Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 16 - Evidence - June 1, 2005 - Morning Meeting
WINNIPEG, Wednesday, June 1, 2005
The Standing Senate Committee on Social Affairs, Science and Technology, met this day at 9:00 a.m. to examine issues concerning mental health and mental illness.
Senator Michael Kirby (Chairman) in the chair.
[English]
The Chairman: Honourable senators, our first two witnesses this morning are Donna Huffman, a policy analyst in the area of mental health, and Margaret Synyshyn, Program Director for the Mental Health Services for Children, Youth and Families. Thank you both for coming.
Ms. Margaret Synyshyn, Program Director, Mental Health Services for Children, Youth and Families: Good morning and welcome to Winnipeg. I would like to thank the Senate committee for the opportunity to do a short presentation on child and adolescent mental health. I had the pleasure of meeting some of you two years ago to discuss mental health primary care in the profession of psychiatric nursing. I am happy to be making a return visit to discuss another topic that is really close to my heart.
I am speaking to you today as a mental health professional who has been involved in child and adolescent mental health service delivery for the last 20 years, both as a clinician and an administrator. For the last five years I have been program director for the Winnipeg Regional Health Authority, Child and Adolescent Mental Health Program. My position encompasses responsibility for service delivery for both hospital and community based mental health services for kids, adolescents, and their families in the Winnipeg region.
In preparation for the presentation, I reviewed the questions posed about child and adolescent mental health in Report 3 of the interim report that had been sent out earlier. A number of the questions posed pointed out the complexity of dealing with children, adolescents and their families in relation to the issue of mental health. Children, adolescents and their families bring with them a host of systems that interact with them and with each other — educational systems, social service systems, justice systems, and health care service providers — and we all bring different conceptualizations, frameworks and language to the table when working with children, adolescents and their families.
All of these areas that I just mentioned need to be discussed, interpreted and really we do need to do interpretation because we do have language issues around these things, and we all need to understand them so that everyone involved has some common understanding of the issues. This must be accomplished while keeping the most important partnership — the child, adolescent and the family — at the centre of all of the planning and intervention that happens.
In my experience, attempts at integration of the systems that I just mentioned that interact with children and their families has proven to be very challenging and are no guarantee of a cohesive and efficient system. Where our program, the Child and Adolescent Mental Health Program within the Winnipeg Regional Health Authority, has had the most success is in partnering with other systems and service providers, usually around a specific issue, group or population. Leadership is dependent on the circumstances and can be shared based on the goals negotiated and set by the partners, which includes the child, the adolescent and their family. The most successful interventions, that is, those whose positive impact can be measured over time, are those that use a client-centred approach that integrate the determinants of health and can be delivered using a population health framework.
To ensure good mental health, a child must be attached to their caregivers, feel safe, have the necessities of life and be afforded equal opportunities to learn, grow, and have positive experiences. This is not a new concept, nor is it one that the committee has not heard before. The National Research Council and the Institute of Medicine in the publication "From Neurons to Neighbourhoods: The Science Of Early Childhood Development," makes the statement that what happens during the first months and years of life matters a lot, not because this period of development provides an indelible blueprint for adult well-being but because it sets either a sturdy or fragile stage for what follows.
We know that all children bring with them their own biological and genetic makeup, which may either be protective or make them vulnerable to the other determinants of health. It makes so much sense, from a number of perspectives, to support those who have the strengths or resiliency to grow and maximize their potential, but it makes even more sense to ensure that those who have vulnerabilities and less resiliency are especially supported to meet their potential.
"The National Longitudinal Study, 1998/99," makes the point that although the largest proportion of vulnerable children come from low income families, the largest number of vulnerable children are from middle to high income families. Programming, therefore, needs to be inclusive of all socio-economic groups, not only targeting the lowest income group.
As a society, we miss many opportunities to invest in the young, as this group is not necessarily seen as a priority, despite the research. Even though we know that the brain is the most malleable in the early years, the majority of our spending in health, education and welfare is minimal at that time when it would have had the most impact, and is focused on adulthood and seniors, based on the data from Bruce Perry, author of "How Nature Becomes Nurture."
Although regionalized in the area of health, including child and adolescent mental health, Manitoba has established Healthy Child Manitoba, a committee of Cabinet which includes the Ministers of Health, Healthy Living, Family Services and Housing, Justice, Tourism, Aboriginal and Northern Affairs and Status of Women. Healthy Child Manitoba has supported a number of initiatives province-wide that can lead to the improved mental health of children in the province. Healthy Child Manitoba has been instrumental in province-wide initiatives that include Parent-Child Centred Approach, FAS strategy, Healthy Baby, Family First, Triple P — Positive Parenting Program, Healthy Schools, and the Healthy Adolescent Development Strategy.
Healthy Child Manitoba has formed partnerships with regional health authorities, schools, daycares and other service providers to deliver population based programs that benefit all children and families. Healthy Child Manitoba advocates for the adoption of a comprehensive early childhood development system, which is publicly funded, evidence-based, multilevel, universal, targeted and clinical. Such a system would reduce risk factors for early childhood development, promote protective factors for early childhood development and measure and monitor activities, determinants and outcomes.
I have provided the committee with information from a presentation made by Healthy Child Manitoba to the Winnipeg Regional Health Authority Children's Population Health Planning Group, that illustrates the return on investment when early childhood development programs are implemented. Within the Winnipeg Regional Health Authority, The Child and Adolescent Mental Health Program has undertaken a number of initiatives that support children and adolescents and their families in accessing mental health services in Winnipeg. In the region we have been fortunate to have child and adolescent mental health differentiated from the larger adult mental health system. Although we continue to struggle with inequity in terms of funding, priority, and overall planning, the fact that child and adolescent mental health is a separate program speaks to the commitment of the region and its senior management to the area of child and adolescent mental health.
Since being established in January of 2000, the WRHA Child and Adolescent Mental Health Program has been focusing on increasing community-based mental health services through the reallocation of funds from some hospital-based services, evaluating existing programs and integrating the region's child and adolescent mental health service providers. The program has been successful in developing some specialty services such as neuro-developmental services and an anxiety disorder service, as well as increasing the number and scope of partnerships with the Departments of Family Services, and Housing, Education and Justice, as well as non-profit and advocacy groups. The program has participated in the implementation of the co-occurring disorders initiative, a model that integrates mental health and addictions services, and will be a participant in Healthy Child Manitoba, Triple P — Positive Parenting Program. I provided the committee with information regarding the Triple P — Positive Parenting Program, a population and evidence-based parenting training program that has been utilized in many countries across the world with positive longitudinal outcomes.
The centerpiece of the Winnipeg Regional Health Authority's Child and Adolescent Mental Health Program has been the development of a centralized intake service for the Winnipeg region. Starting in 2002, clients and their families, physicians, and other service providers in Winnipeg can call one phone number and access mental health services. The individuals who respond to the calls are mental health clinicians, a multi-disciplinary group of professionals, registered psychiatric nurses, registered nurses and social workers who can provide direct service at the point of contact, refer to other services in the region, both hospital and community based, or redirect to other service providers.
The centralized intake service acts as a gatekeeper for the system, and has moved the point of entry into the system away from the emergency department and physicians. I did not put that in my brief, but that is part of it, too, I think the gatekeeping function has moved away from physicians. Parents and other referral sources no longer have to contact numerous service providers for information regarding how or where to access mental health services, nor do they have to put their child or client on a number of wait-lists, hoping that they picked the right one.
Centralized intake provides a monitoring function for wait-list management and can facilitate services throughout the child and adolescent mental health system. A region-wide database is also maintained through centralized intake, which has proven to be very helpful in tracking clients and services, maintaining consistency of service provider, and for statistical data retrieval. Centralized intake has been involved with the Western Canadian Wait-List Project over the last two years as a test site for a wait-list management tool.
I have supplied the Senate committee with additional information regarding the WRHA Child and Mental Health Program, its organizational structure and services. I would like to acknowledge Healthy Child Manitoba for allowing me to incorporate their presentation material into this presentation.
I would like to thank the Senate committee for inviting me to appear and discuss this subject with you. It has been my pleasure.
The Chairman: Thank you very much, and we will have a lot of questions when we get to them.
Ms. Huffman, please proceed.
Ms. Donna Huffman, Policy Analyst, as an individual: Mr. Chairman, I should first state that I am here as a family member, as a client of services, as opposed to being part of the Women's Directorate for the Manitoba government. I do work there and enjoy it greatly, but my experiences have been entirely personal with this issue.
Thank you very much for letting me speak today. I represent a family struggling to find the help that our child needs to lead some semblance of a normal life. Our son, Alexander, was born in 1993. When we first had him, he was our first child so we did not really realize that there were differences, noticeable differences, until we came into contact with other families with children of the same age. After a difficult first year, the terrible 2s came, and never ended. The tantrums of screaming would last three to four hours at a time, often because I had given him juice in the wrong coloured cup, or because there was a smell in the room that he could not tolerate. Every time I took him to the doctor, I was told that I was simply a nervous mom, patted on the head and told to stop worrying. Perhaps if I had known more about development delays, I would have insisted on an early screening. Also, had we been able to access that type of early screening, then maybe early treatment would have considerably helped his condition at the time.
By the time Alex was three, four, five years old, he was physically attacking us; he was attacking other children; he required constant vigilance. He could not be left alone, even sitting beside other people, because he would for no reason inexplicably attack them.
At that time, we were living up north, in the Northwest Territories, in a very small community with limited access to services. We moved south to look for some treatment for our son. We moved to Fort St. John and there we were very fortunate to find a child development centre which was supported by the B.C. government, Health and Social Services at the time. I am not familiar with what the service is now. The child development centre provided services for families who had children with disabilities of various kinds. They offered a pre-school in which half of the children were special needs and half of the children were regular children. They immediately took Alex into the program. We had immediate access to respite care, which was amazing. My husband and I had not been out together since our son had been born. Thus by the time he was four or five years old, it was a real treat to be able to go out together.
The centre also offered access to a child psychologist, to screening. They provided just all sorts of support to the family. What I think we appreciated most was the sympathy and empathy. They saw what we were dealing with, they recognized our problems and they were able to help us with our situation. We were able to access more help in the six months that we were there than we had been able to access in the four years prior to that.
When we were given a permanent posting, we went back up to the Northwest Territories, to Yellowknife. We had hoped that, being in a capital city, we would have access to more services that way. Unfortunately, they do not have any services for children with developmental delays. The schools are ill-prepared to handle these children, despite the fact that there are a number of children with various delays up in the Northwest Territories, and I think statistically more than anywhere else.
In school, Alex was denied all kinds of supports. They believed in a blanket inclusive schooling policy, so our child was denied any kind of extra help at all. He was in a classroom with 30 other children. He was physically attacking other children, swearing, having numerous temper tantrums, hiding under desks, because he simply could not handle 30 other children in a room.
Unfortunately, the school decided this must be an example of poor parenting on our part, or of abuse or neglect on our part. We have the distinction of having a number of letters from the GNWT Social Services saying that we are not abusive parents. Social workers would come to visit us quite frequently, and one of the things that they told us was that, as a possibility, since we could not get any services in our own home if our child lived with us, the only other option was to put Alex under a voluntary support agreement in foster care. That idea was the most horrible thing I had ever heard, and being between a rock and a hard place, we obviously said no.
We struggled on for a couple of more years and finally got access to a visiting child psychiatrist, who put our son on very strong antipsychotic medication called risperidone, which pretty much saved our family. Once he was on that medication, it was not a cure but it definitely lessened the attacks, it lessened the tantrums, and we were able to go on. The school, unfortunately, was still sending him home frequently, suspending him, and still refusing to offer any support.
Finally, last year, he became extremely ill, physically ill, but because of his numerous other problems we could not convince anyone that there was an actual, physical illness there. They blamed it entirely on either the psychiatric illness or on the drugs that we were giving him. We therefore made the heart-breaking decision to leave Yellowknife.
Yellowknife was our home. We left our family, we left our friends, we left our home that we had just finished renovating. Both my husband and I had very good careers up there. My husband took a demotion with his company so that he could be transferred to a city that had a children's hospital. That is how we ended up here, in Winnipeg. Upon arriving, the family doctor that we got immediately noticed that Alex was suffering from chronic renal failure. His kidneys were failing, and that is why he was having such significant physical problems over the past year. The stark difference in the way we were treated with his physical illness and the way we had been treated over the past years with the psychiatric illness was amazing. With his renal failure, we had immediate access. The next day, we had access to the pediatrician. The day following, we were in the pediatric nephrology unit at the children's hospital. We had a pediatric urologist, we had a renal dietician, we had a renal social worker, we had nurses teaching us how to give him injections of the medications that he needed, and how to do his catheterizations, which he now has to do for the rest of his life. We were at the point where we were actually saying, "Okay, that is enough, we do not want to see any more doctors." Juxtaposing that with the struggle that we had had to get adequate care, medical care for his psychiatric illness, was a real eye opener.
We arrived here, and certainly there are more services here than we have ever come across before. We were able to get help in putting Alex into a special education program, in a regular school. Unfortunately, the special education programs tend to lump all of the children together for all of the different problems that may be occurring, so the special education program becomes more of a containment program rather than an actual treatment program, because they could not possibly treat all of the different illnesses with which they are dealing in the classroom. However, it is miles better than what we had experienced before.
