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SOCI - Standing Committee

Social Affairs, Science and Technology

 

OUT OF THE SHADOWS AT LAST 

Transforming Mental Health, Mental Illness and Addiction Services in Canada

The Standing Senate Committee on Social Affairs, Science and Technology


PART III
Service Organization and Delivery


CHAPTER 8:
WORKPLACE AND EMPLOYMENT

 

It is in the workplace that the human and the economic dimensions of mental health and mental illness come together most evidently. On the one hand, the workplace can contribute positively to mental well-being — it is where we derive a good part of our sense of social integration. As Merv Gilbert, a psychologist at the Mental Health Evaluation and Community Consultation Unit, Department of Psychiatry, University of British Columbia, told the Committee:

Work provides a sense of structure, social meaning, social supports, a place to go outside the home…and it also provides an income, which we do know is good for your mental health.[298]

Work has also been found to play an important role in recovery from mental illness.  Employment decreases the rate and duration of hospitalization and enhances quality of life. Surveys show that most persons living with serious mental illness want to work and see employment as a primary goal.

But few are employed. In fact, unemployment for persons living with serious mental illness is estimated to be as high as 90%.[299] In addition to unemployment, exclusion from the workforce often results in dependency on income security programs for survival. Unemployment leads to impoverishment and reduced social engagement, which in turn may worsen mental and physical illnesses. It also contributes to feelings of worthlessness and depression, and can lead to substance abuse.

While participation in the workforce can contribute positively to mental health it can also contribute to the development of mental health problems, including stress, depression and anxiety. Mr. Gilbert added that:

Therein we have one of the fundamental paradoxes we face today: Work is good for your mental health and work can make you crazy.[300]

The issues surrounding mental health and the workplace are complex and multifaceted. As professor Romaine Malenfant from the Université du Québec en Outaouais told the Committee:

Research increasingly shows that we must not only counter the lack of work, or unemployment, in preserving mental health, but also preserve the quality of work so that work plays its full role in building identity and enabling people to achieve their full potential.[301]

8.1        UNDERSTANDING THE HUMAN COSTS OF MENTAL ILLNESS IN THE WORKPLACE

8.1.1     The Many Factors That Contribute to the Development of Mental Illness

Exploring the complex relationship between work and mental health, professor Marc Corbière, from the Institute of Health Promotion Research, University of British Columbia, told the Committee:

…it is not always possible to establish a causal relationship between mental health problems and the workplace. Sometimes, factors stemming from both work and outside of work can explain the occurrence of mental health problems.[302]

In a recent article, “Nature and Prevalence of Mental Illness in the Workplace,” Carolyn Dewa and colleagues point out that:

The picture of mental illness in the workplace is becoming increasingly compli­cated. It is clear that there is a link between mental illness among workers and work-related stress. In turn, both of these are likely to be related to occupation, the work environment and the sex of the worker.

There is also evidence of an association between mental illness and physical disorders. Yet, few studies have considered how all these various factors interact to affect the prevalence of mental disorders among workers. Even fewer have consid­ered their relative contributions to disability in the workplace.[303]

The authors note that many factors contribute to the development of mental illnesses such as depression, but that no one really knows as yet how they all interact:

Yet, the most advanced etiological models of adult depression include factors related to genetic vulnerability, as well as develop­mental factors, neurobiological factors, childhood experiences, life events, chronic situations (e.g., a stressful work environment) and the presence of other disorders. …It is not yet understood what the due weight of each of these factors is and how they fit together.[304]

There are many ways of classifying the risk factors that contribute to the development of mental illness. In her testimony to the Committee, Lucie France Dagenais, researcher for the Commission des droits de la personne et des droits de la jeunesse in Quebec, identified two broad categories of risk factor:

The first are those related to social relations in the workplace. This includes violence, harassment, lack of social support and poor work relations. The second category includes those found in the work organization, which are much less known on an analytical basis. We identified work intensification, lack of flexibility, non-standard work schedules, lack of recognition, lack of expression groups, advancement on the basis of merit and flexibility.[305]

However, as Michel Vézina and colleagues point out in a recent article, “there is a regrettable absence of scientific consensus on how to define and measure a high-risk psychosocial work environment.” These authors define “psychosocial factors” as those that “refer to all organiza­tional factors and interpersonal relationships in the workplace that may impact health.” Among the factors that “make it possible to document the stressful nature of a work situation” they list:

…control (latitude, participation, use and development of skills), workload (quantity, complexity and time pressures), roles (conflict and ambiguity), interpersonal relationships (social support, harassment and recognition), career prospects (promotion, precariousness and demotion), organiza­tional climate or culture (communication, hierarchical structure and fairness) and the interaction between work and private life.[306]

Negative attitudes towards mental illness remain widespread throughout society and can compound the difficulties generated by conditions in the workplace. Employers and co-workers may fear people living with a mental disorder; they may think of persons with mental illness as unskilled, unproductive, unreliable, even potentially violent.[307]  These unwarranted perceptions may contribute to a reluctance to hire someone with a history of mental illness, or to limit that individual’s career advancement if a previously undisclosed mental illness is revealed.  Job loss is also a possible danger for those with the courage to “come out” of the closet at work.

It is important to recognize that this lack of understanding of the relationship between work and mental illness is not only an issue inside the workplace; it extends also to health professionals.  Merv Gilbert told the Committee:

 

Most mental health providers do not have a clue — I say respectfully — about what goes on in the workplace. Typical GPs faced with a patient coming in tears with a diagnosable disorder and being asked to make decisions about whether or not to stay at work, to return to work, how to deal with workplace issues, often are poorly informed. They may have a poorly written job description in front of them, if they are lucky, on which to make a determination as to whether that person should be at work, how the individual should be accommodated and what kinds of issues should be addressed. Therefore, I strongly suggest we need to educate the health care system as well.[308]

 

8.1.2     The Episodic Nature of Mental Illness

The episodic and cyclical nature of most mental illnesses is another factor that makes it harder to assess the impact of mental illness in the workplace. It creates additional difficulties in making the necessary accommodations at work for people living with mental illness. Unlike other disability groups, people with mental illness are rarely ill continuously; rather, they tend to cycle between periods of illness and wellness. When they are symptom-free, they are usually able to work and carry out the normal tasks of life. During episodes of psychiatric illness, however, they may be incapable of functioning at a level that would permit them to work in regular, full-time employment.

