we don’t know. By doing this trial, we will really find out what the impact is. It feels unethical to do anything but evaluate the new program. In terms of treatment as usual, we know that young people are accessing treatment in the hospital, and the hospital provides some outpatient programs once patients leave. I know that those services are great quality and are all evidence based. So I don’t have an ethical problem.”
“I’d have an ethical problem with just setting something up and sending people to it, not knowing if it’s better than what we are already doing.”
“How has your involvement changed the design of the study?”
“One of the key things that people in the community track, which is different from those in the hospital, is functioning. We track whether our clients have stable, safe housing, their attendance at school, appointments made and how many were actually kept, mental health supports, whether there are primary care relationships in place. Hospitals tend to track severity of symptoms. They are both really important, and the study is going to track both. It’s important to track whether people are attaining the things that are important to them – in addition to their symptoms – because it encourages staff to help clients with their goals. So this study will be measuring success in a very comprehensive way. I think I had an influence on that.”