Unfortunately, access to care is a daily struggle. All the services you get in terms of your child with a psychiatric illness are as a result of hard-fought, hard-won battles. Even just getting Alex into the respite program that is offered by the Manitoba government was difficult, since they have a very narrow criteria for who us considered to have a disability and who not. For example, when we first arrived, we applied under our first diagnosis from a child psychiatrist of bipolar disorder. We were immediately told that illnesses such as bipolar, Tourette's, schizophrenia, things like that, did not qualify for the respite program. Thus, families who have children with these illnesses received no respite care support whatsoever. We later found out, however, that they did provide services for pervasive development disorder, which is on the autism spectrum. We had an old diagnosis from a child psychiatrist whom we had seen in Victoria, who examined my son for maybe ten minutes and diagnosed him with PDD at the time. We had that piece of paper, so we reapplied under the program on that diagnosis of pervasive development disorder and were immediately accepted. Same child, same symptoms, same program, but a different label, and all of a sudden we had access to services. However, that took almost a year.
In the end, just to sum up, the tragedy does not lie with the disability; that is not the tragedy. The tragedy is in the way that society treats the child and the family which is dealing with the disability.
We can handle Alex. So far, we have been able to do so with the limited amount of support that we have been able to get, and we are very appreciative for that limited support. What we cannot do is constantly fight to get every single service. Just as an example, I was trying to register my son into a summer program this year. It is a simple two week program, a computer programming course, which he loves, and it took three weeks, and calls to the ombudsman's office, the Manitoba Human Rights Commission, and the Equities Department at the University of Manitoba, because they said that we had to pay for the full-time teacher's aide that had to be with him during the course. That was on top of the regular course admission costs. We finally managed to read to them the Manitoba Human Rights Code over the phone. They realized their mistake and they changed the program. They also contacted all of the people to whom they had previously given this information and changed the program. However, that took three weeks of my time, just forcing them to recognise what our rights were. That is what takes up the majority of my time: advocating and getting the services we need for our family.
Between holding down a full-time job, which I love, having a husband on rotating shift work, doing lots of overtime, and caring for a nine-year old daughter who would dearly love my attention more, I would rather be devoting that time to my family than advocating and teaching people about our rights. That is where I would rather be. We want to raise our child at home. We just need a bit more support, and a lot more people coming to us and asking us what we need, instead of telling us what program we might be able to fit into.
Thank you very much for listening to me. I appreciate it.
The Chairman: Thank you for your story. Your contrast between the physical and the mental health service is extraordinary. By the way, I assume you know it is by no means unique to Manitoba. It is an illustrious example, but you contrasted it better because you had both the example of the physical illness and the mental illness. I will come back later and ask you some questions on that aspect.
Perhaps I could ask you first, Margaret, about the sort of bar charts that are in your submission, because I just want to make sure I understand them. Everybody has your bar charts but you, right?
Ms. Synyshyn: It is always like that, the story of my life.
The Chairman: I just want to make sure I understood them exactly. Your first one is entitled "Opportunity Lost." I would say to my colleagues that it is the first piece just after the presentation. The yellow chart shows "brain," and what you are really showing there is the amount of money that we actually spend relative to —
Ms. Synyshyn: That is true, yes.
The Chairman: Is that Canadian data?
Ms. Synyshyn: It is from Baylor College of Medicine, in Houston, Texas, so it is U.S. data, but I do not know that the situation is vastly dissimilar in Canada.
The Chairman: It would be roughly comparable, then. Looking now at the one on the next slide, and adding up the figures on the two middle purple bars — which is why you said that, although the percentage is higher among low income people, the number is greater among —
Ms. Synyshyn: That is right, the proportion is higher. It is not that there is a problem with targeting, and certainly you need to support people from the lower socio-economic perspective, but certainly a lot of the time, what happens is that because people are coming from middle class families or have some means, the assumption is made that, in fact, those kids are much better off. In some respects they are; they have more advantages around things. However, there are other issues that come up, and I am talking in terms of developmental issues, which indicate that they are really not any better off. Much of the time, programs do not reach that population because there is an assumption that they will be able to figure out how to get there on their own, or that parents are articulate enough and able to do that.
The Chairman: Are you saying that there is an assumption that the ability to handle the situation with a child goes up linearly with income?
Ms. Synyshyn: That is the assumption. Lots of these kids present with extremely difficult situations, behavioural and otherwise, and I do not understand why someone would make such assumptions. It is difficult enough parenting with kids who do not bring extra difficulties into the situation. However, when there is present, on top of the children's regular, developmental things, an overlay of difficulties, whether they are mental health issues or something else, and to then assume that somehow, some parents with some means are better at dealing with that situation than someone else, I do not understand that rationale at all.
The Chairman: The other interesting thing is that we have had testimony, somewhere along the way, in which people providing services to mentally ill children have said that when they went to talk to parents, what they found was that if they said to a parent of middle and, particularly, upper income, "Your child has a mental illness," the parents would immediately say "There is not a chance. He is my kid;" in some sense saying that "My kids are not allowed to have such a thing." Do you know what I am saying? They did not use the word `are not allowed,' but they thought, because of the stigma, they felt it to be —
Ms. Synyshyn: Do not say `mental illness;' do not say that, because that is exactly what happens to people.
The Chairman: Right. Can I ask you to go over two pages to your next bar chart where you are showing how long the effects of the program last. Can you explain that chart to me? I cannot quite figure out what those bars indicate?
Ms. Synyshyn: It is really referring to the "head start" programs and that kind of thing, about the impact that they have. It is a sort of longitudinal effect, that if you actually support kids in those early stages around certain issues, for instance cognitive, or social-emotional, and also the parental family piece of it, if you put some of those things into place, that shows the effect that they have over the long term. That is what they are trying to measure here, I believe. They are looking at the effects of some of those interventions.
The Chairman: It seems that a number of them — the social-emotional one, for example, two-thirds of it, or 64 per cent, lasts well into high school.
Ms. Synyshyn: That is right. In terms of intervening, and in terms of parenting and helping people around parenting issues, and this is referring to even kids who do not have big issues, certainly the effect of that is felt way down the road because what you are really doing is preparing the next generation for things like parenting and that kind of thing.
The Chairman: Right. The next one is the one that, it seems to me, that governments ought to buy into, right?
Ms. Synyshyn: The return on investment one?
The Chairman: Yes. What you are saying is that they get a 32 per cent return on investment for money invested in early child development programs, compared to the highly-touted, 6 per cent rate of return on the U.S. stock market.
What are the four indicators? I do not know what the Elmira PEIP, the Carolina Abecedarian, et cetera, are. What are those four indicators?
Ms. Synyshyn: I would have to get you more information on those. The Perry preschool has been around for years and years and they have followed individuals right into their forties, and there is a lot of documentation in that regard. I would need to get the rest of that information for you.
The Chairman: If you could get it for us, we would be grateful, because we know from talking to various government deputies and ministers that — and I hate to say it — much of the bottom line on this area comes down to whether it is a good investment. Everyone will agree that it is the right thing to do, but then they overlay that on whether or not it is a good investment. If you could give us any of the backup on that 32 per cent, that would be really helpful to us.
Ms. Synyshyn: Yes.
The Chairman: I have some other items that I want to come back to, but I will turn now to Senator Keon and Senator Johnson.
Senator Keon: It is enormously interesting to have these two presentations together.
Ms. Synyshyn: Neither of us knew that the other was coming, either. We know each other, but this is Winnipeg, so it is not surprising.
Senator Keon: The other interesting thing that I will come back to later with you, Ms. Huffam, but I want to throw it out in this context, and that is the psychopharmacology of brain along this road, because the psychopharmacologists claim, in fact, that one of the major problems that confront people like you, Ms. Huffam, is non-recognition that this condition is, in fact, a chemical abnormality. While we would not think of not treating a child with hypertension with angiotension blockers or whatever is necessary, whatever chemical is missing in their system, there is a tremendous reluctance — indeed there is a campaign in some quarters not to treat children chemically with missing chemicals.
Let me start with you, Ms. Synyshyn. We have the basic information — and Fraser Mustard has been preaching this for 20 years so it is not very new — but how did we go about diagnosing that one child in four, at least after birth, when many of the problems occur in the uterus, of course, but at least after birth, how do we get at the problem in society of diagnosing that one child in four who needs special parenting, special social infrastructure, and as in Ms Huffam's case, probably needs some chemical supplement from day one? How do we go about that?
Ms. Synyshyn: Probably what needs to happen is there needs to be better screening right at the front end, whether it is with pediatricians or child development clinics or that kind of thing. Probably what happens in many cases, I believe, is that when mental health issues come up — first of all, I think that people do not believe that kids actually can have mental health problems. They really do not think that that can happen. Again, especially now when there is so much work being done on the biology of things, and more understanding that there are some individuals who, in fact, will have difficulties from day one, I think that a large percentage of the population actually believes that that is not possible. I think they believe that so much stuff happens because of the nature/nurture thing, and much of it too seems to be that they really cannot believe that this little guy can have that much difficulty. Consequently, in many cases, there is a reluctance to treat, particularly with medication, because very little, if any, research has been done in that area.
We have a neuro-developmental clinic at MATC, and we deal with a lot of kids who are in the Asperger spectrum disorder group. They are pretty young, usually under the age of 12, and a lot of them need medication to help a bit with controlling some behaviour. It is not used as a "strait jacket" sort of thing, but the idea sometimes is that just a little bit of this or that medication would be helpful. Most of the work that is done we need to do very carefully because so much is off label. As I said, little research has been done, although there is more so now, and I know in fact that even working in this area has not been necessarily one of the most appealing things for a lot of specialists.
However, now we are finding that more residents and more physicians are becoming interested in this area. In fact, professionals and other people are beginning to identify kids at an earlier age, and starting to look at treatment at an earlier age, but usually very carefully and very cautiously, because the idea of using medication with children is still a pretty shaky area, particularly in this field.
Senator Keon: What kind of a screening program would you envision, for example, here in Manitoba? You have a nice little entity to work with, with a population of about a million people, some native people and a nice rural-metropolitan mix. What kind of a screening program do you envision?
Ms. Synyshyn: We have a child development clinic that is operated out of Children's Hospital, and I could see expanding on some of that. I could see expanding the partnership between pediatricians, in particular, and perhaps mental health clinicians with a background in the area of early childhood development so that we may be able to identify and pick up those kids earlier.
With respect to primary care and partnering between primary care and mental health providers, again, specialty or particular expertise in this area would probably be helpful. At least it could be helpful to parents who come for their primary health care, because usually the first stop is your primary health care provider, whether it is the GP, family practitioner or pediatrician; that is the first person whom parents usually see. I think if we had the ability to partner with people with expertise, we might be able to pick up on some of that earlier so that what we would not be seeing are parents feeling very blamed because of the fact that they are not being good parents. That does not mean that parents could not use help around parenting with some of these kids, and that kind of thing, but it would be a help, rather than a blaming situation.
Senator Keon: I suspect that this requires both a public and a professional education campaign of some kind?
Ms. Synyshyn: I believe so.
Senator Keon: Similar to some of the screening programs for somatic diseases.
Ms. Synyshyn: Parenting is a funny thing. I think that people think that adults have this innate ability to parent. It is like assuming that all mothers are great mothers, and that kind of thing. I think it is a learned thing, in a lot of ways. Depending on how you were parented and what you know about it, that is what you yourself bring to the task, and it is a pretty difficult thing to do.
Senator Keon: Ms. Huffam, have you been told by experts that had there been intervention with medication very early on, it would have made a significant difference?
Ms. Huffman: No, I have not been told that; it is my own perception. Certainly, once Alex started on the medication, he was able to learn, whereas before, he was entirely in the moment and unable to see consequences. Thus if he did something wrong, he did not understand, (a), that he had done something wrong, and (b), that punishment was related to that. Because he was simply acting out, he had no control over what he actually did.
The medication was able to calm him down to a point, to slow him down to a point where he was able to actually cognitively think about what he was doing. It helped. I mean, it certainly is not a cure, but it helped immeasurably.
Ms. Synyshyn: It is a self-regulation thing.
Ms. Huffman: Yes. That is the type of program that the parenting support would certainly help. You need to be able to coach your child on how to self-regulate, despite the illness. The fact is that the child will grow up, he will go out into the community, and you will not always be there to support him. Thus the process that we are undertaking over these years is to try to teach him how to control himself. These are things that most children will learn at two, three and four years old. Alex is now almost 12, and we are still working on it.
Senator Keon: You see, we have heard the paradox of the chemical treatment of mental disease. Some groups that have come before us have said there is tremendous abuse of medication and chemicals in the management of psychiatric disease. I have a very close friend who is a psychopharmacologist, a very good one, and I made a point of raising this issue with him. He said that, in his opinion, this is one of the major problems with mental disease now, that it is perceived as some kind of aura that you cannot measure, when in fact most of it is a chemical phenomenon, for most mental disorders. Of course, he is pushing for research in that area, because with research we can perhaps identify tangibles.
My point is that there is resistance, and there is the accusation that teachers, for example, demand that the kid who is disrupting the class just be cooled out with a pill, instead of taking the time to analyse the child and manage them with psychotherapy or whatever. I think you have given us a very important illustration that there are times when you need chemical management.