The cyclical, episodic, and unpredictable nature of serious mental illness can impede the establishment of a long-term and stable employment history. Having unexplained work-gaps on one’s resumé poses a formidable challenge when seeking to return to employment.

 

8.1.3     The Varying Nature of the Relationship Between Mental Illness and Work

People fall into a number of different categories, each of which confronts its own particular challenges with respect to employment-related mental health issues.

In many cases, the onset of a mental disorder occurs in late adolescence or early adulthood, at a time when the affected person’s education and training are not yet complete.[309] The process of obtaining qualifications can be interrupted, often never to be resumed. Young individuals in this category are significantly disadvantaged; their lack of skills and qualifications constitute a major and lifelong barrier to future employment.

For others, their careers may be disrupted by serious mental illness or addiction. Many never regain their foothold in the marketplace. For those who do find work, the periods outside the labour force caused by their mental illness often hinder their re-entry.

Three key barriers apply. First, individuals may be subject to discrimination by their employer and/or co-workers. Second, to cope with their illness they may require flexible work arrangements that employers are unwilling, or do not know how to provide. And third, those who have been outside the labour force for extended periods are unlikely to have the type of credentials, skills and employment experience that make them attractive to employers.

Finally, there is the broad category of people who are currently employed but whose productivity is affected to varying degrees by mental health difficulties, a state often referred to as “presenteeism.”

This diversity means that the issue of mental illness, addiction and work has to be explored from a number of different perspectives: making employment accessible to individuals who have never had a job; enabling individuals who have lost their job due to mental illness or addiction to reintegrate into the labour market; and studying how mental illness and addiction affects currently employed individuals.

 

8.1.4     Many Unanswered Research Questions

A review of current research illuminates how little is known about work-based mental illness and stress-related disorders, in terms either of defining the scope of the problem or establishing best practices to manage it.[310] In a recent article, Elliot Goldner and colleagues note that:

 There has been significant research activity on workplace health that has considered disability management, return to work and treatment. For the most part, however, such research has not directly addressed mental health problems or mental illness but have been focused upon various physical health problems encountered in the workplace (e.g., back injury and other musculoskeletal problems, brain injury, cardiac illness and chronic rheumatic diseases).[311]

They also point out that the paucity of research into mental health at work is not a new phenomenon:

In an article in 1993, Rachel Jenkins asked why mental health at work was so under-researched. More than a decade later, the same question remains relevant. There are many gaps in knowledge to be filled. Little is known regarding best practices in managing the disability associated with the most prevalent mental disorders (i.e., depression, anxiety disorders and substance use disorders). Although some information is available to assist people with severe mental disorders in obtaining employment, knowledge to help people maintain employment is lacking. Additionally, knowledge regarding systemic factors that influence disability management and return to work (e.g., employee assistance programs and disability insurance regulations) relevant to people with mental disorders is yet unavailable.[312]

Importantly, a further barrier to integrated research into mental health at work originates in the fact that specialists in different fields do not always speak the same “language.” This point is well made by Aldred H. Neufeldt:

A major challenge is that much existing knowledge is subject to what might be called an “isolated pockets syndrome.” The different kinds of research…are published in different types of journal, with cross-referencing infrequent. Epidemiological journals examine the relationship between functioning and psychiatric impairment. Occupational psychology and health literature examines topics such as workplace stressors, health, performance and absenteeism. Literature on rehabilitation and psychiatric fields examines specific treatments for psychi­atric conditions, along with the effective­ness of interventions such as short- versus longer-hospital stays, supported employ­ment, case management and others.[313]

For employers and employees alike this “language” diversity makes it even harder to establish best practices derived from full reviews of the scientific literature.

8.2       THE ECONOMIC IMPACT OF MENTAL ILLNESS IN THE WORKPLACE

To repeat, there are many important gaps in the research into mental health in the workplace. In its interim report, the Committee noted the absence of definitive statistics on the prevalence of mental illness and addiction in the workplace.[314]

Nonetheless, the Committee was informed that disability claims attributable to mental illness have overtaken claims associated with cardiovascular disease as the fastest-growing category of disability costs in Canada. Currently, mental illness and addiction account for 60-65% of all disability insurance claims among selected Canadian and American employers.[315]

Dewa and colleagues report that:

Over the last few years, the number of disability claims for mental disorders has been soaring. Between 1989 and 1994, according to the Health Insurance Association of America (1995), such claims doubled. In Canada, short- and long-term disability related to mental illness accounts for up to a third of claims and about 70% of the total costs — $15 to $33 billion annually.[316]

When compared to all other diseases (such as cancer and heart disease), mental illness and addiction rank first and second in terms of causing disability in Canada, the United States and Western Europe. Of the ten leading causes of disability worldwide, five are mental disorders: unipolar depression, alcohol use disorder, bipolar affective disorder, schizophrenia and obsessive-compulsive disorder.[317]

Moreover, as the Global Business and Economic Roundtable on Addiction and Mental Health has pointed out, mental illnesses — depression, anxiety disorders and substance abuse — are concentrated among men and women in their prime working years and among people aged 15 to 24.[318] Those Canadians most likely to experience a mental illness are amongst those at the heart of our working and consuming population.

Mental disorders, unchecked and disabling, impair the capacity of a significant segment of our population to contribute actively to the economy. Innovation and productivity are increasingly key to economic growth and prosperity. Mental disorders should be recognized as a leading source of disability among those we rely on to wield these critical levers of growth and competitiveness.

Productivity is affected both by “presenteeism” — days during which an individual is present at work but functions at less than full capacity — and by absenteeism — days during which an employee did not report to work. Mental illness and addiction are among the most important causes of absenteeism and presenteeism worldwide: a 1998 report of the World Health Organization observed that “more working days are lost as a result of mental disorders than physical conditions.”

In Canada, 20% of the normal work time of employees suffering from an undetected mental illness or addiction is not productive because it is “taken off.” Absenteeism at this rate is four times the rate of unaffected co-workers.[319]

Dewa and colleagues point out that:

It has been observed that a significant proportion of the burden of mental disorders arises from presenteeism days…This disability pattern distinguishes mental disorders from chronic physical conditions. Chronic physical conditions are associated with total disability days, while the predominant effect of psychiatric disorders is on partial disability; in fact, psychiatric disorders were responsible for 23 times as many partial disability days as total disability days.[320]

The value of lost productivity in Canada that is attributable to mental illness alone has been estimated at some $8.1 billion in 1998. More recently, if substance abuse is taken into account as well, that estimate grows to a loss to the economy of some $33 billion annually. This corresponds to 19% of the combined corporate profits of all Canadian companies, or 4% of the national debt.[321]

The costs of mental disorders in the labour force in Canada fall mostly on employers and employees through their payment of operational, payroll, premiums and out-of-pocket expenses. In statements made to the Global Business and Economic Roundtable on Addiction and Mental Health,[322] a number of major Canadian companies have indicated the extent of the costs of mental disorders in their workforces:

§         At CIBC, mental disorders produced absences averaging 95 days, compared to 40 days for other illnesses.

