Invited Commentary: ACCESS Open Minds National Youth Council

As members of the ACCESS Open Minds National Youth Council, we are pleased to comment and summarize our reactions to site level transformations as described in this supplement. We express excitement at the change that the ACCESS Open Minds (ACCESS OM) network is making across Canada. Many members, however, still share some scepticism in regards to the healthcare system, based on their lived experiences with existing services: long wait times, bed shortages, burnt out clinicians, ageism and lack of flexibility or adaptability. The ACCESS OM objectives, as core components to service transformation towards better quality care to more youth in need, sooner, were based on needs expressed by youth themselves in addition to gaps identified by researchers, service providers and decision makers. Overall, the increase in youth seeking care as well as the statistics surrounding wait times and access to services are inspiring. ACCESS OM has brought a whole new level of care to a country that is in need of a youth mental healthcare transformation. Despite a central framework and a set of agreed-upon core objectives, each site can implement the five objectives detailed in the supplement in ways deemed appropriate by the community. Communities have considerable autonomy and agency over the transformation process. While accommodating diversity may create some difficulties for a research project, it also recognizes local knowledge. It is exciting to learn about this contextual expertise and how it can translate to individual sites. The efforts of the ACCESS OM network are inherently scalable in this respect—between the sites across the network, there is undoubtedly something that can be applied to another context. Sites serve unique communities varying from remote Northern communities to large urban sites. The youth population in many sites is large and is growing rapidly. The needs of the community also vary. This flux requires strong leadership and significant operational flexibility to achieve the objectives outlined by the ACCESS OM model. Youth workers must respond to youth in ways that are culturally safe, respecting and honouring their identity and their culture. Descriptions of youth-friendly clinical models illustrate the strategies that site teams have implemented to meet youth in environments that are conducive to therapeutic alliances. Council members view these strategies as innovations in youth mental health service delivery. Specific examples of innovation include Eskasoni First Nation's Fish Net model, the use of Facebook and texting services, the Réseau d'intervention de proximité auprès des jeunes de la rue (RIPAJ)'s “there is no wrong door” care pathway, mobile services, meeting youth in a location of their choice and the integration of mental health programming into other types of programming. These innovations improve services by rendering them more accessible, more approachable and less intimidating. Sites have adopted various strategies to involve youth in early identification activities and strategic planning: social media campaigns (news, radio, community agencies, local television, school presentations, hosting weekly “family nights”), peer navigators creating safe spaces for youth engagement in daily operations (steering committee, developing welcome videos, strategic planning, youth as peer advisors), designing physical space of the ACCESS OM site (including residential spaces, access to Wi-Fi, art materials, etc.), community mapping, inclusion of youth in hiring panels. Council members, however, remain critical of youth engagement strategies and question whether different communities are offering youth an authentic way to actively collaborate with service providers, researchers and decision makers. The creation of youth advisors and councils is paramount as they facilitate a structural relationship between care providers, service providers, administrators and youth. This may, however, be insufficient to achieve sustained, authentic youth engagement. All stakeholders must make significant efforts towards meaningful collaboration and not merely assign advisory roles to youth. While youth may need to be guided to become aware of their limitations, other stakeholders may miss the opportunity of gaining valuable insight through an enhanced agency of the youth. At the same time, structures may also need to be managed cautiously to avoid an unwieldy bureaucracy and to maintain empathetic human connections among all stakeholders. While the ACCESS OM Family and Carers Council has commented in greater detail, we are encouraged by examples of innovations such as, University of Alberta's work to integrate “chosen family” (roommates, coaches, friends, etc.) and the Acadian Peninsula's work to integrate family substitutes in healthcare planning. Prior to the initiation of ACCESS OM, there had been no mental health services specifically designated to this population of 11 to 25 year old. Various youth services are now working in collaboration with ACCESS OM to provide youth with the most adequate support and care possible. Drop in programming, walk-in appointments and single session interventions are seen as an innovative way to offer youth the care and support when they need it. This article provides in depth and insightful information about this large urban ACCESS OM site, including the challenges they faced and the positive outcomes of the ACCESS OM transformation. The steps that were taken prior to Edmonton officially joining the ACCESS OM network is an illustration of this community's investment in the lives of youth. Smart investments were made based on community mapping which identified the most significant gaps in youth mental healthcare. Changes to the clinical