Senator Johnson: This is such a vast area, one hardly knows where to begin. Your presentation was good. I want to know, you talked about the largest single proportion of vulnerable children being from low income families but that the largest proportion, over all, are from middle to high income families. Why is that? One in four are vulnerable, one in six have behaviour problems, and one in eight have learning issues. Is the issue of stigma part of it, and is coming forward for help an issue in the middle to high income families, in particular? I know that is a second question.
Ms. Synyshyn: You are probably right. I think that part of it, too, is recognition that there is a problem, but the issue of actually having to come forward, or not knowing where to go, not understanding where it is you might go and where you start out, depending perhaps on what door you open, or on whether in fact you get help or not. It also depends on where you start, or how that issue is conceptualized by the person to whom you are speaking.
As I mentioned at the beginning of the presentation, if you, as a parent, choose to go through the educational system, the situation may be conceptualized in one way; if you choose to go through the health system, it may be conceptualized differently. Thus conceptualization is one of the other issues. Depending on which door you go through, you may get something a little different through each one.
Senator Johnson: The entry level to getting help was Ms. Huffam's story. We heard another one yesterday from a woman who took a child for help: if you have a broken leg, you get attended to in five minutes; if you have an eating disorder, you get attended to in ten months. It is the same story all around.
You are right about parenting. It is only recently that people have realized, or it has become popularly well known, that the first years of life are the most critical, and after age six it is over, really. Where do parents turn?
I have been very involved in Special Olympics for 25 years. I am curious to know, just as an aside, if you do not mind, Mr. Chairman, are the services for mentally handicapped now, which were zero 25 years ago, actually not better than they are for the mentally ill, or the vulnerable population? We get a cross mix in our specialty programs, but I am curious because we have excellent group homes, we have excellent Special Olympics programs, we have excellent workshops, and we have them competing in events. Do you know what I am saying? They seem now to have better services, or we have better services for that population. Is that true or not?
Ms. Synyshyn: I think in Manitoba, if you looked at it now, I think there has been excellent advocacy done by parent groups and other organizations around kids with very identifiable developmental delays and that kind of thing. If I were a parent with a child who had such a difficulty, I probably would not necessarily rave but I would say that if you compared the present situation to 25 years ago, it is a lot better now.
Then there are the children with Iqs of less than 70, who are targeted for lots of services and that kind of thing. Thus if your kid has an IQ of less than 70, you probably have access to a lot of services, in Manitoba at any rate, such as children's special services and a number of other things, with respect to education. From the special education point of view, there is lots of help there.
It is when you hit that group of individuals who do not fit the criteria for community living and all of these other things that you run into a lot of difficulty, because they kind of fall through the cracks. They do not qualify for a lot of services, but they may be higher functioning so they need a different type of service. Also, the help or support needs to be provided within mental health, education and family service routes. It is all sort of spread out among these three areas.
However, the answer to your question is yes, I think probably, if you had a child with a very identifiable —
Senator Johnson: Very well.
The Chairman: Ms. Huffam, do you want to make a comment on that question or response?
Ms. Huffman: I just know myself — and this sounds horrible — but I often wished that my son had been born blind instead, because people would recognize that fact. They would take one look at my son and say, "Okay, we know what it is, we know what the problem is, we know the services that he needs," and that would be that, and I would not have had to spend so much time advocating and begging for help.
The Chairman: The Special Olympics makes me think, am I right, that we have come a very long way, in the last 25 years roughly, in terms of the services that we are prepared to provide for the physically disabled. I just think of obvious things like ramps into buildings and that sort of stuff. The impression I have is that the stigma that existed with respect to someone in a wheelchair does not exist today, but the stigma that existed 25 years ago with respect to someone who is mentally ill still exists today.
Senator Johnson: Yes. That is even drawing a further line, saying that if they are identifiable ones, say, with Downs Syndrome, or are blind or whatever. The mentally handicapped, based on Downs Syndrome or something else that is obvious, that is even less of a stigma now, even though they were hidden away 25 years ago. Now that is less of a stigma than the mentally ill.
Ms. Synyshyn: Again, lots of advocacy has been done by parent groups. They have done a wonderful job, and nobody is about to tell them that they cannot have anything they need. It is their child's right. If they need to have something then they will fight for it. They are an articulate group of people. A lot of times, though, with mental health issues, it is the stigma issue, and it is not very visible.
Again, depression, as an example, happens to everybody to some degree or another at some point in their lives, and I do not know if people want to see it as a disability. I think it is all in the way that you conceptualize it and that kind of thing. It is one of those hidden things that can be problematic for people, or people do not necessarily want to share that information. I think the idea of people talking about it more and more openly is probably a very good thing, because it comes to the forefront. We now have very prominent people talking about issues such as bipolar disorder or psychosis, and that kind of thing is very helpful all round, because it help to illustrate just how common some of these things are. I have hopes that that will be helpful.
Senator Johnson: We had a young man yesterday giving a presentation who told us that he has had an anxiety disorder since he was eight years old. He said yesterday that he was very anxious, but he did extremely well, since this was the first time he had ever presented. He had been dealing with this issue all of his life and now he has finally found some level of comfort with the fact that he is able to talk about it and to ask for — and get — some assistance. That is a major mental thing for anybody to deal with, of course, but the more it comes out of the closet, the more people feel that they can talk about it, which is where the community level comes in, and being able to have support systems and everything else.
Ms. Huffam, I am really curious to know, did your son ever get properly diagnosed? Was it not autism?
Ms. Huffman: I do not know. We have had two different diagnoses. We have had the bipolar disorder diagnosis, which is cyclical in nature, but we do not see those cycles. What I mean is, we see them, but on a daily basis. He is up, he is down, he is up, he is down. So parts of that just do not fit. We have also had the diagnosis of pervasive development disorder, not otherwise specified, and we are told that it is on the autism spectrum, and that could be it as well.
I actually do not describe his illness as a mental illness. I actually describe it as a brain disorder to people. I do not know whether or not that is the right thing to do but, frankly, I am so tired of the stigma around the phrase "mental illness."
Senator Johnson: Exactly, because they are proving that genetics is totally involved with depression and other forms of mental illness. It is like diabetes — and I said this yesterday — the more we can talk about it publicly, the more it will be understood. The media was criticized here yesterday as well for the way they presented people, and people are still afraid. I know lots of people who receive help, and kids, and they do not talk about it. This probably represents the last frontier on which this chair and this committee is doing its work.
I will turn the floor over to my colleagues now. I just find it so frustrating for you, having worked with kids, with especially the undiagnosable, as you say, that area is just a wilderness. Like with addictions, such as alcoholism, or whatever, these families are just totally disrupted and torn apart. I do not think that we have all of the answers but I think this committee is doing its best to find some.
Senator Pépin: Ms. Huffam, while I was listening to you, I was wondering if you could tell us, what changes are needed? Let us say in the current delivery of services. Do you believe that, as you say, you were seeing the pediatrician and he was telling you that it was not your son's fault but it was you as a mother. Do you see a way in which we could organize it better? Do you think that if the doctors were more alert or had special training to know and to recognise those disabilities, or if there were more psychiatric nurses or social workers, things would be different? What kind of changes do you think could better help those parents who come looking for help with a child suffering from a mental disorder?
Ms. Huffman: There are one or two things that I think would have been helpful — and this, of course, was ten years ago; maybe these things are now being put into place, I do not know. I was visited by a public health nurse after I gave birth and was home with our first child. She came, I think, once every couple of weeks and weighed Alex. Of course, he was huge and eating like a horse, so there was no problems there. I am wondering if it is possible for parents to be provided with access to a public health nurse who is trained in early development screening at, say, a public health unit? If new parents simply had the phone number of such a facility, it would be of value. For example, my son did not sleep during the day. He was three or four months old, and he would sleep for maybe five, ten minutes at a time, maybe once or twice during the day, and then he was up a lot during the night.
The Chairman: We are all grandparents. We know how much you need a break.
Ms. Huffman: But I was a new parent, and whenever I complained to someone that my son did not sleep, they would be like, "Oh, we know what that is like." My answer, in hindsight, is no, they do not. If I had actually been able to talk to a nurse and say "Is this normal? He wakes up in the middle of the night screaming for three, four hours at a time?" Now I know that that is night terrors, and it is a strong indication that there may be a developmental delay. At the time, I did not know that. Had I been able to phone an early screening person at the public health unit, then maybe I would have been told, "That is not quite right. Let us put him through the screening. Let us see how he is doing, and then if he is not doing well, we will get you in to see the doctor." Maybe then the doctor would take a parent more seriously because the family had already been through the early screening with the mental health professional. That is one idea.
Senator Pépin: Also, later on, when the child starts school, do you see a role for the school regarding detection? Do you believe that there should be a screening when the child starts to go to school. I mean, for everybody, not just for the ones making noises?
Ms. Huffman: Maybe I am not the right person to answer that question because I have had such terrible experiences with the schools. By the time the child gets to the school, they are five years old, and I just feel that that is so late.
Senator Pépin: I agree with you, but I was just wondering if you believed that there should be screening there, too?
Ms. Huffman: I think they could refer parents and children, and maybe bring in a professional to do a professional screening at the kindergarten. But to actually have the school themselves doing that, I think not. I would prefer to go through the medical system as opposed to the educational system.
Senator Pépin: Early detection is so important that it could be better in the kindergarten.
Ms. Huffman: I think parents see problems long before their child ever gets to kindergarten.
Senator Pépin: Do you feel, then, that parents — as you say, you were a new parent and, yes, you believe everything, but that parents need someone, as you say, to talk to and to exchange information, and someone whom they can trust earlier, so it has to be organized, not at the hospital level, but at the service level when the visitor goes to see the family, the nurses and things like that?
Ms. Huffman: That is right. Just someone to check in with, and maybe that would lessen the intake of people taking their children into the doctor or hospital, asking routine questions, who really do not need to be there. It could help break that logjam as well.
Senator Gill: You talked about using the telephone system to manage the waiting list. What I mean is that people who want to have treatment try and go out through the telephone system. You seem to be happy about that system.
Ms. Huffman: It is better than it was, let me qualify it that way.
Senator Gill: What are the results? Is it better? I am taking about the treatment itself, about the waiting list to be treated. I suppose it depends on the number of people who are doing the treating, such as doctors, psychiatrists, et cetera. What is the situation after that?
Ms. Synyshyn: Access is easier because there is one phone number to call, and anybody can call that number. What was happening before was that the parents, most parents would have to get a referral from a professional. That was the first thing. If there was an issue with one of your kids or whatever, you would have to go the route where you would have to talk to somebody, and they would say, "I will do this," and then they would call. What is better now is that parents themselves have access, and they are a referral source. Sixty per cent of the calls that we get are from parents themselves. They are the referral source, not the profession. That is not to say that they have not seen anyone, but that is what is different, and from my way of thinking and from the feedback we have been getting, that is certainly better. In terms of how it is managed, they actually all come in through this one door, so to speak, and they are triaged. Thus you do not have people going to four or five different places.
In fact, because we have professionals answering the phones, rather than a secretary, with all due respect, but when we have someone who is a clinician answering the phone, sometimes what happens is that the questions that parents have, in particular, much of the time that is the intervention. The intake clinician will actually meet with the parent and the child and actually do an intervention, and say, "What are you doing tomorrow afternoon? Let us get together and try and sort this situation out." Sometimes that is the intervention, and it does not need to go any further than that. The parent says, "Okay, that is good. I think I have a handle on it now, and can I call again if I need to?" We are always open to where they can just call again.
Sometimes you need more than that, and then we can help them through the system that way. We can have someone seen for a psychiatric assessment within 24 hours or less, if it is necessary. The emergencies are skimmed off right at the beginning and dealt with on an emergency basis. However, the majority of the calls that we get are not emergency calls. They are calls from people who are dealing with their kids; the kids will not go to school; this is going on, that is going on — sort of behavioural issues. Those are then dealt with, and again, if we can deal with them with the least intrusive intervention, that is the way we will go first. Then after that, if the parent needs more help, certainly we help them to sort of walk through the system and advocate for them throughout the system. Again, I am talking about just through the Child and Adolescent Mental Health System, not the school system or corrections or family services. This is just through the health system.
It has to be better; it certainly can get much better, because much of the time we cannot necessarily do or give what that person on the other end of the phone is asking for. They must go through this process, which can be pretty frustrating for parents. I can understand that and appreciate it, but they do have to go through a process. Sometimes that is the frustrating part. Parents call; they know what they want and they know what they need, but we make them go through these hoops anyway, which is unfortunate.
Senator Gill: Tell me, are the Aboriginal people using the system as much as the others? Do you know that? The Aboriginal people, the native people, are they using the system as much as the others?
Ms. Synyshyn: Probably not. We do not do well with First Nations in terms of providing —
Senator Gill: Even those who are living in Winnipeg here?
Ms. Synyshyn: You know what? Probably our treatment numbers and our call numbers would reflect the percentage of population that are First Nations in Manitoba, so probably 10 per cent of our clients are First Nations.
I do not think that we do a particularly good job. We do not do a good job with First Nations communities from the North. We have 14 in-patient beds for the whole province of Manitoba, which are emergency beds at psych health for kids. Fifty per cent of those 14 beds are generally filled with First Nations kids from the North. They have very few services in the North. Again, just because they are so desperate, they tend to Medevac the kids out. A lot of the time it is serial. It is not just sort of one episode; the kids come out frequently. Again, the issue has to do with social determinants on the reserve itself. They do not have a lot of the things that they need.