§         Great-West Life Assurance Company estimates that 30% of disability insurance claims relate to mental illnesses, and in the remaining 70%, a quarter or more have mental illnesses as a secondary or underlying diagnosis.

 

8.2.1     The Impact of Global Economic Trends on Mental Health Issues in the Workplace

Two trends, both highlighted by the Global Business and Economic Roundtable on Addiction and Mental Health, are of great significance for how mental health issues in the workplace must be addressed in the 21st century.[323]

The first — the growing importance of knowledge, and of brain-based skill sets generally, to economic performance — provides a major positive incentive to address mental health issues in the workplace.

The second — the demands imposed by an investment-driven, globally competitive economy — reinforces the first trend in many ways, but it can also be the source of significant risk factors for mental illness in the workplace, in particular by increasing the level of stress placed on employees.

Most new jobs today demand brain-based (cerebral) skills and not the manual ones that were so important to previous generations. If it is true (as it almost certainly is) that we are in the midst of the emergence of a brain-based economy, mental health issues must now become front and centre in the economic affairs of Canada. 

This new reality is increasingly recognized at the highest levels of corporate Canada. Gordon Nixon, President and CEO, RBC Financial Group, has been quoted as saying that “this is an economy of mental performance and this defines the capacity of employees to be innovative — to think — a key asset.” Robert MacLellan, Executive Vice-President and Chief Investment Officer of the TD Bank Financial Group, has pointed to the importance of mental health in this context: “High rates of mental illness (brain-based disorders) rob our economy of employee capacity to be productive, innovative.”[324]

The Honourable Michael Wilson, former special advisor to the Health Minister on mental health in the federal government workplace, has formulated what the Global Business and Economic Roundtable on Addiction and Mental Health calls “The Wilson Principle”:

We have seen tremendous progress in preventing physical injuries and illnesses at work. The safety records of companies I am associated with are a source of great pride to them. I strongly encourage employers to build on these achievements.

It would be a shame to un-do 30 years of great progress in physical health and safety as a result of massive losses of productive capacity due to untreated mental illness in the workplace, especially depression.[325]

Evolution of the economy has thus produced a new and costly convergence — the advent of a brain-based economy at the same time that brain-based disorders are becoming the principal cause of disability in the labour force.

 

 

However, the implications of this new reality are not always immediately apparent, especially given the second trend mentioned above. The tendency for business to face intense pressure, especially from investors, to maximize shareholder value has led some companies to lay people off, and to struggle to “do more with less.” Beyond the tremendous human costs for the people involved in massive corporate downsizing, it is also important to recognize the possible longer-term consequences of this strategy for the enterprises themselves.

In an economy that puts a premium on workplace productivity and innovation, the prudent deployment of human capital is critical to competitive success. Human capital is really productive capacity. In an economy based on the mental performance of employees, the capacity to think, concentrate and innovate is critical. Strategies that undermine this capacity are likely to have detrimental effects on the long-term interests of the corporations that engage in them.

There is thus a strong and compelling business case to be made for making the workplace an environment that is conducive to mental health, since the payback in greater productivity will outweigh the costs of the investment required to significantly reduce mental health risk factors in the workplace.

8.3       WORKPLACE-BASED INITIATIVES

There are two broad categories of mental health intervention in the workplace. First, primary prevention measures aim to eliminate, or at least reduce, factors in the workplace that have a negative impact on the mental health of the workforce. Second, there is a range of secondary intervention strategies designed principally to reduce the effects of stressful work situations by improving the ability of individuals to adapt to and to manage stress.

 

8.3.1     Primary Prevention

There is evidence to indicate that well-structured organizational approaches generate more important, longer-lasting effects than secondary intervention strategies directed at individuals.[326] Preventative intervention research identifies work-related causes that must be addressed in order to reduce or eliminate stress. Two risk models identify those psychosocial and interpersonal relationship factors that contribute to making people sick: 1) Karasek’s “job demand-control-support” and 2) Siegrist’s “effort/reward imbalance” models.

The “job demand-control-support” model is based on the finding that a work situation characterized by a combination of high psychological demands and low decision latitude increases the risk of developing physical and mental health conditions.[327] The “effort/reward imbalance” model is based on the finding that a work situation characterized by a combination of high effort and low reward can be accompanied by emotional and physio­logical reactions that can have a negative impact on mental health.[328]

While “control” is central to the Karasek model, “social reciprocity” (i.e., the possibility of having access to legitimate advan­tages, duly earned in the process of performing the work) is the key concept for Siegrist’s model. Siegrist’s model is particularly well adapted to measuring the impact on mental health of a major characteristic of workplace changes in the past decade, namely, reduced security of employment.[329]

Various studies have identified workplace attributes that contribute both to profitability and to better mental health, including: employment security, self-managed teams and decentralized decision-making, extensive training, reduced status distinctions, and reduced barriers to sharing financial and performance information across the organization. Vézina and his colleagues refer to studies that identify five factors that are necessary for the success of a primary intervention project. They are:

…support from senior management and involvement of all of the hierarchy; employee participa­tion in discussions of problems and possible solutions; preliminary identification of worker populations at risk on the basis of validated theoretical models or their associ­ated manifestations; rigorous implementa­tion of necessary changes in targeted worker populations; on-site management of the procedure and changes.[330]

Studies have shown that if those factors are in place, interventions focused on organization of work can have considerable benefits, notably decreased absenteeism and symptoms of depres­sion, and even increased well-being and productivity. Despite this empirical evidence to support the health impact of these models, however, few comprehensive workplace intervention strategies have been implemented.

The Global Business and Economic Roundtable on Addiction and Mental Health has identified 10 management practices or behaviours that can precipitate or aggravate mental health problems in the workforce:

1.      Imposing unreasonable demands on subordinates and withholding information materially important to them in carrying out their jobs.

