FROM OCTOBER 2022 ISSUE OF WEST END PHOENIX

On one of the hottest days of the summer, Becca Lemire and I meet for the first time at the western entrance of High Park. It’s a muggy Monday just after the rain and the park is fairly empty, the sounds of traffic filtering through the trees. When I spot Becca, she gives me a smile that’s warm and relaxed, and asks if I’d like to sit on the grass somewhere under the shade. She’s brought a picnic blanket.

We choose a secluded spot, and she unfolds the blanket and takes off her shoes. “Do you mind if I just lie down for a second? I feel like it helps me collect my thoughts if I’m just lying here like this,” Becca says. I follow her lead. Her eyes are closed, her hands resting softly on her belly, and she takes a few breaths.

“This is the first time I’m really talking publicly about any of this,” she says. “I’ve never talked about hospitalizations or how I felt for years. I didn’t have a normal, typical experience.”

Almost two decades ago, when she was in Grade 9, Becca experienced traumatic events that she believes precipitated a mental health decline. Although she is not ready to talk about what happened, she says that because of this experience, her school marks slid, as did her sense of self. This is also when she began to smoke weed heavily.

Becca’s parents worried about her cannabis use and – encouraged by her doctor and educators – removed her from high school in Grade 10 and put her in an outpatient substance abuse program for youth at SickKids. Becca gives a wry laugh. “I was just smoking weed with my friends, but my parents grew up in the 1960s when weed was the devil.”

While Becca was in that program, her doctors and psychiatrists diagnosed her with a variety of disorders, ranging from depression and anxiety to PTSD and ADHD. “At an early age, I was put on a constant merry-go-round of different medications,” she says. Her memories of many of the details have been smoothed over by time, but she does remember that the teachers who came into the hospital to deliver her high school education would often tell her that the program wasn’t the right place for her. She was inclined to agree, but she didn’t know where else to go. “A lot of [the other kids] had been in juvenile incarceration, they had criminal records, they were selling drugs. They were doing hard-core drugs like heroin. They needed this type of program.”

She sighs and shakes her head. “Then there was me.”

Still, Becca’s mental health was in crisis, and in that respect, she’s not alone. According to the Centre for Addiction and Mental Health (CAMH), 39 per cent of Ontario high school students say they experience moderate to serious levels of psychological distress, including symptoms like depression and anxiety. An additional 17 per cent of students indicate serious psychological stress. In 2020, nearly a quarter of hospitalizations for children and youth were for mental health conditions.

The impact of that distress and those hospitalizations can linger long after discharge. It’s hard to cobble together a conventional education when your high school experience is so interrupted. It can be harder still to build a strong sense of self-confidence or self-worth. “Looking back, it’s like maybe [all of] this gave me the message that something was wrong with me,” Becca says. “Where do you go from there? [Hospitalizations] didn’t help me complete high school.” As she puts it, they derailed her.

When young children are surrounded by consistently supportive environments, they establish a positive (maybe even grandiose) self-concept, the term psychologists use to encompass that sense of self. A healthy self-concept – reflected in beliefs like “I am talented” or “I am a good person” – provides the foundation for a child to feel confident, competent and strong. Inevitably, as children mature into their early teens, their self-concept begins to even out and often takes a hit: Puberty, peer comparison and social media can all take a toll on self-esteem. Ideally, as those adolescent years fade into the background, their self-concept rebounds into a view that’s both realistic and healthy.

But for youth like Becca who have spent time in psychiatric hospitals, whether inpatient or outpatient, those teenage challenges are compounded by feelings of otherness and brokenness. Being removed from their peers makes it difficult for youth to form strong connections and develop an individual identity. Their beliefs can form instead around statements like “I’m not normal” or “I don’t belong.” And their self-concept is put at critical risk.

Dr. Mark Ferro is the Canada Research Chair in Youth Mental Health and a researcher at the University of Waterloo. In his work he looks closely at self-concept, particularly for those who have spent time in hospital settings. In a soon-to-be-published study, he and his team found that youth who have been hospitalized for mental health reasons have some of the lowest self-concepts among their peer group. This self-concept is worse still for youth who have been hospitalized for both physical and mental disabilities.

Many youth with mental health conditions already struggle to make sense of a highly contextualized and nuanced world. As youth enter their teenage years – a crucial time for connection and friendships – social cues and norms become far more complex and can be difficult to navigate. For teens with mental health conditions like depression or anxiety, their perceptions can be quite distorted, which affects their ability to construct a healthier view of both themselves and the world.