Things develop, you know. I would be depressed, too, if I did not have much to look forward to. The kids come down, then they go back up again. There are no resources, and bang, they are back down again. It is unfortunate. We do not do a good job with First Nations in these situations at all.
Senator Gill: What do you see? I know it is not easy, but I know that lots of people are in jail instead of perhaps being treated in the proper place.
Ms. Synyshyn: I think what would help would be partnering with the First Nations and developing that relationship, and not going in and telling them what they have to do, but supporting them to do the things that they need to do, using some of our expertise, but having First Nations people do the work, and not shipping kids down into an artificial setting that really is not very helpful to them or their communities.
Senator Pépin: You spoke about your telephone program, but I thought I heard someone yesterday speak about email; computer service and email. Have you thought about that approach?
Ms. Synyshyn: It is interesting. I went to a presentation recently on the Triple P — Positive Parenting Program, one of the interventions that they use is checking in with people via telephone and email, and it is something that we probably need to do more of. With respect to delivery service, sometimes people are reluctant to do this. Even if you go out to people, a lot of times they may be reluctant. But that phone call, if we are checking three times a week about how are things going, it is very helpful, because people know that you are there for them.
Email is another thing. I know some of our clinicians see people, or they actually talk to them via MSN because they are not willing to come into a facility, or they really do not want to see you, so it is easier. They will talk to you via email, and you can have a relationship with them via email that is a lot easier than you might have face to face. However, it is a new technology that we have not yet factored into how we do business.
Senator Pépin: For the people who live in the region, it could be —
Ms. Synyshyn: That is right. Telehealth is another thing. We really have not exploited telehealth as much as we should, either. That is another way, in terms of some of our northern and remote communities, through which we need to be able to do the telehealth piece as well. In that way, you can actually have people communicating quite frequently, as opposed to having to send someone up there or, at massive expense, bring the patients down.
Senator Pépin: Thank you.
The Chairman: Go ahead.
Senator Johnson: Can you just tell me how many FAS kids you are getting in your program? Is it increasing again or not?
Ms. Synyshyn: I would say that if you are looking for kids who have a pure FAS diagnosis, who have the dysmorphia and that kind of thing, I am not sure what the number is. However, I can tell you that kids who have the effects of fetal alcohol, which means that although they do not have the physical features, they certainly have issues around their impulsivity, judgment and that kind of thing, I would say probably a good percentage of the kids that we see probably have had some type of involvement in that way. Either that or it is what I would call a wiring issue, more so than anything else. Whether it is because of the mother drinking or doing whatever, or some other environmental factors, I think there are probably a lot more than we are aware of.
The Chairman: I want to just finish off by asking you some questions about your centralized intake system, which is, by the way, the only one that we have heard of in the country, so we will be inclined to plagiarize it as a good example.
Ms. Synyshyn: Feel free to do so.
The Chairman: Two things strike me: First of all, how did you get all of the required services to cooperate? The stories we have heard would suggest that there are silos in which they all operate, and they love their own autonomy. Was it brute force? I mean that seriously, in the sense that, did you say to people, "We do not fund your service unless you agree to participate," How did you do it?
Ms. Synyshyn: Remember, this is just within Child and Adolescent Mental Health.
The Chairman: I understand that. We have to start somewhere.
Ms. Synyshyn: Yes, that is true. Part of it is the way in which we are organized. There are three large organizations that are part of our Child and Adolescent Mental Health program. Two of them are general hospitals, or teaching hospitals, the Health Sciences Centre and St. Boniface Hospital, and the other one is the Manitoba Adolescent Treatment Centre. We have a hospital base and a large community base. Probably MATC delivers the largest part of the mental health services within the region.
Senator Pépin: What was the acronym?
Ms. Synyshyn: MATC, Manitoba Adolescent Treatment Centre. We were already doing some of this work because we had the largest portion. When we started the program, and my responsibilities as well as those of the medical director, Keith Hildahl, started overarching into the other two, we found that it just made sense to have a centralized intake, because we all kind of communicated already. I have to say that within Child and Adolescent Mental Health we probably communicate more than what happens within the adult system, just because kids bring all of this stuff with them. You cannot help but talk to each other. We had already had a sort of mini-triage group going, and we knew that we had so many kids in common, so the centralized intake was not a super hard sell. We have been working together quite well.
I think what happened is that the physicians needed to be convinced about giving up some of their control of the gatekeeping function. Let me say that I use that expression here. I do not know that I would necessarily have used that type of description when we were originally doing this.
The Chairman: I am sure you would not; it would not have sold well.
Ms. Synyshyn: It depends on how I felt that day. It depends on how well they were cooperating and that kind of thing. I think what happened is that the physicians found out, once they did not have to take the phone calls and they did not have to say "No," or deal with people, they found it much easier to do what it is that they are supposed to do, which is deliver treatment and deliver service.
Therefore, it has not been such a hard sell. We still have lots of issues around information exchange and that kind of thing, even though we are the trustee for the whole program in terms of information. It is also still difficult because the teaching hospitals kind of do see themselves as having a very special role, and we try and respect that, but it has not all been super easy, although it was not as hard as I thought it would be. I think we were sort of doing some of it already, and our system is manageable enough in size to be able to do it. That is where we were lucky. Again, it was happening in Winnipeg, as compared to Toronto or some place else, so it is a lot easier to do it.
There are some centralized intake systems in Alberta. When we were doing the WCWL, we became quite familiar with those, although they operate somewhat differently than ours. I think ours is probably the best model of all of them in Western Canada.
The Chairman: It is the best that we have heard of.
How do you link to the primary care system, in the sense that you are in Manitoba? It is not true in Ontario, but it is true in Quebec, it is true in Alberta, it is true in B.C. and it is true here. You have moved to or are moving toward multi-disciplinary primary clinics. As I say, it is not happening in Ontario at all, but everywhere else it is. What is the linkage? If someone walks into a doctor's office, a primary care clinic, and the doctor detects a problem, or the nurse, or the nurse practitioner, whoever, do they have a tendency to treat that person in their multi-disciplinary practice, or do they first refer to the central gatekeeper, who then decides where they go?
Ms. Synyshyn: I think it depends on whether they feel competent to manage the issue. If they know that they have some support, if they have within their health facility some mental health support within that facility, they may decide to handle it to a certain degree, because they know that if they run into a jam, they can talk to the person whose expertise is mental health. That is what I think is the determining factor. We get lots of referrals directly from pediatricians because they see an issue, and they are really not sure what it is that they need to do about it. They do not really have access to anyone with mental health expertise.
We have done up these printed cards for our centralized intake, and we have covered the Winnipeg region with them — pediatricians, GPs, schools, guidance counsellors — they are all over the place, so there is a fair bit of knowledge, from our perspective anyway, about centralized intake. However, it depends on whether or not they feel competent, or if they know whether they have somebody to call or fall back on, they might handle it for a while and, if it gets to the point where they feel they have sort of maxed out, then they will call us.
The Chairman: What do you do when the service that someone needs is not available? You were very careful to say that you deal only in the health care system, and that you do not deal with schools, you do not deal with prisons.
Ms. Synyshyn: We deal with schools, but not in the way —
The Chairman: Right. But what do you do with the child, you know, a 14 year old for whom some element of clinical counselling would deal with their problem? Do you pay for the psychologist, or do they have to wait and see a psychiatrist? I am interested to know what happens, because so many so-called mental health services are not delivered by health departments, or funded by health departments. How do you deal with that?
Ms. Synyshyn: Within our program, any services or any clinicians that we have are not fee-for-service. The doctors in the teaching hospitals are fee-for-service, but we have mental health clinicians within our region who provide a majority of the service.
The Chairman: They are called mental health clinicians but they are not necessarily such, because somewhere in here you describe some of them as perhaps being psychologists or social workers. They are not trained "in a health profession"?
Ms. Synyshyn: Our mental health clinicians are all professionals. They are either social workers who have —
The Chairman: But a social worker is not typically what one calls a "health professional," that is all I am saying.
Ms. Synyshyn: I suppose we could argue that point.
The Chairman: Anyway, you cover the cost, even if the services are not provided by a doctor or nurse?
Ms. Synyshyn: For sure, yes. I mean, there were — I forgot how many we saw last year — 8,000, 10,000 kids. The majority of those kids did not necessarily see physicians; they saw mental health clinicians or other professionals who delivered the service.
The Chairman: What happens when someone turns 19?
Ms. Synyshyn: Much of the time, we will follow them, but that is the other really big problem, the transition between child and adolescent, because a lot of times with the child and adolescent system, they are covered. For example, kids are enveloped for many services, not only from the mental health system or from the health system, but from other areas as well. When they turn 18, it is like they fall off a cliff.
The Chairman: That is why I asked the question.
Ms. Synyshyn: Yes, and they do.
Senator Gill: Ms. Huffam, have you ever made a chart with regard to your son? I am saying that because I was very much involved in education, and as you know, of course, there are some good teachers, some good educators, and some not so good. Whatever, they always analysed the kids and they put that chart in the file. The child is carrying his file. How do you see that stigma? The child has been carrying that file, and it is not always true? That is what I mean. Sometimes, it is too bad, but kids are creating something which is not true based on their behaviour. That is why I am asking you, have you ever made a new start, you know, just forget about the file?
Ms. Huffman: Manitoba was a new start. When we were in the Northwest Territories, because Yellowknife is so small, we actually went from one school to another, and were treated fine until all of a sudden one of them, one of the teachers clearly decided to call the previous school and speak to someone who believed that we were abusive parents, and then everything changed from there. We requested our official file to correct any type of perception, because that is what we understood was going on, and there was nothing in the file. It was just clearly talk.
The Chairman: As a matter of curiosity, did your son get better treatment when they thought you were abusive parents than when they did not?
Ms. Huffman: No.
The Chairman: I just thought maybe it kicked them into a different system.
Ms. Symyshyn, can you finish off? They get to 18 and they fall off a cliff, to use your word. What happens next?
Ms. Synyshyn: It depends. There are certain populations of kids with autism spectrum disorder, eating disorders, psychoses, or major mental illnesses, and that kind of thing, where you know that this is not something that will just stop at 18. Some things are reactive. You put in treatment items, you do some things and people are okay for a while. However, it has always been a struggle. We struggle with it all the time. Sometimes we carry these kids into their twenties, because there is not any alternative. Sometimes what happens is that you try and develop a plan, when you know that this individual will need some support in the rest of the system for quite a while. You start doing that in their mid-teens if they are part of your system. Sometimes you can have some successful transitions, but for the majority of them it is quite difficult because the adult system is a very different world; very different.
The Chairman: As scary as that is, let me tell you, in both Ontario and Nova Scotia, we have had evidence that there the children's mental health system applies to 16 and under, and the adult system applies to 19 and over, and if you are 17 and 18, you are not covered at all.
Ms. Synyshyn: We will cover them until 18. We did not believe it, either.
The Chairman: What happens is that if you are 17, you are not allowed to be treated by the children's system, and none of the even rudimentary programs available for adults are available for you. We had a case in Halifax of someone telling us that they kept the child, believe it or not, a 17 year old, in the Children's Hospital in Halifax, occupying a $1,400 a day bed for two years, because he was not eligible for community housing, he had nowhere to go and he wasn't sick. He was mentally ill, but he did not need a hospital bed. I was just curious, because we have been stunned by the inability of the system —
Ms. Synyshyn: Again, some Child and Family Services things I know about stop at around 16.
The Chairman: But there, everything stops at 16.
Ms. Synyshyn: No, we have been fortunate.
The Chairman: That is just —
Ms. Synyshyn: We have been fortunate, because we will carry them until 18, and we will take kids into our system who are almost 18 as well, and we will try to bridge them into the adult system, if that is what they need. Again, we have been fortunate with that, that somebody had enough foresight to make that apply up until 18. You are right; there is this big pit.
Senator Pépin: What about medication, though? We heard, depending on which province we were in, that there was some medication which is not paid for. In the case of autism and other illnesses, it could be very important if the family is hardly able to afford to pay for the psychiatrist, let alone the medication.
Ms. Synyshyn: The pharmacare system here is actually quite decent around a lot of those things, but with some of the newer psychiatric medications, particularly clozapine and a number of others, we have an arrangement with the pharmaceutical companies. The patients who use these medications are followed quite closely, so you can get sort of special consideration around some of those medications.
The Chairman: I want to thank you both for appearing here today. We appreciate your taking the time.
Senators, our next witness is Irene Linklater, who is with the Assembly of Manitoba Chiefs. Appearing with her is Dr. Javier Mignone, a research associate with the Centre for Aboriginal Health Research at the University of Manitoba. Thank you both for coming.
Ms. Irene Linklater, Research Director, Research and Policy Development Unit, Assembly of Manitoba Chiefs: On behalf of the Assembly of Manitoba Chiefs, in particular the Research and Policy Department, we are pleased to be here to make a presentation to the Senate committee on mental health, mental illness and addictions.
I would like to identify to you that the presentation focus will be on six key areas that we will seek to address, and that is within the scope of mental health services of the First Nations of Manitoba.
We would like to address the selected demographics with respect to population health approach. We will be looking at three of the contexts with respect to inter-jurisdictional policy complications, financial and policy barriers, current programming in place, and also looking at cultural importance and competence. To conclude, I will look at the recommendations from a collaborative based approach specific to the five questions raised in the options interim report.