2.      Refusing to give employees reasonable discretion over the day-to-day means and methods of their work.

3.      Failing to credit or acknowledge their contributions and achievements.

4.      Creating a treadmill at work — too much to do, all at once, all the time.

5.      Creating perpetual doubt, employees never sure of what’s happening around them.

6.      Allowing mistrust to take root. Vicious office politics disrupt positive behaviour.

7.      Tolerating, even fostering, unclear company direction and policies, job ambiguity and unclear expectations.

8.      Sub-par performance management practices — specifically employee performance reviews — even good ones — which fail to establish the employee’s role in the company’s near or mid-term future.

9.      Lack of two-way communication up and down the organization.

10.  Managers rejecting, out of hand, an employee’s concerns about workload.[331]

The Committee agrees with the Roundtable that a successful primary intervention strategy must attempt to modify these unhelpful practices, and therefore recommends:

 

 

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That the Canadian Mental Health Commission (see Chapter 16) work with employers to develop and publicize best management practices to encourage mental health in the workplace.

 


8.3.2    Secondary Intervention

Three types of secondary intervention are of particular importance: (1) disability management; (2) workplace accommodations; and (3) Employee Assistance Programs (EAPs).

 

8.3.2.1  Disability Management

Workplace disability management is widely used to return people with physical disabilities to the workplace. Factors found to enhance return to work are: employer participation, a supportive work climate, and cooperation between labour and management.  Although widely practiced in association with physical conditions, disability management programs are relatively new to the mental health field and are too little studied to determine their effectiveness.[332]

Managing disability within the workplace can be complex, given that it is a shared responsibility of the worker, supervisors and managers, employee assistance programs, human resource managers, and the public health system.[333]  The lack of “mental illness literacy” amongst employees, managers and supervisors also reduces the likelihood of speedy identification and resolution of mental health and addictions problems in the workplace.

A further challenge stems from the fact that the health care system and the workplace are very different, with differing cultures, languages, practices and priorities. The differing conceptual frameworks used by mental health and occupational health professionals can create gaps in understanding, that can lead to a poor coordination of services and result in delays in returning people to work.[334] Creating common goals, a shared understanding and a common language that will allow information to be shared and knowledge to be conveyed across different systems is essential. What is needed are boundary walkers — leaders who are versed in both mental health and employer issues and who can help to integrate disparate systems more effectively over time.

The Committee therefore recommends:

 

 

 

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That the Knowledge Exchange Centre to be created as part of the Canadian Mental Health Commission (see Chapter 16) assist employers, occupational health professionals and mental health care providers in developing a common language for fostering the management of mental illness in the workplace and in sharing best practices in this area.

 

8.3.2.2 Workplace Accommodations

Accommodation refers to “any modification of the workplace, or in the workplace procedures, that makes it possible for a person with special needs to do a job.”[335] Just as individuals with physical disabilities may require physical aids or structural changes to the workplace, individuals with mental disorders most often require social and organizational accommodations to be made.

Generally these involve changes to the way things have traditionally been done in a particular workplace. Permitting someone with a mental illness to work flexible hours, for example, provides him or her access to employment in the same way a ramp does for an individual in a wheelchair. Accommodation means, in effect, providing equitable treatment for individuals with disabilities, regardless of their type and source.

 

According to the Canadian Psychiatric Association,[336] accommodation should be built on positive arrangements that promote equality in employment, including:

§         Creating an environment in which arrangements are made in relation to the individual needs of each employee;

§         Respecting the employee’s desire for confidentiality as well as identifying the specific form and the degree of confidentiality required;

§         Being willing to engage in joint problem solving;

§         Making all arrangements voluntary for the employee, and being prepared to review plans periodically to meet changing needs;

§         Being flexible in enforcing traditional policies;

§         Being concrete and specific when identifying accommodations that are made. Putting them in writing is a good idea.

One study followed 240 persons with serious mental illnesses over a 10-year period who were able to maintain gainful employment, largely because formal work reintegration programs were in effect. These individuals earned $5 million, paid $1.3 million in income taxes, and saved the government an estimated $700,000 in welfare costs. The result was a net $2‑million increase in collective wealth.[337]

According to Mental Health Works, CMHA Ontario,[338] there is no comprehensive list of the accommodations needed by people who are dealing with mental health issues, nor is there research that defines “best practice” approaches. Accommodation requires consideration of the individual needs of employees and the resources available to the employer. In any case, as systemic barriers are removed, the need for individual accommodation will decrease. For example, flextime programs can benefit all employees, while also allowing an employee with a mental illness who needs to modify his or her hours of work to do so without having to ask for any special further accommodation to be made. 

The duty to accommodate is not the employer’s alone — trade unions share this responsibility. In the Committee’s view, the interests of the employee are best served when management and unions work cooperatively in accommodating the return to work through job modifications and other such arrangements. In this context, it is important for all parties to remind themselves that the return to work process is, in effect, part of the recovery process for employees living with a mental disorder.

 

8.3.2.2.1           Other Mental Health Accommodations

Other possible mental health accommodations include the following.

Flexible scheduling

§         Part-time shifts (which may be used to return a worker to a full-time position).

§         More frequent breaks.

 

Changes in supervision

§         Modifying the way instructions and feedback are given. For example, written instructions may help an employee focus on tasks.

§         Having weekly meetings between the supervisor and employee may help to deal with problems before they become serious.

Changes in training

§         Allowing extra time to learn tasks.

§         Allowing the person to attend training courses that are individualized.

Modifying job duties

§         Exchanging minor tasks with other employees.

Modifying work space or changing location

§         Allowing an employee to relocate to a quieter area where he or she will be free from distractions.

§         Allowing an employee to work at home.

8.3.2.3 Employee Assistance Programs (EAPs)[339]

EAPs are employer-sponsored programs designed to alleviate and assist in eliminating a variety of workplace problems.  The source of these problems can be either personal (legal, financial, marital or family-related, mental health problems and illnesses, including addiction) or work-related (conflict on the job, harassment, violence, stress, etc.).

Typically, EAPs provide counselling, diagnostic, referral and treatment services.  Those staffing EAP programs usually hold a degree in a mental health or social service discipline (social work, psychology, psychiatry, counselling and/or marital and family therapy).  Some services may also be contracted out to qualified persons.

EAP services are available both in private and public organizations and are usually administered completely independently of other programs within the organization.  Confidentiality is the cornerstone of an effective EAP.  The anonymity of clients, the confidentiality of interviews, the maintenance, transfer and destruction of files are subject to applicable federal and provincial laws that define the conduct of counsellors.  Generally, information may be released by an EAP counsellor only in situations in which the client has provided informed and signed consent specifying what information is to be released and to whom.