The additional layer of hospitalizations amplifies that harm. Youth who have been hospitalized for mental health conditions are often victims of peer exclusion and isolation. For many youth, being in hospital isn’t just a one-time occurrence, which compounds isolation. Despite growing public dialogue around mental health, with organizations like Canada’s Jack.org giving the mic directly to youth, and figures like Olympian Simone Biles speaking openly about her own struggles, stigma remains. According to StatCan, more than 40 per cent of students with a disability experienced bullying at school because of their condition in 2019. For those with a more severe disability – which includes both physical disability and mental illness – this rate increases to more than 60 per cent. “Children who have mental illnesses often have poorer outcomes over time, whether they are educational, social or employment-related,” Ferro says. If not addressed, this spillover effect can last years.

Sometimes, it can last a lifetime.

Toward the end of Grade 10, Becca left the program at SickKids. After her discharge, she struggled to integrate into life outside the hospital and was eventually admitted to CAMH, where she took her Grade 11 classes. Being at CAMH became her “comfort zone,” she says. She didn’t feel like she was meant to be part of normal society, because as she saw it, being in hospitals reinforced the idea that she wasn’t normal.

Throughout Becca’s hospitalizations, her education was delivered at a slower pace, meaning that no matter how capable she was, she knew she wouldn’t graduate with classmates her age. After she was released from CAMH, she finished high school at City School Alternative High School and Parkdale Collegiate, earning her diploma at nearly 20. She didn’t bother to go to the ceremony, and she hasn’t kept track of where her diploma is. It’s too much of a reminder of what she feels was taken from her.

For students who have spent time in psychiatric hospitals, putting together a university application can be nearly impossible. While admission requirements vary between post-secondary schools, competition is only getting stiffer given the ballooning student population. The University of Toronto is one of Canada’s most competitive schools, and the average admission GPA can sit around 3.7 – that’s a 90 to 92 per cent high school average. On top of that, students need to show robust extracurriculars and have strong references. That’s challenging enough for students who are mentally healthy with solid support, but it’s difficult for students like Becca, who often haven’t had the opportunity to build the relationships that lead to enthusiastic references or devote time to extracurricular activities.

Plus, without the right support systems in place, students who have spent time in psychiatric facilities can’t reclaim the sort of self-concept that helps pave the way to post-secondary education. I ask Becca if she’d ever wanted to go to university or college. “That wasn’t even a possibility,” she says. “It just wasn’t in the cards for me.”

Students with mental illness who do manage to get to post-secondary school face further barriers, including policies that are stigmatizing rather than supportive. University is already high-pressure, and becoming increasingly so. A 2019 survey of 55,000 post-secondary students across Canada found that 68.8 per cent of students had felt “overwhelming anxiety” in the past year, while 51.6 per cent felt depression so severe it was difficult to function. Post-secondary students must balance academic stress with financial insecurity, unaffordable housing, increasingly competitive graduate school admissions, and an uncertain future. In the midst of all that, how are students with a history of psychiatric hospitalizations expected to cope?

“Most universities are ill-equipped to give full support to their students,” says Austin Hurley, vice-president of external affairs at Brock University Students’ Union and a board member at the Ontario Undergraduate Student Alliance (OUSA). “[They] don’t have comprehensive supports with culturally relevant practitioners. Just a lot of generalists.”

Hurley, who has ADHD, says he personally struggled during the winter term of 2020 and throughout COVID lockdowns. Remote learning isolated him from his friends and communities, and symptoms of his ADHD worsened. Hurley says that finding his way through the system was challenging. “Someone who is in a crisis is most likely not going to spend the time to figure out what [resources are available],” he says. “If you have to go through layers on layers of [websites] to figure it out, you’re not going to do it.”

There are programs and policies at universities that, on the surface, appear to help students with mental health challenges. The Campus Assessment, Response & Education (CARE) Program at Brock University, for example, says it will “connect the students with the appropriate service(s) that will address each unique situation and provide the student with support to enable a healthy and successful future.”

But this program, Hurley says, “isn’t necessarily [designed] for student reintegration after hospitalization, but for more general crises.” And CARE defines that crisis as one where the student is “a threat to her/himself, others, the educational process or the Brock community in general.”

This rigid approach – which conflates a mental health crisis with a kind of menace – is also reflected in U of T’s controversial University Mandated Leave of Absence Policy (UMLAP). First drafted in 2018, UMLAP gives the university broad power to remove a student if they display harm to themselves or others, among other risk factors. Almost immediately, the Ontario Human Rights Commission (OHRC) expressed concern about the policy, stating that it potentially violated students’ human rights. At the time, the OHRC raised the issue that UMLAP allowed the university to put a student on leave and “withdraw essential services [housing, health and counselling services] at a time when the student is in crisis and most in need of support.” In an open letter dated Nov. 8, 2021, the OHRC expressed continued concern over the policy.