I would like to thank the committee for the invitation to present on behalf of the Assembly of Manitoba Chiefs today on mental health issues facing First Nations of Manitoba, in particular on the urgent need to address the high rates of suicide, family violence, psychiatric illnesses, substance misuse, to name just a few. In light of this interim report that focuses specifically on looking at mental health, mental illness and addiction options for Canada, and speaks to the development of mental health and addictions treatment systems on two key characteristics, as you note, the patient centered and focused on recovery, and speaking to a seamless system in support services that are accessible, high quality, and well coordinated. Thus that is what we are seeking to present here in looking at First Nations mental health policies, programs and service delivery within the broader context.
I am actually looking at the page called "Overview and Brief." The presentation is being presented within a broad context of provincial and federal health care systems, and how it impacts on First Nations in particular. Then I will look at the scope of the mental health issues, first of all.
First Nations people have long been involved with issues that affect their mental health, with the introduction of the reserve system, residential schools and child welfare, and institutions — that is institutions of thought and philosophy and theories with respect to mental health, as well as institutional buildings or structures, which is what I am referring to when I say "institutions." Many First Nations people suffer from anxieties, phobias, post-traumatic stress disorder, and all addictions within the sphere of health. I am not focusing on a health-specific scientific presentation here. I am speaking more from an advocacy, political, legal, social justice approach to looking at mental health requirements of First Nations people in Manitoba.
A majority of the First Nations people need long-term assistance to address the oppression felt for the last few hundred years. Our elders refer to this as unresolved grief that impinges on our First Nations' rights to self-determination, addictions to prescription drugs, street drugs, alcohol, solvents, that have been plaguing First Nations' communities for a number of years. These addictions stem from oppressive policies as well, enforced upon First Nations people.
Many First Nations communities suffer from poor housing, poverty, lack of employment, relocation, residential school experiences, intergenerational impacts, and of course the child welfare policies. Dealing with these issues every day causes stresses and takes a toll upon the individual, his and her family and the community. In turn, the responsibility is then a burden upon the leadership in that community which does not have the resources to address it.
In addition, these stresses are usually symptoms created by the pain of child abuse, neglect and other physically, mentally, emotionally, and spiritually damaging effects that First Nations have been exposed to. Those who have tried to live a drug/alcohol-free lifestyle struggle with a despair due to lack of supportive systems. Others struggle with identity issues and tend to fall back on addictions.
It is clear that comprehensive, coordinated and culturally appropriate approaches are required to fight this modern plague of emotional and spiritual illness and rebalance our lives through taking a holistic approach, and beginning the healing of First Nations individuals, families and communities.
I would like to refer to a quote that was taken from the Aboriginal Healing Foundation report, which says:
Throughout the history of First Nations peoples, the definition of health evolved around the whole being of each person, the physical, emotional, mental, and spiritual aspects of a person being in balance and harmony with each other, as well as with the environment and other beings. This has clashed with the Western medical model which, until very recently, has perpetuated the concept of health as being the absence of disease.
I will skip through some of the demographics here and just highlight some of the population health approaches. Here in Manitoba there are 115,000 First Nations people, with 56 per cent of that population being on reserves. The population is geographically dispersed across the wide area of the province, and of the 64 First Nations communities, 23 are classified as remote or isolated communities with restricted, fly-in access. Of course, that then touches on having access to physicians and a limited access to provincial health care systems, and also the in-migration and the continuous mobility between on and off reserve First Nations communities.
The life expectancy rates are eight years less than the average Canadian, even though there have been some improvements in the past years. The leading cause of death and injury is poisoning, circulatory diseases, cancer, respiratory diseases, with suicide and self-injury leading the cause of death for youths and adults up to 44 years.
Looking at First Nations women, the First Nations women aged 10 to 14 years has a birth rate nine times higher than similar aged Canadian women.
Looking at economic and social implications, the Department of Indian Affairs spends 13 million on social assistance to every $1.00 in economic development. The impact has been that Manitoba First Nations communities have at least one-third to one-half of the First Nations on-reserve population on income assistance, with a range of 24 to 88 per cent in some communities. That statistic was reached through the research that the AMC conducted on the power of conductivity of 2001.
I would like to return to the Aboriginal Justice Inquiry. Manitoba found that one of three Aboriginal women were abused by their partners, as opposed to the national figure of between one in ten and one in eight for Canadian women in 2001. The landmark report in 1989 stated that 84 per cent of those surveyed responded that family violence occurs in their communities and that 80 per cent of the respondents had personally experienced family violence.
The housing stock that does exist is more likely to have mold or drafty conditions, faulty construction and materials, and there is no other place to move to. That was a Cowichan tribe's report, but similar circumstances are to be found across Manitoba as well as in other regions.
The experience of what is considered homelessness and what we see as invisible homelessness is that by living in such crowded conditions, there is a constant moving of people and houses, and they are not found within the statistics; in other words, you do not see that reflected within a statistical framework. Lack of proper housing is associated also — and research studies confirm this — with lack of personal care, ill health, and lower longevity.
I know that our time is running short, so I will skip through some of the areas on which I wanted to focus and go quickly to the recommendations, which are very extensive, toward the back. I would like you to perhaps read in full the whole 18-page or 13-page report, because we are all aware that there are inter-jurisdictional policy context problems between provincial and federal departments with respect to the ambiguities and fragmentation of services and policies being drafted in an unintegrated manner.
We are hopeful with the announcement that you must have all heard today — it is not in my paper but there has been an accord signed on behalf of the First Nations through the Assembly of First Nations and with the Prime Minister — that there will be a collaborative development of policies from now on into the future. We hope that the same can be started at very early stages in looking at new policies, program development, and service delivery with respect to mental health, mental illness, and addictions for First Nations people here in Manitoba as well.
In looking at the financial context, that deals with having the appropriate funds to ensure that it will not be a deficit reduction goal; there must be consideration for current and projected First Nations' health care needs, population growth, and the critical factor for community-based solutions to address our own ways of well-being that is respected, and can also be looked at as an integrative, collaborative partnership with institutions.
I have provided the First Nations and Inuit Health Branch, or FNIHB, Manitoba Region budget figures, just for information purposes, to illustrate that there are some areas of mental health that are minimally funded through the FNIHB, and there are complications with respect to how those are implemented through the bureaucracy or the department, as opposed to having a joint development with First Nations as to what the needs are. It is to be hoped that the health transfer policy review will seek to address those issues in greater detail in its recommendations.
That then touches on the program context with respect to the national evaluation as I have just mentioned, which is addressed at the start of page 7 in your package. There, the National Native Alcohol and Drug Addictions Program has not kept pace with the community needs, due to the expectations to intervene on family issues such as family violence, suicide attempts, individual crisis, to provide support and aftercare to those returning from treatment, and a community-wide support following tragedies. It is an epidemic, in my opinion, and it needs to be addressed. It has been expressed as such yesterday with respect to youth and the leadership on the multi-faceted needs of looking at community-based solutions, and that drug addictions have become more complex with harder drugs being used, and also with the influx of the gambling addictions that are not recognized within that treatment model, within the Brighter Futures Health Communities and the Building Healthy Communities Program of the FNIHB. I am speaking specifically of the First Nations and Inuit Health Branch, that tends to provide health services through a continuum ranging from promotion to prevention services. However, they do not incorporate within that plan a traditional healing process. That, for us First Nations people, must be a necessary part of planning for programs and services.
In exploring options, we also refer you to the finding of Adrian Gibbons, who produced a report for FNIHB entitled there, on your page 7. Dr. Gibbons addresses similar issues to what we are also expressing, that is accountability, issues of equity, sustainability of funding and, looking at the scope of transfer programs, that there must be an enrichment policy. Presently, the transfer health programs have no enrichment policy, which means that there is no incremental growth for expansion or complexity of needs with respect to the health transfer, and that it does not factor in the population growth and additional identified needs of the community that were not initially contemplated within the written context of those contribution agreements.
The integration issues also brings complexities for us, as Dr. Gibbons notes in her report. While the intention of integrated services for economies of scale, and so on and so forth, is a very good thing, and something of which we are also in support, we also have to be cautious about our communities where there are risks to integration. That is in respect to the jurisdictional issues. Sometimes integration, as she notes, can place greater demands on the resources of smaller communities with limited health planning and management capacity.
Then touching on the similar expression that she presents here on the capacity issues with respect to limited funding, which then brings with it the increased scope of management functions and increased funding required for education, training, and career partnerships.
In discussing new models of health service delivery, it is imperative that the requirements for human health resources are available to provide the care in all of the spheres. That was identified through the Romanow report and also through the Kirby report, restating, reinforcing the recommendations of the report of the Royal Commission on Aboriginal Peoples, that there must be an increase to the supply of professionals in all health care disciplines.
The cultural context is also very important, as I note at the beginning of my remarks. Much of the research tells us, the elders tell us, our teachings tells us, that a strong sense of self and strong cultural identity improves one's ability to cope with circumstances in our lives and we are more likely to be successful in adopting and sustaining healthy behaviours and healthy lifestyles.
In First Nations cultures — and here I am on page 9 — the family, the community traditionally provided support to the individual. The use of traditional healing methods is an essential option for the First Nation individual. The Aboriginal Healing Foundation has indicated in their 2004 report that First Nations people who become more connected to their culture tend to learn more and better coping mechanisms.
I am referring now to the start of page 10. In Manitoba, we have the Framework Agreement Initiative, which has been in progress for the past ten years, and we are hoping for its continuation as we speak, with respect to self-government negotiations representing the 63 First Nations. We have now come nearer to conclusions of agreements in principle on education, Child and Family, and a comprehensive agreement that will address other issues. That is in contemplation also of a health self-government agreement, which made an appearance in the very early discussions but is not, in fact, on the table.
This focus has been on ensuring a community-based process reflective of diverse cultures, goals and histories of the First Nations peoples to build a coordinated, multi-nation government system in a modern government structure. The most important goal of the FAI, as we call it, is to provide First Nations with a voice in their governance institutions, both in theory, thought, culture and philosophy, and also the type of structures that need to be in place, which is inclusive of those powers, from meaningful consultations.
With that, we then turn to the recommendation that I have. Since my time has probably almost run out, there are those five recommendations, questions, to which I wanted to respond. Perhaps if I could just touch on a couple of them?
The Chairman: Go ahead and do all five.
Ms. Linklater: Do all five? Very well. The first question asks for the top priorities of the federal government — and I am looking here at the continuation of page 10 to the presentation — and that is: What should be the top priorities of the federal government in respect to delivering services on mental health services and addiction treatment to First Nations?
First, for us, First Nations, are the issues of multi-generational — and I think this is continuing on page 10 for you, the first question. It says "Recommendations" at the beginning.
Multi-generational impacts of colonization and assimilation have to be understood to be part of our history and how to begin the healing process. That has been identified through, the "Gathering Strength" document, the Residential School Foundation approach. We have made recommendations that there must be implementation of upstream investments into mental health programs and suicide prevention strategies that reflect a culturally relevant, holistic model of care.
Second, institute equitable compensation for survivors of residential schools and ongoing healing resources through the Aboriginal Healing Fund Foundation. Settlements of compensation to individuals does not end there with the healing process; it continues to the generations that are not directly impacted, as some might say, but to those that are affected. Those of us who went to those schools, such as myself, and those of us who are affected because our families were affected, in the broad family and community context, as well as in the context of being a nation.
Third, to incorporate emotional and spiritual care through ensuring access to traditional healers and ceremonies at every entry point into the mental health continuum. That is contained in a research paper that was done through Aboriginal Research Centre for Aboriginal Research. There is also some research that was done by Dr. Mignone and Professor John O'Neil, that also supports that recommendation.
Fourth, redefine and approach mental health services in a wellness framework as opposed to a deficit illness model that focuses on crisis management. A mental health promotion model will build the foundations to enhance the coping abilities and nurture self-esteem, self-respect, confidence of individuals, families, and communities to make healthy lifestyle decisions.
Fifth, improve the effectiveness and the financial sustainability of the health care system through better coordination, integration and access to financial resources geared to equitable outcomes.
Sixth, create a multi-entry point, well-coordinated and seamless mental health delivery framework that promises healthy lifestyles and prevents risky behaviours, addictions, self-harm and violence against others, and provides access to treatment services for those requiring such care. Redesign, establish and support ongoing professional infrastructure required to support any existing and new programs at the community and regional levels.
Next question — and most appropriate — we need structures and processes to ensure that First Nations have adequate input into the design of services. The First Nations must lead every step of the way in this Crown government and departmental partnership, as well as within academic institutions and other knowledgeable partners to look at redesigning and redefining the scope of the mental health continuum, both on and off reserve, with required linkages to other agencies and health programs. Together with government departments, academic institutions and employment agencies, First Nations must train sufficient numbers of community mental health workers, psychologists, social workers, to respond to the emotional needs of community members.
Third, establish community holistic councils with representatives from relevant health programs. We then had listed some examples, such as nursing, or from the nursing field, mental health therapists, Brighter Futures initiatives, building healthy communities, and NADAP workers, who are community based.
Looking now at the relationship within policing and justice services, and that also includes penal institutions. When we look at justice services, we are looking at a broad context of justice, not only through the judicial process of the court system but at probation, penal institutions — that broad array. Those discussions are underway at our office. We have established a dialogue within the Manitoba region on those fronts at this moment. We are seeking — although it is not noted here in this report — an accord, or a political accord and service agreement discussions to pursue that initiative.