The Committee was told that between 60% and 80% of Canadians who are employed in a medium-sized or large company (over 500 employees) currently have access to some form of EAP.  According to Rod Phillips, President and CEO, Warren Shepell Consultants Corporation, EAPs are very effective; they have become the primary portal through which working Canadians often get their first access to mental health care and addiction treatment:

In many cases, in our experience, you would have about 85 per cent of the people who we see in a given year getting sufficient treatment through the EAP program that they would require no further treatment. About 15 per cent of the people would then be referred into community programs or into the public health care system.[340]

EAPs also have a strong prevention component.  Much of the work being done with employers focuses on wellness and other programs that support a healthy mental health work environment.

EAPs have been widely adopted across North America and are positively regarded by employers and employees.[341] They have certain limitations, however. For example, Ash Bender and his colleagues[342] expressed concern about the number of therapeutic sessions being offered to EAP clients; based on anecdotal evidence, these have decreased dramatically from seven per individual to fewer than three over the last 10 years.  The authors concluded that the likelihood is low of effectively addressing any serious substance abuse or mental illness problem in this limited therapeutic time frame.  This concern requires particular attention.

Mary-Ann Baynton, Director, Canadian Mental Health Association in Ontario, suggested to the Committee that it would be helpful if EAPs were able to provide people with access to “advocates” who could assist them in a variety of ways: 

That leads to the last recommendation, which is that we should have advocates. Many times, employers will say that they sent out the forms and people never filled them out or called back, they are not doing their part. The employers do not understand that the mental illness itself often makes it impossible for the person to get out of bed, never mind fill out a complicated set of forms. We are looking into having an advocate who can do this on behalf of people with mental health issues. However, it could be something that the EAPs or the employers themselves could provide.[343]

With regard to EAPs, the Committee recommends:

 

 

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That employers increase the number of counselling sessions offered through Employee Assistance Programs (EAPs), especially in communities where access to other mental health services is limited.

That research be undertaken to evaluate EAPs, and that the results be shared through the Knowledge Exchange Centre that the Committee recommends be created as part of the Canadian Mental Health Commission (see Chapter 16), with a view to strengthening the effectiveness of these programs.

 

8.4       TRAINING OPPORTUNITIES

Canadians with serious mental illness have relied heavily on community vocational rehabilitation programs that have often struggled to obtain adequate funding. The limited research that has been done suggests that not all vocational rehabilitation approaches achieve the same degree of success in moving people into employment.[344],[345],[346] 

 

8.4.1     Vocational Rehabilitation Programs

Vocational rehabilitation programs are intended to help people become or remain economically independent through work.  Specialized vocational rehabilitation programs include career counselling, work assessment, work adjustment and conditioning programs, temporary employment and transitional employment placement.

 

Research into vocational rehabilitation is limited in scope and tends to be descriptive and anecdotal.  The assumption behind most vocational rehabilitation is that careful planning combined with a supported and slow re-entry into the workforce will increase the likelihood of success. The evidence available, however, suggests strongly that moving people quickly towards employment is more effective than a gradual, slow re-entry.  The longer the delay, the greater the risk in reducing employability through insufficient work experience.[347] 

An additional barrier to employment includes relegating people with mental illness to entry-level, low-wage fields where they often experience little economic progress even when their job retention rates are similar to those of people without disabilities.  Minimal expectations by staff, paternalistic protectionism that shields clients from failure, and lack of outcome accountability have all contributed to the low success rate of vocational rehabilitation programs.[348]

 

8.4.2    Supported Employment

In the mid-1980s, a new approach to employment emerged, known as supported employment.  Its emergence was prompted by a concern to avoid models that tended to foster dependency and to reduce the need for mental health clients to compete in the job market for employment. Supported employment involves placing clients as quickly as possible into jobs without any extensive preparation, while simultaneously providing ongoing, intensive on-the-job support and training using assigned job coaches. 

 

A comparative research review indicates that supported employment models have produced more positive outcomes than traditional vocational rehabilitation services, brokered vocational rehabilitation services, day treatment programs, pre-vocational programs, or sheltered workshops.[349]  Reviewing 18 randomized control trials, researchers found that people participating in supported employment programs were significantly more likely to be employed than those who received pre-vocational training (at 12 months, 34% of those in supported employment were employed, compared with only 12% who had pre-vocational training).[350]  It is important to note however, that this success rate (34%), although positive, remains relatively modest. 

 

8.4.3    Consumer Economic Development Initiatives

Consumer development initiatives emerged in the 1990s as a response by people living with mental illness to the failure of traditional vocational rehabilitation programs to help them achieve their employment goals.  People living with mental illness began to develop businesses which they both owned and operated. The underlying belief was that, if given the tools, they could play an important role both in supporting themselves and in advocating for mental health services and supports that are more effective and accountable.[351]

These initiatives have included self-help organizations in which peer counselors facilitated mutual aid and education initiatives, as well as diverse consumer-run businesses which offered employment opportunities and business development skills to mental health consumers.  The research done on consumer-run initiatives demonstrates that this is a promising avenue to move people living with serious mental illness into the workforce.[352] 

 

8.4.4    The Club House Model 

In many jurisdictions, Club Houses continue to be a mainstay in funded community service delivery.  Initially developed in the 1940s by former psychiatric patients, the goal was to help others make the transition from hospital to community.[353] Club Houses offer vocational opportunities, problem-solving groups, case management, recreational activities, and academic preparation.[354]  They operate under egalitarian rules and are run by staff and clients who seek to provide an accepting, culturally sensitive environment where people can socialize, mutually support each other and gain experience in graded employment opportunities to prepare them for their return to competitive employment.[355] 

Pre-vocational training programs are intended to assist people living with mental illness to make the transition to employment through a two-step process.  Phase one is the provision of a “work ordered day” where clients work in teams with staff to operate and manage the Club House.  The second phase is an opportunity to participate in transitional employment programs where clients are placed in a series of paid but temporary jobs controlled by the Club House.  Despite the longevity and continued popularity of this concept, however, there is, however, limited evidence of the efficacy of Club Houses in achieving their vocational goals.

 

8.4.5    Sheltered Workshops

Widely used up until a decade ago, sheltered workshops now primarily serve the needs of developmentally delayed adults, although some provinces continue to include sheltered workshops in their community-based rehabilitation programs for people with mental illness. The little research that has been done shows a low success rate (in the range of 5‑10%) in assisting people living with a mental illness to obtain non-sheltered employment. In fact, participation in sheltered workshops may further entrench in those involved and the general public alike low expectations of the capacity of people with mental illness to work. 