team are very detailed; however, more information is needed on how professionals work together to illustrate the community impact of these transformed services. Innovations include breaking the silo between mental health and addictions, implementing peer support in formal service delivery, visit codes and the creation of a youth council. We believe, the location of the AOM site within a YMCA is an excellent way of integrating formal mental health services with other less stigmatizing environments that also offer opportunities such as fitness. ACCESS OM seems to be a significant resource to this First Nation community given its large youth population and its history. The wide variety of services and programs offered to youth is impressive. Many communities can learn from Eskasoni's way of integrating mental health programming into cultural Mi'kmaq traditions. More information on suicide prevention and any service gaps would deepen our understanding of this community's reality. The outcomes of community mapping may lead to additional strategic partnerships for sustained funding, casting a larger “fish net.” We want to learn whether language barriers exist and how services were adapted for First Nation youth and their families. This article brought attention to the struggles of a minority culture/language group. It provides information on challenges and the impact ACCESS OM is having on youth in the community. Community mapping seemed to be a specific event with a small focus group, which may have limited outcomes. The early identification and youth engagement efforts to meet youth in local coffee shops are intriguing. We wonder how youth feel about completing an assessment in a public space. We would also like to emphasize the link between addictions and mental illness (eg, addictions can trigger or intensify mental health issues). Homelessness and mental health, two very stigmatizing concepts, are being addressed together and supports the most marginalized group of youth by offering multiple pathways to care (no wrong door/no bad timing). Youth want and need access to all services under one roof. Examples of how the media are being used effectively to promote help-seeking and a description of the types of family engagement training would have been helpful. The authors admitted to not being able to “reach all youth effectively”, which illustrates the site's profound commitment and ongoing effort to come to the assistance of all youth in need. The Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ+) specific themed meetings give youth the opportunity to discuss how mental health varies from group to group. This paper is an illustration of the adaptability of the ACCESS OM framework, though there is still much more that needs to be done to provide specialized services to youth in their local community. The article provides the historical context to understand the impact of residential schools and intergenerational trauma. It is alarming to learn that emergency services and crisis intervention resources are not readily available in the community. Stigma appears to be an influential deterrent to help seeking. Investments need to be made for suicide prevention and health prevention in general. If the Royal Canadian Mounted Police (RCMP) is seen as presumably trustworthy ally for youth, perhaps they can allocate time to prevention and outreach to begin to address stigma from multiple fronts. It is interesting to read about the lay health workers. More information is needed to learn about how peers can support one another in such a small community where identity and sense of self is linked to reconnecting with cultural practices and the land. A university is an important location for an ACCESS OM site; the transitions that university students encounter can have a massive impact on their mental health and emotional well-being. It is an age where many mental health conditions begin to emerge. The dedication to understand stressful lives of university students is evident through their accessible services and diverse clinical teams. Offering aid in redirecting students to other services in the community demonstrates a co-operative attitude for meeting students where they are at and supporting mental health needs in a safe environment however transitions and continuity of care between campus and community services remain a gap in service provision. More information is needed about the socio-economic status of students and their origins (eg, rural, international), which can impact student life on campus. We are optimistic that the innovations described by ACCESS OM sites will change the way young people feel about mental health services. These innovations are breaking many structural barriers and are better responding to the needs of young people. These changes have begun to make services more readily available to youth in need. While much work has been done to engage youth in site level transformation, the ACCESS OM network must further its efforts and partner with youth (defining it as “youth partnership”) rather than engaging youth (“youth engagement”). Youth voices should be emphasized in all areas of ACCESS OM work and documentation: youth are not simply research subjects but partners. As such, the perceived barriers of working collaboratively with youth need to be understood and addressed. Young people want to change mental health services. ACCESS OM is facilitating the process by beginning to offer meaningful opportunities for youth to shape service planning, delivery and evaluation. These efforts will build a better system. ACCESS Open Minds is a Strategy for Patient Oriente Research (SPOR) network funded by the Canadian Institutes of Health Research and the Graham Boeckh Foundation.

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