Fourth, collaboratively with the justice system, we recommend the development of community zero tolerance policies for the protection of children, women, men, and elders from emotional and physical violence.
Fifth, collaboratively with government health agencies, we recommend the development of culturally relevant and community-based strategies to respond to alcohol, smoking, substance and drug misuses.
Next question: How can the federal government organize itself to deliver those services most efficiently and effectively? We would request that the federal government open its policies and its processes and doors to ensure that First Nations are fully involved in the development of those initiatives that directly impact First Nations, with respect to, say, the processes that are currently only available to internal government departments.
With respect to the memorandum of cabinet and Treasury Board submission processes, we have had some unsuccessful experiences that I do not note in this report. Through our social policy development initiatives here in the Manitoba region, we have been very vigorously engaged, at the very top level, in looking at social policy changes, only to find that when we get down to the end submissions to cabinet, that those submissions were not reflective of the recommendations that were presented by First Nations. Thus there is a problem for us in that once that submission gets to a certain top level of the departmental review process, it gets distilled or refined so that our voice is not there. With the new accords that are being signed, I hope that that will change also within the process, because the sumission must be reflective of the community's priorities and needs. There must be program flexibility and dual accountability between First Nations and governments. That is a really important and central element for us.
Second, integrated models of funding between federal agencies allowing for comprehensive programs and long-term sustainability of funding. We understand at this point in time that there is a new contribution model between First Nations Inuit Health Branch and Indian and Northern Affairs Canada that looks at block funding, multi-year arrangements. We are encouraged by that process. There are onerous accountability structures within that as well, and we feel that we can meet those responsibilities adequately.
Third, needs-based funding formulas providing stable, predictable funding to facilitate financial planning. As I said to number 4 already, bilateral or double bilateral protocols, political administrative arrangements for health and social programs pertaining to First Nations, federal and provincial governments, looking at multi-year funding agreements.
Next question: Should the federal government offer financial incentives to encourage First Nations to train to become mental health workers? We say that in order to attract and encourage First Nations citizens into mental health specialties, it must be along the continuum of mental health workers to those specialised fields. It states here psychiatrists and maybe others. We say that it must be done through designing culturally reflective health education programs conducive to family and community realities and responsibilities of the First Nations students, developing partnerships between First Nations government and academic institutions, negotiating First Nations seat designation, and in order to address long admissions waiting-lists, the creation of additional bursaries and sponsorships, inclusive of sponsorship criteria.
Second, provide safe supportive work environments which offer a high standard of professional attainment. We also seek competitive recruitment and retention incentives.
Next, safe work environments, continuing education, lifelong learning, personal and professional isolation issues, jurisdictional challenges with respect to the mediation process, and wage parity between government and non-government health professionals. That is something that we need to address very particularly, with respect to what is classified as "expertise" when it comes to elders, for example, or the knowledge and teachings that our elders hold. They do not have the academic paper that says they have achieved a Ph.D., but in life they have comparable, extensive education and knowledge from which we can all learn.
The final question: Who should take the responsibility for the environmental scan to determine what programs exist and identify duplication among government departments and significant gaps in programming, and how best to maximize the effective use? As First Nations people, we have always been prepared, as identified within the self-government process and our working relationship politically, to look at collaborative approaches, integration of services, sharing of information, sharing of resources, a shared relationship to co-exist, but at the same time also require some respect for autonomy and exclusivity over certain areas of programming services and jurisdiction. Those are essentials to be considered.
In Manitoba at the present time, we have a health committee. It is an inter-governmental committee on First Nations health. We used to call it the Romanow Working Group Committee, because it was established immediately after the Romanow report was issued, and the Kirby report also. We wanted to broaden the mandate to look at the RCAP recommendations, to look at our treaty relationship with the Crown, so that it is based on an array of those relationships over time and through history. We have had this process, and it is endorsed through the Assembly of Manitoba Chiefs and the Northern Chiefs Organization, Manitoba Keewaytinook Okimakanak, and also the Southern Chiefs organizations as well.
Collectively, we have a process that has been ongoing for two years. It has been going very well. We are now running into complications. We have had our provincial, federal, Health Canada, Aboriginal and Northern Affairs, Manitoba Health, INAC, all contributing to this process; we have also had an environmental scan partnership with our partner from the University of Manitoba in this regard. We have had a health forum on looking at primary health care. We have had meetings on studying First Nations health human resources. We have engaged and we have begun relationships within our region. We have reports that we could share with the committee, once they are endorsed and approved.
Our senior official steering committee meeting of this body will be held next Thursday, June 9, after which we will be able to release those documents to you, to show you that a great deal of work has been done in the Manitoba region with respect to looking at collaboration, and seeking to examine integration and research partnerships.
There is a research report that gives an overview of the gaps in services and issues associated with the jurisdictions. Currently under way is a fiscal analysis of health services report, which is a two-part strategy, research being funded by the Department of Aboriginal and Northern Affairs and endorsed through this aforementioned committee. I will provide copies of those documents to you once they are released by that committee.
The First Nations continue to lobby for the continuation and support of this process, but as I mentioned, problems with identifying who will fund, should we continue for another year, is a very serious concern to us. We hope that the collective powers-that-be will come to an understanding and see that this is a very important initiative that needs to be continued. Mental health and the treatment of illnesses and addictions are, of course, part of the health planning strategies that we have at the Assembly of Manitoba Chiefs with respect to our ten-year strategy.
Before I finish my presentation, I want to make a reference to our research partnership. I will just refer you to the last page of that information sheet. For five years now, we have had a research partnership with the University of Manitoba and the Assembly of Manitoba Chiefs at the Manitoba First Nations Centre for Aboriginal Health Research, and a presentation will be made by Dr. Mignone very shortly. We have just completed an evaluation report on our five-year partnership. It has a vision to look at the research needs, with an evidence-based approach to looking at the development of policies, and also looking at traditional knowledge and the importance of engaging First Nations and a university research science approach together, towards building a more informed, more reflective approach to looking at program services and policies. I will just leave that with you. If it is possible for to us submit that report to you as you are concluding your research, we will also present that.
The Chairman: That would be helpful.
Ms. Linklater: Just to conclude on that, we will also be seeking funds for a multi-year funding arrangement. Our five-year funding is concluding on that one.
In conclusion, I wish to thank the Senate committee for pursuing their research, focusing on the very complex issues involved in the three topics that address us all, mental health, mental illness and addictions. We trust that you will take our recommendations forward. (Speaks in a foreign language) In other words, best wishes and thanks from Assembly of Manitoba Chiefs.
The Chairman: Thank you.
Dr. Mignone, the floor is yours.
Dr. Javier Mignone, Research Associate, Centre for Aboriginal Health Research, University of Manitoba: Thank you for inviting us to be here. As Ms. Linklater has explained, our centre is a partnership. It is university based, but it is a partnership with the Assembly of Manitoba Chiefs. Given that Ms. Linklater's presentation was very comprehensive, and I obviously agree with what she has presented, I will try to use your third report as a springboard to some of the issues that I would like to raise.
One point is that you identify the issue of data, of epidemiological data on mental health. There is, of course, a lack of good data; we agree with that, and that is an important endeavour that has to be continued. A good example that is going on is the longitudinal regional health survey of First Nations, lead by NAHO. That survey is gathering data in a broader perspective, and this is what I wanted to emphasize.
When we talk of mental health data, we cannot only look at the psychiatric aspects of it. That, I think, is a burden. Mental health is heavily weighed in terms of interpretation of the data, in terms of how we look at the system from a psychiatric perspective, and that is a very limiting factor. If you think of it, most of the acute situations, even chronic but severe situations of mental health, are only the tip of the iceberg of much broader and important issues that are going on in communities and with people. That is one thing. Added to which is the interpretation of the data. Data itself does not tell us anything; it is the interpretation of data which is important. As Ms. Linklater was saying, there are many different types of knowledge, but it is in the sharing of this interpretation that we will acquire the more meaningful type of information to enable us to pursue certain changes.
The second aspect, and this is specific to a term that has been used here, and that is cultural factors. I think I understand what you mean in terms of cultural factors that affect mental health, et cetera. I would suggest the use of structural factors, specific to First Nations communities, to Aboriginal peoples. The reason is that "cultural" in the sense that you are using that expression here, it is almost as if there were cultural factors because of the culture that are detrimental to mental health. I think the point is that there are structural factors, as again Ms. Linklater was saying, upstream factors and historical factors, that have a severe impact on the well-being of Aboriginal peoples.
I would like to briefly talk about this. We have been trying to pursue this avenue of research in the sense of trying to understand, from a research perspective, and get a better grasp on communities as the object of policy, and understanding what is it about communities that have such an impact on health in general, or mental health in particular. That is one line of reasoning.
We talk about social determinants of health, but specifically the terminology that is a bit more in use is the idea that there is a bit of a distinction between individual determinants of health and what we could call ecological level determinants of health. That is that there is something, for example, about community level features or characteristics, and even broader than that, per se, that above and beyond individual factors have an impact on health and mental health.
The other issue — and obviously if there is time, we can talk more about it; if not, there is some documentation out around this. The other issue that you raise is the fragmentation of services. We absolutely agree that this is a very serious issue. We had the opportunity to do a review of mental health services of FNIHB here in Manitoba. You have been provided with a copy of that report, and that is clearly one of the findings there. It is quite severe, and it is severe at several levels. It is severe intra-departmental, like within the same department there is an interesting "stove pipe" phenomena. I have experience with mental health agencies. Sometimes they just seem to be the worst. Obviously this has to do with the notion of being able to structure institutions, organizations, from a real sense of mental health continuum, and this is where it breaks down.
I will jump ahead a little bit to the issue of health care staff, to mental health staff. First, within the professional bodies, we have quite a divide. I will address this issue because this is one of the issues that your committee faces, and that you have also asked a specific question around. Psychiatrists are important, that is a given, but the truth is that they are minimally important in mental health. It is our particular experience in doing this work, and really having had the opportunity to talk with many of the community workers that Ms. Linklater was mentioning, such as the BFI workers, the BHC workers, the NADAP workers, that they are the ones who are essentially carrying the load, and they are the ones who lack support at several levels. Some of the things that they lack could be very simple things that would make a really big difference, in my opinion. One I would say has to do with the issue of salaries. For example, there is no salary scale for experience, so a worker could have 10 years of experience; a very skilled worker who has carried an important burden in the community in terms of helping lots of people, is receiving the same pay as someone who is just starting out. That has been identified.
Second is career development opportunities; to be able to have more training but also to receive real certification, and for the experience itself of certification. We know that formal education is not the only way to accredit people. We must look seriously at that, because the workers care about this. It also has to do with their professional pride.
Third — and I think many times this is lost — the workers need support in the sense of supervision, but they also need support in helping them to cope with what they have to deal with. They are dealing every day with very traumatic circumstances. They are also traumatized, and they have to be supported in that respect. I do not have time now to explain what specific mechanisms could be put in place, but this is an issue that has been raised by them repeatedly. This links to one idea that we did put in the report — and this is obviously up for debate, but it might be interesting — a creation of an Aboriginal mental health accrediting body, perhaps, in two ways: one, because it will be able to incorporate its community workers into some form of accreditation, but it would also require, for example, mental health therapists who do not have a First Nations background to meet certain criteria. What I mean is that we are parachuting people into these communities who have no background at all; they have no clue. Simply from a professional perspective, and not even talking about from a value perspective, that is a serious matter.
The last issue I have — and I do not know how much time I have left — is that you, the Senate committee, do embrace the issue of delegation, of transfer. I cannot remember the exact words that you used, but I would emphasize here again that if we are talking about delegation, that it be a real delegation; not the type of, "You do it; I decide" type of delegation. This is linked to the reporting mechanisms that are ongoing. This, again, is quite an interesting burden. Many of the communities are really doing a good deal of reporting — which, by the way, takes a tremendous amount of time from their work; time which they could be dedicating to working with people.
The serious matter of gathering information, I think it does go to a black hole. It disappears; that information is not used. If we do not use information, let us not gather it. In any event, it is putting the cart before the horse. Because information takes time and resources to gather, it is an expensive product; it uses lots of energy, and so, therefore, it has to be meaningful. This is something that community workers really are very frustrated about, and that also added to the ethical issues around it. In the case of a review, at least, of FNIHB, much of the information was going to FNIHB from communities through the mental health therapists with names and other identifiers. There was a real possibility of a breach of confidentiality there. Insurance companies do not ask for that type of information; Blue Cross does not ask for that type of information. Why is this being done when nothing is coming back from the gathering of this information?
Senators, there is perhaps more that I could say, but I will be short. Of course, again I think that Ms. Linklater presented a much more comprehensive picture of the issues that we were talking about.
The Chairman: Ms. Linklater, on page 12 of your presentation, you refer to two particular documents which I would like to know if you could send us. One is dated April of this year, and it is entitled "Overview of Gaps in Service and Issues Associated with Jurisdictions." Can you send us that?
Ms. Linklater: Yes.
The Chairman: The other one is the one in the next paragraph, which is essentially your primary care document, dated March 2005.
Ms. Linklater: Very well.
The Chairman: I know that there is some other material that you will see if you can send us, but I presume you can send us those two because those are already done and dated. Is that right?
Ms. Linklater: Yes. They are the ones that will be discussed next week at the senior official steering committee. There are three of those reports. The one, though, that is the fiscal analysis is expected in the fall 2005, so I am not sure —
The Chairman: No, I understand that, but if you could send us the others, that would be great.