 

8.4.6    Federal Initiatives

The Opportunities Fund for Persons with Disabilities was originally created as a pilot program in 1997, as part of the Government of Canada’s response to the report of the Federal Task Force on Disability Issues (the Scott report) in 1996. Funding for the Opportunities Fund became permanent in December 2000 and is administered by Social Development Canada.

The Opportunities Fund is an employability program for people with disabilities who have had little or no attachment to the labour force. Its objective is to help these people prepare for, get and keep jobs, or to become self-employed. To meet this objective, the government works in partnership with non-governmental organizations that represent people with disabilities, with the private sector and with provincial governments.  

The Opportunities Fund supports initiatives that:

§         encourage employers to hire workers with disabilities;

§         help people with disabilities build their employment skills, integrate into the labour market and/or become self-employed;

§         provide opportunities for work experience that could lead to stable employment; and

§         improve access to employment or employment services by providing personal support.

The Opportunities Fund now serves about 4,500 people with disabilities a year, although it is not known what percentage of these are people living with mental illness.

According to an evaluation conducted in 2001, one of the Opportunities Fund’s strengths is its individual, flexible approach to delivering services to clients. Assessments from Opportunities Fund participants, as well as the outcome data, have also shown that the program has helped individuals find work and has improved their employability and quality of life.


The Committee recommends:

 

 

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That the Department of Human Resources and Social Development, through the Opportunities Fund for Persons With Disabilities, facilitate the establishment of a nation-wide supported employment program to assist persons living with a mental illness to obtain and retain employment.

That this program promote the development of, and provide support for, alternative businesses that are both owned and operated by persons living with mental illness.

That the Department of Human Resources and Social Development report on how many people living with mental illness are assisted through the Opportunities Fund for Persons With Disabilities

 

8.5       INSURANCE AND INCOME SUPPORT

8.5.1     Workers’ Compensation Boards[356]

In all provinces and territories, Workers’ Compensation Boards (WCBs) receive an increasing number of mental health-related claims (referred to as “occupational stress”); and in a growing number of cases, the Boards have provided compensation for such claims.

A review of occupational stress claims reported to WCBs was undertaken by the Association of Workers’ Compensation Boards of Canada to find out how many types of claims were filed on an annual basis, whether they were of an episodic or chronic nature, and how much compensation was paid in each case. This review proved to be very difficult. In many cases, the Boards do not collect this type of data, or if they do, the data are not comparable because the definitions employed by each WCB may be different (see Table 8.1). The review could not, therefore, provide a national perspective on the number of claims resulting from occupational stress and the associated costs of compensation.

Terry Bogyo, Director of Corporate Planning, Workers’ Compensation Board of B.C., explained to the Committee that provincial and territorial variations in the treatment of stress disorders was a consequence of the different legislative frameworks that exist in each jurisdiction:

…It is not reluctance on the part of the boards to provide the benefit, because the boards do what the legislation tells us to do.  We are the body that gives life to the legislation.  …That variability goes back to the responsibility of legislators to design legislation that is responsive to the social, political, economic, cultural and historical values that are inherent to that jurisdiction.  Whether it is right is not for the boards to say.  It is our job to administer that legislation.  It is not a matter of reluctance.  If the legislation says that we cover it, then indeed it would be covered by us.[357]

A major issue raised with respect to compensation by WCBs concerns the fact that, regardless of jurisdiction, it is more difficult to prove the genesis of a mental disorder than that of a physical illness. As a result, there is some controversy about whether and how mental disorders should be covered under workers’ compensation schemes. Under the occupational disease model used by WCBs, compensation for a disability is based on whether the disability arises from continuous exposure to hazardous conditions related to an individual’s employment. Yet, as we have seen, most advanced etiological models of mental disorders include a variety of factors, such as genetic vulnerability, developmental circumstances and neurobiological factors, in addition to factors such as a stressful work environment. The relative weight of each of these dimensions is not yet understood, nor is it clear how they fit together.

The Committee believes that it is important for all concerned parties to address these issues and recommends:

 

 

35

That the Canadian Mental Health Commission (see Chapter 16) work closely with provincial and territorial governments as well as with Workers’ Compensation Boards, employers and trade unions across the country to develop best practices with respect to compensation for occupational stress-related claims.

 

8.5.2    Employer-Sponsored Disability Insurance Plans

Two types of disability income insurance plans are offered by employers: short-term disability (STD) and long-term disability (LTD). STD plans replace a percentage of pre-disability employment earnings (70%, for example) for periods of less than one year’s duration (e.g., six months). They are generally harmonized with sick leave, other employee benefits and Employment Insurance (EI) benefits, providing continuity of income for the plan member who has suffered a disabling illness or injury.


TABLE 8.1

WORKERS’ COMPENSATION BOARDS IN CANADA: INTERJURISDICTIONAL COMPARISON OF OCCUPATIONAL STRESS COMPENSABILITY

 

Alberta

Compensation for occupational stress provided if:

§       there is a confirmed diagnosis under the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders;

§       the work-related events or stressors are the predominant cause of the injury;

§       the work-related events are excessive or unusual in comparison to the normal pressures experienced by the average worker in a similar occupation; and

§       there is objective confirmation of the events.

British Columbia

 

Compensable forms of stress include:

§       stress caused by a sudden and unexpected traumatic event; and

§       stress that results from a compensable injury such as severe anxiety following the amputation of a leg.

§       Stress that is caused by the pressures encountered in daily personal and work life is not compensable.

Manitoba

Definition of accident/occupational disease excludes stress except as an acute reaction to a traumatic event.

New Brunswick

Definition of accident/occupational disease excludes stress except as an acute reaction to a traumatic event.

Newfoundland and Labrador

Legislative definition of injury covers stress only where it results from an acute reaction to a sudden and unexpected traumatic event and to exclude stress due to labour relations issues.

NWT & Nunavut

Claims for occupational stress are considered on a case-by-case basis.

 

Nova Scotia

 

Definition of accident/occupational disease excludes stress except as an acute reaction to a traumatic event.

Ontario

 

Mental stress is compensable in respect of situations where there is an acute response to a sudden and unexpected traumatic event arising out of and in the course of employment.

Mental stress due to the employer’s employment decisions does not entitle a worker to benefits.