Withdrawing essential services from students in crisis heightens damage to their mental health. Then, of course, there’s the hidden cost of this policy: that students in need won’t risk seeking help.

Rather than penning policies that stigmatize students with mental illness, it’s crucial to introduce structured support before a mental health crisis hits, Ferro says.

Mental health first-aid training for both students and faculty is a good place to start. Even in the absence of a mental health crisis, these programs can inform individuals in the post-secondary community about the challenges that students with mental illness face. They also shed light on compounding factors that contribute to mental health decline, such as previous hospitalizations.

Dr. Ferro suggests that treatments like cognitive behavioural therapy can help reframe a student’s perception of themselves and their situation, but stresses the key is giving them access to such treatment right away. Given the high risk of hospital readmission for youth with mental health challenges, removing wait times at student mental health clinics is a start – something the University of Toronto is now attempting to do.

Access to temporary housing in emergencies can also help mitigate financial stressors, and safe and consistent reintegration back into student life for those who have been hospitalized can help students settle into normalcy. That’s where peer support might be able to fill the gaps, helping to remove isolation and stigma, and build a sense of community around the student in need.

A new Health Canada initiative called Campus Peer Support is providing $2 million to improve mental health care on campus. This initiative, which is already rolling out in some universities, will fund training programs and engage students with lived experience of mental health challenges to help peers navigate their own struggles. Of course, the program raises some important questions: What sort of meaningful support can those students with lived experience access first? And how many of them will this initiative be able to count on when there are so many barriers to care in the first place? Furthermore, peer support programs draw attention away from the larger issue: It’s the institutional and educational systems that need to change.

There have been scant few studies investigating the post-secondary challenges faced by students who have been previously hospitalized. We do know from studies on remote education during the pandemic that the loss of in-person schooling has had a considerable negative effect on the student population at large. According to a 2021 CAMH study, there is a strong association between time spent online learning and depression and anxiety in school-age children, and the more time students spent learning outside the classroom, the more they experienced symptoms of anxiety and depression.

It’s reasonable to assume that youth who already struggle with mental illness and the low self-concept that accompanies hospitalizations would face more hurdles than their peers. But unless and until these studies are done, making assumptions is all we can do.

A few weeks after I first meet Becca, she invites me to her home, a place where she has started a career as a Registered Massage Therapist (RMT). There’s a riot of green foliage from all the potted plants in her kitchen’s large bay window. A massage table is laid out in the centre of a cozy room at the front of her home. The walls are white; there’s more greenery from her plant collection. I can smell lavender.

Becca brings me into the kitchen, where she makes a breakfast smoothie. She explains that she’s always been drawn to yoga and meditation as a way of keeping her mind still and remaining conscious of her body. After a trip to Costa Rica where Becca became a yoga instructor, she knew she wanted to work in this space. Massage was a natural extension and in late 2019, she decided to make that passion her career.

Becca enrolled in the RMT program at Kikkawa College, in Toronto’s West End. In the midst of her application process, she discovered that there were special OSAP grants called the Bursary for Students with Disabilities (BSWD). These bursaries would not only help with the cost of her education, but would help pay for therapy. “I never even thought I could get something like that,” she says. “Having that support is huge.” Becca’s total investment in RMT school was around $25,000, almost all of which OSAP covered, and the bursary, which can be put toward services such as tutors, technical aids and counselling, doesn’t need to be repaid. It can’t completely defray the skyrocketing costs of living in a city like Toronto. But it’s a start.

Becca knows that schools could and should find more ways to support students who struggled like she did years ago. In the meantime, she’s trying to do her part. “I’ve treated youth [with massage], which has been so rewarding. I can tell they’re really struggling. They’re sensitive. They’re different,” she says. “I’m trying to [address that] more in my practice, because then I’m [helping to create] the space and the safety that I didn’t have.”

Youth are resilient. But being separated from their peers and from a sense of normalcy at an early age – and landing in an institution that is systemically viewed with stigma and from which they can struggle to reintegrate – is a tough hurdle to clear. Unless they can count on continuity in support, including tutors, therapists and a positive school experience, these youth are bound to struggle. As they grow into their adult years, looking for employment, housing and community, they might not always have a place where they can feel like themselves. But thankfully, surrounded by plants and the light from a lovely bay window, Becca has found hers.

This is the first instalment in When We Return, a series that explores the varied experiences of mental health patients after discharge from the hospital.

This series is supported by the Joe Burke Fund for Social Justice Reporting, which was created in memory of Joe Burke, the late social justice advocate and lawyer.