Let me ask just a technical question and then a general one. In terms of service on reserves — I am only now talking about First Nations members on reserves. They are the only services that the Federal Health Department actually funds, is that correct? They do not fund services provided to First Nations members living off-reserve; they only fund services for people living on reserves, am I correct on that?
Ms. Linklater: They can provide for services off=reserve if you are going from reserve to off-reserve.
The Chairman: To get the service?
Ms. Linklater: To get the services.
The Chairman: Right.
Ms. Linklater: But if I am living in Manitoba, I can also get services such as my glasses, for example, which they will provide for me, so those kind of services are available, even though I live off-reserve.
The Chairman: They provide some off-reserve services, a bit like an insurance company, but for what we would all think of as traditional health services —
Ms. Linklater: Right.
The Chairman: — they provide on-reserve you said?
Ms. Linklater: Other than what is covered. Then Manitoba Health Services covers for us as well.
Senator Gill: I agree with you there, but provided that individuals are still attached to the reserve, they still are considered being on-reserve. Sometimes they are living off-reserve on a temporary basis, but they have to be considered as living on a reserve?
Ms. Linklater: Right.
The Chairman: Who pays for that?
Ms. Linklater: Manitoba Health.
The Chairman: On-reserve?
Ms. Linklater: Off-reserve.
The Chairman: On-reserve, the feds pay the physician, is that right?
Ms. Linklater: Yes.
The Chairman: Which really means that because there are no hospitals on reserves, the on-reserve services are basically primary care services, is that right? I mean what we would think of as primary care services?
Dr. Mignone: In most cases, except that Norway House has a hospital.
The Chairman: But as a general statement, it is primary care services that are provided on reserve, correct?
Dr. Mignone: Right.
The Chairman: Are those services provided by the federal government, contracting with the band council, the chiefs, some First Nations authority? Do the feds contract with them and they provide the service, or do the feds provide the service directly?
Ms. Linklater: It depends on what the service is. Sometimes the feds flow the money to the province, and the province holds money on a per capita basis for First Nations —
The Chairman: Right.
Ms. Linklater: — based on First Nations population in the region. Thus the federal government does have a health transfer policy agreement with the provinces here. Some of the services that First Nations receive come directly from First Nations and Inuit health branch contribution agreements.
The Chairman: What is the contribution?
Ms. Linklater: Contribution agreements for health programs and services.
The Chairman: No, contribution agreements to the band council or —
Ms. Linklater: Yes.
The Chairman: Very well.
Ms. Linklater: Depending on the types and range of services, sometimes the province will enter into an arrangement with a First Nation for specific health costs, so there is a multiple, confusing, assortment of health services.
The Chairman: I want to try to find a way to clear up the confusion. Given the description that you gave, would the First Nations people living on the reserve be better off if the feds contracted everything to the provinces, which in turn would be contracted to the bands? Basically, the feds got out of this business of, to get to Javier's point, putting all kinds of conditions on it. I mean, what are the feds usefully doing?
Ms. Linklater: The feds are just offloading, as far as we are concerned, to the provinces, and the provinces do not want that responsibility without money.
The Chairman: I understand that; they would have to get the money.
Ms. Linklater: However, the First Nations say, "If you are offloading to anybody, offload to us, because we are capable and responsible and have the capacity to undertake our own management of services, programs, and delivery, within our communities," and that includes the portability of individuals in our communities to the urban centres.
The Chairman: Is that universal? Surely there must be differences in the capacity of the various band councils to, in fact, take —
Ms. Linklater: Sure, and that has been agreed to. However, there is also the issue of aggregation, of support systems so that we can enter into agreements internally, amongst ourselves, to come to an aggregate support system for delivery of services.
Dr. Mignone: The tribal councils are a good example.
The Chairman: Right.
Dr. Mignone: Thus there are communities in which health transfer has occurred and, obviously, there is more control —
The Chairman: When you say "health transfer," you mean from the feds to the —
Dr. Mignone: To the communities or to a tribal council, but with others that has not occurred at all, or it is in between; there is a range there. As Ms. Linklater was saying, of course there are many small communities that in themselves could not provide the full range of services, but they can aggregate, and actually tribal councils are good examples of that; they can take on the control themselves.
The Chairman: Go ahead.
Senator Gill: Please explain for us a little bit the difference between tribal and band council, because I think some people —
The Chairman: I am using the words interchangeably.
Senator Gill: Go ahead.
Ms. Linklater: There are nations, and it encompasses all of the people of that nation. Then we have structures called tribal councils, the idea of which essentially came out of the original Indian Affairs regional offices. Sometimes tribal councils sprang out of that. We have seven tribal councils here in the Manitoba region, but we have nine independent First Nations, and they are not part of a tribal council.
Senator Gill: And you have 60-some bands?
Ms. Linklater: 63 bands.
Senator Gill: Often people are using a "nation" as a "band," or a band as a nation.
The Chairman: Senator Gill understands this because he lives on a reserve in Northern Quebec.
Ms. Linklater: A First Nations council is the community-based government body.
The Chairman: Let me use the word "council." Javier said that the federal government has downloaded, contracted — however you want to describe it — to some community councils, and in other cases it has not. What has been the difference? Why do some councils get the right to provide the service and some do not?
Dr. Mignone: I do not know the details. Perhaps, Ms. Linklater, you could —
Ms. Linklater: Some of the arrangements are dependent upon what services already exist. For example, Norway House First Nation has a hospital facility that had been the old Indian hospital from days gone by for regional health services, like the zone hospitals of the past. It is still there, and they would like to continue to provide enhanced health services and not lose their hospital. That was an agreement that was entered into.
The Chairman: Right.
Ms. Linklater: Other communities have smaller populations so they then go to, say, Thompson, or to the nearest urban centre to access health services, depending on what their health needs are. There are also the regional, the community nursing stations, which are run through the First Nations Inuit Health Branch.
Dr. Mignone: There is a historical process here. We can provide — actually, people in our centre did an evaluation of health transfer last year. For some reason, I do not think they have allowed us to release it.
Ms. Linklater: It has not been approved yet.
The Chairman: By whom?
Dr. Mignone: I think it is FNIHB.
Ms. Linklater: There is a working body, a national working body, that also includes First Nations.
The Chairman: If you can get the title of that document, I can get my hands on it.
Dr. Mignone: Sure. I have a pirated copy of it.
The Chairman: That is even better. That makes my life easier.
Dr. Mignone: There are historical reasons, and there are negotiations that occur. The bottom line is, there are several factors that explain why certain communities or certain tribal councils have transfer and others do not.
The Chairman: Let me tell you what my frustration is and then I will turn to my colleagues. My frustration is that you have a situation in which, by any measure you want to use, the services that are provided that are directly funded by the federal government are not very high quality, and in large measure the evidence that we have — which is anecdotal, granted — is that they constitute a hindrance to providing better quality services. I am not trying to save the federal government money, not in the slightest; what I am trying to do is get rid of an obstruction.
I suppose my question is — and I do not need an answer today; I would like you to think about it — what is the model that would meet the following two objectives, one of which is to download as much as possible while maintaining some element of accountability. I am not referring to the stupidity of collecting information that nobody uses, but how do we balance that, even if it meant the federal government, in a sense getting rid of the First Nations and Inuit branch because it just became a financial transfer? I would love to know what that model is. If you have any thoughts on that, we would like to hear them.
Dr. Mignone: Health transfer, I think, is a good model precisely because it also would allow —
The Chairman: Why can we not do it everywhere?
Dr. Mignone: I cannot answer that question. As I say, maybe if you want to read that report, that might provide some insight. It was quite a comprehensive evaluation. I participated in visiting, in some cases; I did case studies, but I do not have the global picture so I do not want to answer.
The Chairman: Very well.
Dr. Mignone: That is because the tribal council, for example, could also potentially contract with the province certain services. It gives more flexibility. What we saw in the mental health review, that was a good example. Tribal councils were providing mental health services.
Senator Keon: You covered a lot of ground, Ms. Linklater. In any event, we have drifted into a discussion of Aboriginal health as opposed to Aboriginal mental health and addiction disorders, and mental illness. Let us try to drill down, in this tremendously complex system, and discuss Aboriginal mental health, addiction, and mental illness.
The rest of the country does not have to deal with the burden of three systems. They are dealing with the burden of two systems but you are dealing with the burden of three systems. It would appear that a small province like Prince Edward Island, in coming to grips with this situation, would best be served by a major investment in combined primary care and community care, with mental health service delivered at that level, with the appropriate social services, the appropriate medical services, and the appropriate mental health services. Of course there could be an integration into a system, and the patients would need to get out of Prince Edward Island into Halifax for some of these sophisticated services, and so forth. There is an analogy there to the situation that you are dealing with.
Senator Kirby and I have had discussions, together and separately, with various provincial ministers of health about how we might be able to come up with a report that would make it easier for you to walk through this system.
It seems to me that you are imminently positioned, with your culture and so forth, to construct and provide the community systems you need, which would be a combination of primary care, social services, et cetera, and building on top of that platform, that infrastructure, you could provide good community mental health services, deal with the whole nine yards in policy and money, when people are out of money, et cetera. Then you would need to go up to a stage two, or level two of care where you have to get your mentally ill patients into a provincial system some place, because the systems are all provincial. Indeed, when you get up to level three, you fundamentally are back into a national system, even though those systems are provincially controlled, because there are only a few major sophisticated centres in the country.
The question then becomes, what construct, what structural framework will work best for you in order to design that system? Senator Kirby just raised one possibility for you, which you quickly dismissed, and that was, flow resources to the provinces and let the province work with you. Fundamentally you said "No, culturally we cannot have that. If the money is to flow to anybody, let it come to us and we will construct whatever system we need," which I have tried to just describe, drawing out of your presentation, "And we will fund it as we see necessary." Thus we must grapple with this in our report.
Ms. Linklater: I also said at the beginning that we are open to and have always been receptive to sharing within our co-existence a collaborative relationship. I did not dismiss outright or in totality the opportunity for engaging in partnerships, because we have already demonstrated that we are engaged in partnerships.
Senator Keon: I understood that very clearly. I am trying to simplify things, but clearly you cannot live without partnerships, and you did say that very clearly. However, from our point of view — let me add the other piece which came up this morning in Dr. Mignone's presentation, and that is accreditation, which I think is absolutely essential. Senator Kirby and I have not discussed this yet, but in my opinion this will find its way into our report, and we will discuss it later. I think it is absolutely essential that you have accreditation at every level, even your little peripheral operations where it may just be a nurse, up to the bigger community clinics which will have primary care specialists, nurses, doctors, social workers, psychologists, et cetera, so that you have this ongoing feedback in the design and function of your system.
Let me come back to you, Ms. Linklater.
Ms. Linklater: I have a lot of hope riding on the first minister's meeting that will take place in the fall, as well.
Senator Keon: Yes. It will take you years and years — some years, anyway, to put in place what you really need, right?
Ms. Linklater: Yes.
Senator Keon: If the vision for it could be clearly developed, it will come. Would you then take a couple of minutes and tell us, if you were queen of the world, what you would envision and what you would implement?
Ms. Linklater: For a "constructural" framework that would best work for the design of a system with respect to mental health, mental illness and addictions, if I were the Chief of Canada I would say that we need to look, first of all, at the community resource base, and that means people. If we can look fundamentally at the first premise of how to strengthen an individual's community, then that will have the impact of addressing problems of people being institutionalized, whether they are in penal institutions within the justice system or in mental health institutions. Certainly, I know that some physiological or biological things happen to people, whether it is at birth or through time, and that there are complications and mental disorders that sometimes require institutionalization. However, I think that the part of mental health and mental illness and addictions that is not looked at enough, and that is probably a complexity, is that people are seeking to adjust within their cultural self-worth, and that builds on a resilience for human nature or the human being to be a part of self-respect, self-recognition, and be part of a community, to strengthen the family, to be responsible, as well as be entitled to what all other people have with respect to services.
Therefore, I would say that it is important to look at the cultural underpinnings and the relationships first, as a foundation for that structure. It must be community-based health in a broader context but, as you say, when we get into — I think that if we look at that in a big way, a big investment is made just in looking at the strength of the individual in the community, that we would see less people requiring more complex mental health, mental illness and addictions treatment and institutional services.
The Chairman: No question.
Ms. Linklater: Then I would say that there is a necessity to look at how to strengthen services, as you mentioned, at the second level I think you called it, and the third level responsibilities, and that those existing institutions be enhanced to be inclusive of looking at the cultural dimensions in order to meet the particular issues of First Nations when it comes to healing. I am talking here of healing medically, mentally and spiritually, in the holistic way. I am not saying that we need to build new structures but we need to look at sometimes redesigning the programs and services as to how medicine or science applies its treatment services. We can also look at prevention. Thus I am looking at the spectrum of prevention and education as the first step, which then begs the question: what kind of services would there be then as far as treatment is concerned.
For example, there is the Addictions Foundation of Manitoba, where my husband works with addictions and with gaming addictions. Gaming is a new area of addiction for First Nations people. Thus the mandate needs to be broad. Of course, there is also the family violence issues. That is an illness that relates to abuse of elders, families and children. I think the thrust has to come from within the community and the people to gain that strength and build from there. Also, the institutions have to be changing at all levels.
Senator Keon: But the big investment has to come at the community level?