Prince Edward Island

Definition of accident/occupational disease excludes stress except as an acute reaction to a traumatic event.

Quebec

 

Stress is compensable if the worker can show a relationship between the illness and the work or a risk in the work.

Saskatchewan

Compensation for occupational stress is specifically allowed for as a matter of policy where clear and convincing evidence is provided that the work stress was excessive and unusual; routine industrial relations actions taken by the employer are considered normal and not unusual.

Yukon

 

Post-traumatic stress considered compensable under legislation; current practice is to assess all other stress-related claims on a case-by-case basis.

Source: Kishchuk, P. (March 2003) Expansion of the Meaning of Disability. Paper commissioned by the Yukon Workers’ Compensation Board, p. 12.

 

LTD plans focus on longer periods of disability. They typically commence payments after the disabled individual has been off work for a significant period, such as six months, and replace a specified percentage of the person’s pre-disability employment income, for example 70%. LTD benefits typically run for up to two years for recipients who are unable to perform their own jobs, and can continue to a limit of age 65 or the onset of retirement benefits for recipients who cannot perform their own or any reasonably comparable job. LTD benefits provided by the employer’s plan may be reduced by the amount obtained by the recipient under the Canada Pension Plan (Disability) (CPP(D) — see below).

An important aspect of both STD and LTD plans is the commitment to assist recipients to return to the workplace, preferably to their own jobs, or to another job if that proves not to be feasible. Consistent with this commitment, disability income insurance plans are designed to ensure that there is a financial incentive for recipients to return to work; thus disability income replacement benefits do not exceed, and are usually less than, pre-disability employment income. Disability insurance should not be a disincentive to work. In this context, the Canadian Psychiatric Association explained:

Disability insurance for any illness requires a precise definition of that illness. Whereas it is important that disabled psychiatric patients receive an adequate income to protect themselves from serious financial reverses over the time that they are not able to work, it is just as important to recognize that disability payments may constitute a major secondary gain actually impeding a patient’s progress and delaying rehabilitation. There are two factors to be considered: a) the prevalent misconception that work is ipso facto stressful and likely to aggravate a diagnosed psychiatric disorder; and b) the recognition that some patients who have undergone a serious psychiatric disorder may want to avoid exposure to what they presume to be stressful factors at work because of lack of confidence even after they have improved clinically. It should be recognized that return to work as soon as possible is likely to improve the patient’s self-esteem, reestablish him/her in a familiar social network and otherwise aid rehabilitation. There is some evidence that work deprivation may be one of the causes of psychiatric disorder.[358]

Employers, managers and insurers must become more knowledgeable about mental illness and addiction in order to better manage disability claims. During a recent speech, Bill Wilkerson, co-founder and CEO, Global Business and Economic Roundtable on Addiction and Mental Health, commented:

[The insurance] industry must develop a perspective based on knowledge of mental health issues. Like business generally, the insurance sector needs a mental health education agenda.

An example of where this is especially true is in the comorbidity of mental illness and physical chronic diseases as this pertains to: origin and the duration of human disability; the complexity, lengths and risks of treatment and recovery; and, the pace and timing of the sufferer’s return to work.

The insurance industry needs — at the levels of claims management — to know more about the medical science of mental health. … The industry needs to develop a knowledge base about the expanding universe of neuroscience and its illumination of the origins of behaviour.

 

8.5.3    Provincial and Territorial Social Assistance Programs

Insurance and income support programs provide some level of protection for persons living with mental illness who find themselves unable to work.  However, programs operated by workers’ compensation boards, employers, and the Government of Canada (e.g., CPP(D) and EI) share a key attribute — to qualify, individuals must have a job, often for a prolonged period of time.  This, coupled with a myriad of other eligibility criteria and time-limited benefits, frequently results in people living with mental illness having to turn to the income assistance programs of last resort — social assistance (i.e., welfare) programs operated by the provinces and territories.

Most often, social assistance programs distinguish between individuals who are able to work but unable to find employment, and those who are unable to work due to illness, disability or other cause.  For example, the Government of Ontario operates the Ontario Works program to assist those persons who are able to work but unable to find employment.  Here, applicants are expected to first use up their personal assets before they become eligible for assistance.  Benefit levels are low, and recipients are required to participate in retraining or other “employment activities.”  In short, “eligibility rules are designed to ensure that people turn to welfare only when all other financial resources have been exhausted.”[359] 

In contrast, those who are unable to work may be streamed into the Ontario Disability Support Program (ODSP).  Benefit levels are roughly twice those of Ontario Works, and while recipients are encouraged to work to the greatest extent possible, participation in related programs, such as retraining, is voluntary.  Also, applicants may retain a small amount of personal assets, some $5,000 in cash and RRSPs.[360] 

Unfortunately, as is the case with other income support programs, eligibility for ODSP is restricted.  Applicants must “have a substantial physical or mental impairment that is continuous or recurrent and is expected to last one year or more.”  Given the cyclical and unpredictable nature of mental illness, persons living with mental illness, and unable to work, may find themselves ineligible for ODSP. They are thus forced instead to rely on Ontario Works, even though they are not the target group for this program.

Strict eligibility criteria, including a requirement to first exhaust one’s own financial assets, are not the only problem associated with social assistance programs for persons with disabilities.  Benefits, while generally higher than those available under general welfare assistance programs, remain at a level that may result in financial hardship.  The following table includes a sampling of assistance rates and earning exemption amounts (i.e., the amount that can be earned before benefits are reduced) from across Canada:

 

British Columbia

Ontario

Quebec

Amount per month for a single person with a disability

$856.42[361]

$959.00[362]

$835.67[363]

Earning Exemption Amount

$400.00[364]

$160.00[365]

$100.00[366]

Those who seek to return to work may be dissuaded by policies that would result in varying amounts of earned income being deducted from their benefit cheques, a loss of specific benefits (i.e., medical or drug benefits) or a loss of benefits altogether. 

Joan Edwards-Karmazyn, Manager, Consumers Health Awareness Network Newfoundland and Labrador (CHANNAL), summed up the dilemma faced by persons living with mental illness who rely on social assistance programs, saying:

The members of CHANNAL expressed a need for more affordable housing; fewer barriers to receiving educational and vocational services; and increased wage earning allowances while receiving social income supports.