Ms. Linklater: It has to come at the community level where the people must do it for themselves: build that strength and capacity, and then be able to contribute towards how the changes can be made for the individuals who are not able to be healthy within that first level, the community level, but require the services, at levels two, three or four, whether it is mental health institutions or penal institutions, and so forth.
Senator Keon: I think you have been very clear. I can read what you are trying to say very clearly. I hope we can express it as clearly and be supportive of you, and I hope you achieve it some day.
The other interesting thing about this situation is that you have no aspiration to become queen of the world but you would like to be chief of Canada.
Senator Gill: I really enjoyed your presentation, Ms. Linklater. I think it confirms a great deal. I also liked your comments about the agencies, mainly. Sometimes it is good for the people; sometimes it makes people more sick, it seems, or it is like something else. Anyway, it confirms, really, what we heard yesterday from the chiefs from the Assembly of Manitoba.
You see, for example, I will take your first point at the bottom of page 10, where you say that First Nations must lead every step of the way in working with the Crown governments and their departments, as well as academic institutions, et cetera. I think this is the thing that people sometimes have difficulty understanding. While we are talking about health services and things like that, you are talking about political structures; you are talking about culture. It is very difficult, usually, when doing that to be understood by the public in general, because people are asking themselves sometimes why the Aboriginal people are following that route. Are they asking for some special treatment? As you know, the treatment or the services are there for the non-native, so why not have the same services for the Aboriginal people across the board? On a rational basis, people used to say that. I have been hearing that a lot all over, but mainly in Ottawa. This is the place where we hear all kinds of things, good and bad.
I know it is very difficult to make this point because people have difficulty in imagining that, at the beginning, the objective of the government was integration, meaning assimilation at that time, and that was the case for a long time. I have been living on the reserve, so I know that. Assimilation means that you have to become the same as everybody else, so the same services should apply to the Aboriginal people in the same way as they apply to the others. It is very difficult to make people understand that. I think it has to be repeated, even though we have been hearing that quite often across the board. It is always difficult to obtain something.
Also when you said that First Nations must lead every step of the way, if it is every step it should not start only at the provincial level; it should start at the national level. What I mean is that the Assembly of First Nations eventually have to deal with the Indian Affairs Department, but eventually I imagine they should be dealing with Parliament, or with the government directly instead of going through all of the machinery of Indian Affairs. Even at the regional level, in Manitoba or in Winnipeg here, you have a regional office and you must go through the regional office; you must go through the health services agency. Those people have been dealing with the public servants in Ottawa, and they decide the policies that should apply across the country.
I would like to hear your comment about that. I imagine that, in order to be able to control your own system, you would eventually like to see the budget being dealt with directly by Parliament, or perhaps by the minister responsible, but not through the public servants. What is your comment on that? Remember that they establish the conditions.
Ms. Linklater: I will start by saying that for too long we have been `administrated' by a federal department, so we have asked for a dialogue to begin in order to put in place a relationship building process; to begin to look at ensuring that there is a direct relationship with the Crown, so that we can begin to consider having institutions that give respect to that relationship, which was based on treaty. For us, that is really paramount.
In order to begin looking at such a relationship, however, I would point out that there is a gap — I will call it a gap — in the relationship between the constitutional arrangements as set out by Canada, having established an administrative body called Indian Affairs, whose powers in this regard are now delegated to a federal department called Health Canada, to FNIHB, and that structure filters the money. This has all happened, mark you, without our involvement.
Therefore, what we are asking is that consideration be give to establishing an entity which requires a direct relationship to, if not the Prime Minister then to the Privy Council; to primary decision-making bodies that have a fiscal arrangement directly with First Nations, and a direct First Nations-to-federal government relationship, a nation-to-nation relationship, if you like. As what may at one time have been identified as — let us look at what the Charlottetown accord said with respect to a third order of government. I am not saying re-open the constitutional discussions, but let us look at borrowing that Charlottetown accord process that said, let us strike up what they called a third order of government, which speaks to a direct relationship, so that we, as First Nations, do not have to be filtered through a provincial or a federal decision-making process. I see that we are getting closer to that kind of arrangement. If we are to have it as it was in that accord — and I have a copy of that in my briefcase — that was struck between the Prime Minister and the national office for a policy decision-making body arrangement, that is created according to that accord, it would be called a First Nation Federal Crown Accord. That would be going beyond, I hope, more than a policy exercise, but we will be looking at implementation of policies that would be more reflective of a genuine relationship.
That, then, requires not only looking at socio-economic issues but requires that a fiscal arrangement be in place. That fiscal arrangement, as I see it, needs to come directly to the First Nations people. What that entity will be has yet to be identified by the people through a dialogue with the federal and provincial Crown, which I hope will be coming through when we look at that new accord that is in place, because there is an accord already in place with other national Aboriginal organizations, as they are classified, as being recognized by Canada. There is the Metis Nation Council, the Native Women's Association of Canada, and the Inuit organization, and also the Congress of Aboriginal People.
We do have our political issues as well with respect to representation, but I am hopeful that we will see a lessening of that gap that exists between the constitutional relationship; that section 35 really is given full meaning; that there is to be a structure of some type of arrangement in place to give life to section 35, and that it brings us to the centre as equals, at parity of the First Nations to that of federal and provincial bodies.
Senator Gill: It is difficult to make just that point that you have tried to explain. However, suppose we have some success there; that the Indian Affairs Department is no longer there as such, and you are then dealing with the Privy Council, or with a minister appointed by the government to deal with the Aboriginal First Nations. Suppose that you are able to deal with those people. Then after that, when you have the control, when you can establish your own priorities and your own conditions and policies, and things like that, once you have that, what will happen about the services that you would like to have, that you do not have on the reserve, and that you cannot provide through your own people because you do not have the expertise, or training, or whatever? What would you do then?
Ms. Linklater: I would say that you look then at the existing institutions that are provided through the provincial and federal jurisdictions, as I will call them, and that we then set about providing services for and by First Nations. However, why can there not be some interchange, and reciprocity of services, programs, delivery and policy work that could be done through a tripartite process, tripartite arrangements, or bilateral arrangements, whether they are bilateral between the provinces and the feds, or between the provinces and the First Nations, or the federal government and the First Nations peoples? There already exists the uncertainty and jurisdictional wrangling, as the Prime Minister called it. Let us lay out some arrangement whereby we can have an involvement of the First Nations. There is a way, I believe, whereby we can have an arrangement so that services of existing institutions can be maximized to support First Nations, as well as support the general population.
Senator Johnson: I think we have covered a lot of territory that I was about to ask you about. I am wondering, there are 115,000 First Nations people in Manitoba, and you say 56 per cent are on-reserve. Does that mean that 44 per cent are urban and non-treaty, or are they urban and treaty status in the cities? Do you have any figures on that?
Ms. Linklater: First of all, the accuracy of the statistics right now on the numbers is questionable. The sources is either the Indian Registry, Census Canada, or FNIHB's own data, but the reference to the 56 per centage of First Nations people on-reserve refers to First Nations who are the registered Indians, classified under the registry system, who are entitled to medical service benefits for health. Those who are off-reserve, are they classified as registered Indians under the federal system?
Senator Johnson: Are you saying that the services that they receive on-reserve would be different than the services received by the ones in the city in terms of access to care?
Ms. Linklater: Yes. As long as you do not leave. There is a residency issue there, that once you have been away in hospital for three months, then you no longer have that benefit; you then must go to the province. There are other complications that can arise, such as if you go away to school, or if you leave and then you have palliative care requirements, you cannot go back to your community because medical services does not pay for your trip back home to die with dignity. You must take care of your own costs.
Senator Johnson: Yes, that is one of the things that has to be corrected, absolutely. It leads me to ask you, you talk about a culturally relevant holistic model of care. Would you mind elaborating on that, as it would be doable in both settings in which you are involved, reserve and off-reserve? I think it is a critical part of the whole process of healing and of delivery of care, but I think, too, it has to be really organized in terms of the two populations.
Ms. Linklater: We see ourselves as one whole population, and geography does not make a difference to us, but we know that physically and geographically —
Senator Johnson: I am talking physically, not culturally.
Ms. Linklater: The same application of programs and service context or content, philosophy or foundation treatment can be the same whether you are on-reserve or off-reserve. It does not matter: the same principles, the same goals, the vision of prevention, education and treatment would be the same, no matter where you live.
It can be applied to non-First Nations programs and services as well, if there is an acceptance to having that kind of holistic, spiritual, mind, body, cultural foundation. Physiological, spiritual, emotional, mental, that is culturally based and relevant to you, however you see that philosophy being helpful to you as a human being in your lifestyle. In the same way that many people who go to see other cultures, like the Chinese or the Asian cultures, or the Hindu cultures, and find them helpful to them in their healing journey, the same would be true here.
Senator Johnson: Right. When we were doing our Urban Aboriginal Youth Study in the Senate two years ago, we had statistics showing the number of young people of First Nations culture, and half the population was under the age of 25. That is still accurate, right?
Ms. Linklater: Yes, that is true.
Senator Johnson: What is being done in terms of involving those young people more and more? When we meet with and talk to the youth councils, there are some very proactive young people, and they really want to get involved and do more. However, many of the ones that we met were in the urban centres. We went outside of the urban centres as well, but the spokespeople were groups within the urban centres. What about the other young people on-reserve?
Ms. Linklater: There is a national body of a youth council, and there are regional youth council. Those also exist in the communities, a sort of youth representation. One of the problems that they have is access to funding. There is really no specific funding for youth engagement at the community level for, say, the youth suicide strategies.
In Manitoba here, we have funding for youth through the Assembly of Manitoba Chiefs, but every year we fight for that funding. We sometimes do not get our funding until October. Our own budget, our core budget at our office covers the staff so that they do not have to be, shall we say, laid off from there. However, that has been a constant struggle for us.
There is a direct relationship between the youth council of our region and the community of Winnipeg, with other linkages to other urban centres, and the youth council directly works with the communities. They go to the communities; they have a strong relationship with the young people; they have camps for youths — more now focused on youth suicide because that has been a big problem for the young people. They want to be engaged; they would like to be with their own peer group to share those experiences and not be — how do I say it — they want to have their own peer group program, counselling and support systems that is given some respect. They do have elders working with them as well, and they have cultural teachings, and also many of them have academic training, so there is a blend of education and teaching.
Senator Johnson: Are they satisfied with some of the programs? We saw a lot of very positive programs, the ones in Winnipeg, for example, the Aboriginal Centre and Thunderbird House. I think there are some very positive things happening as well that we should talk about in terms of the overall work being done. Do you have any comment to make on that, such as are there other programs on which you could enlighten the committee that are really being helpful in this whole area of mental health?
Ms. Linklater: We also have a very strong active First Nations women's group within our region, as well as nationally. They also go internationally, to the international forums to express the views of women with respect to health, mental health, family violence, protection of children, and also with respect to our citizenship. By virtue of the fact that Indian Affairs' policy is that some communities, like for example the Brokenhead First Nations, studies have told them that within the next generation or two, there will not be any registered Indians in that group, and that is the end of the line as far as looking at whether or not they are recognized as First Nations people. That is another area that we are working with.
Senator Johnson: One thing you said was that, in future, you would like to deal with the Privy Council as opposed to any other arm of government. Does that mean that you would like to see the Department of Indian Affairs —
Ms. Linklater: Disappear?
Senator Johnson: Yes.
Ms. Linklater: That is the focus of the self-government process, is to downsize or to displace, I will call it, the Department of Indian Affairs. Not just that department but any other federal department that has a direct, specific service or program on First Nations. As First Nations, we do not want to have to just take what they give us, even if it is faulty; we do not want to inherit something that is already problematic. The idea of self-government is that you scale down the requirement for having a direct responsibility held by a government for you. That is what we aspire to. The fiduciary responsibility does not necessarily get eliminated, but to the extent that First Nations have their powers and authorities held by themselves, the entitlements and obligation, then go with that —
Senator Johnson: Why did the Nault initiative fail, in your opinion?
Ms. Linklater: It failed because it was not initiated with or by First Nations people.
Senator Johnson: Did you not see anything positive in it?
Ms. Linklater: I would say the Nault report was not unique in that it was not a creation of ideas just unto itself; it borrowed from what we were already working on, as far as self-government processes and discussions with government through the constitutional accords such as Meech Lake and Charlottetown, for example. Those were already in place. It was just presented as a package that we were supposed to accept, and that was not acceptable to have it done in Ottawa and imposed upon us. It was accepted by some groups and some bodies or organizations across the country, but in the way it was done it was an imposition.
Senator Johnson: You were not leading it?
Ms. Linklater: We were not leading, and we did not accept the approach.
The Chairman: Are there any last questions or comments?
Senator Pépin: I have to admit that my question regarding the support system for youth has been answered. The only other thing, also with respect to women and violence against women, I am quite involved in this issue, and I meet some of the women's representatives when they come to Ottawa. I only hope that our committee will be able to make a good recommendation, where it will be possible to have a true partnership with the Aboriginal community.
Senator Keon: One brief comment: Dr. Mignone, I did not have time to draw you out on your very important suggestion of accreditation. I wonder if you could commit your thoughts to paper, just a couple of pages, and send them to us? That would be helpful, if you would.
The Chairman: I thank the two of you for coming. I know we prevailed on your time a lot longer than we said we would, but thank you very much. You were really great.
The committee adjourned.