Members state that they are caught in the system due to the need…for medication allowances. Therefore, one is hesitant to stop income allowances as stopping income allowances has a direct impact on also having medication benefits stopped. People are afraid to come off their benefits because the income they would make out in the real work world would not allow them to afford the $1,500 a month for medication alone.[367]

Therefore, the Committee recommends:

 

 

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That benefit levels and earning exemption amounts for social assistance programs for persons living with a mental illness be increased to reduce financial hardship and increase the incentive to work.

That recipients of supplementary aid, such as help with the costs of medication, continue to be eligible for assistance for an extended period of time even if their incomes increase to levels where they are no longer eligible for financial aid for shelter or other living expenses.

 

8.5.4    Federal Income Security Programs[368]

The federal government has two income support programs that may be of assistance to persons living with a mental illness: the Disability Benefit provided by the Canada Pension Plan, and sickness benefits provided by Employment Insurance.  Tax assistance is available through the Disability Tax Credit.

8.5.4.1  Canada Pension Plan (Disability) Program (CPP(D))

The Canada Pension Plan (Disability) program is the largest single disability income program in Canada.  It is generally the “first payer” of disability benefits, preceding other entities such as provincial workers’ compensation boards and private insurance companies.

CPP(D) benefits are paid to contributors under age 65 who have a physical or mental disability that is “severe and prolonged” (lasting at least one year and preventing work on a regular basis) and who meet specific requirements relating to the level of earnings and years of contribution (contributions must have been paid in four out of the previous six years). Between 1980 and 2000, the proportion of individuals receiving CPP(D) benefits attributable to mental disorders increased sharply — from 11% to 23%.  Mental illness ranked second, behind disease of the musculoskeletal system, and affected a higher proportion of females than males.  In 2000, mental disorders also represented the most prominent cause of CPP(D) disability among younger beneficiaries.

For many years, individuals with mental illness and addiction and their representatives have raised concerns that CPP(D) does not address the question of mental illness and disability appropriately.  For example:

§         Many individuals with mental illness have limited work histories.  Because mental illness often strikes in early adulthood at a time when education, job skills and careers are being developed, many of these individuals are not eligible for CPP(D) due to their having insufficient years of employment.  Out of necessity, many turn to provincial social assistance programs for support.

§         To qualify for CPP(D) disability benefits, the beneficiary must accept the designation of having a “severe and prolonged” disability that means they cannot pursue any gainful employment on a regular basis.  Because of the cyclical and unpredictable nature of mental disorders, many individuals with mental illness can work, but often only on a part-time basis; they are not necessarily capable of achieving full financial independence.  In this vein, Jason Turcotte, of the Canadian Mental Health Association Office in Portage La Prairie, a member of the Partnership for Consumer Empowerment, told the Committee that “the all-or-nothing approach must be eliminated.  To provide benefits only to someone while they are 100-per-cent disabled is discriminating, disempowering, and a disincentive to recovery.”[369] Individuals with mental illness and addiction have recommended that CPP(D) pay partial or reduced benefits rather than full benefits to enable them to work part-time and still retain a portion of their benefits.

§         Since disability is currently equated with permanent unemployability, individuals on CPP(D) are reluctant to look for or take employment for fear of losing their benefits.  Those affected are penalized for trying to improve their circumstances even if they are not capable of participating in regular full-time work again.

§         Just over half of all initial applications to CPP(D) are denied; almost two-thirds of those rejected do not apply for reconsideration.  It has been suggested that the proportion of applications rejected from those with mental illness is much higher.  Some claim that the system is designed in such a way as to discourage individuals from pursuing rightful claims.  This is particularly true for individuals with mental disorders who, because of their illness, may lack the ability to “push the system.”

Once qualified for CPP(D), individuals are often reluctant to make any attempt to return to work or engage in other activities that could bring their declared impaired health status into question. Many fear that to do so risks triggering a reassessment of their CPP(D) eligibility, and raises the potential of a loss of income support.  According to one individual living with mental illness:

CPP-Disability puts individuals in a position of having to paint themselves in the worst possible light, and define themselves in the most negative way, just to convince the worker they actually require assistance. The entire process is based on pathology rather than recovery.[370]

An additional concern is that CPP(D) may also inadvertently contribute to the process by which persons living with mental illness come to be viewed as permanently unemployable. Private insurance companies, in an effort to reduce their financial liability, often require their clients to apply for  CPP(D) because of its “first payer” status.  However, moving from employer-sponsored private insurance coverage to CPP(D) may further distance the individual from his or her employer, making a return to work more difficult.

Some progress has been made in addressing a number of these issues in recent years. For example, an allowable earnings provision gives recipients the flexibility of earning up to $4,100 a year while remaining on CPP(D) benefits. Greater personalized contact with applicants means that clients receive telephone calls during the decision-making process to discuss individualized needs and provide appropriate information about programs and services.

As well, a legislative change to the CPP was made in 2005 allowing for the automatic reinstatement of CPP(D) benefits.  This provision allows beneficiaries who are able to return to employment to try working without fear of losing their CPP(D) benefits.  If their disability recurs within a two year period, these clients are quickly returned to benefits.  Cecilia Muir, Director General, Office of Disability Issues, Social Development Canada, explained to the Committee the significance of this modifications to CPP(D):

I acknowledge it is not a whole solution, but this is a huge step forward.  This feature allows a person for up to five years not to have to go back through a reapplication and all the process that one would normally need to go through.  … The projections were that at least 300 persons a year would be able to benefit.  Those are individual people.[371]

Finally, to make people more aware that CPP(D) supports clients in their efforts to return to work without risking a loss of benefits, the program has implemented a communication strategy.  Communication tools include an annual “Staying in Touch” newsletter, website and annual correspondence to clients outlining CPP(D)  return to work provisions.  In addition, clients who are most likely to benefit from automatic reinstatement, in particular those with episodic disabilities,  receive letters explaining how the new provision works.

In its 2003 report, the House of Commons Standing Committee on Human Resources Development and the Status of Persons with Disabilities recognized that CPP(D) does not address the question of mental illness and disability appropriately.  The Committee made a number of recommendations to ensure that CPP(D) takes into account the cyclical and unpredictable nature of mental illnesses.  In addition, it recommended that the federal government develop, in consultation with stakeholders and health care professionals, specific evaluation tools for these particular disabilities to be used in assessing eligibility for CPP(D).

In its response to the House of Commons committee’s report, the federal government indicated that CPP(D) guidelines already recognize recurrent and episodic disabilities, including mental disorders, and that many individuals with mental disorders currently receive CPP(D) benefits.  Furthermore, it stated:

The Government therefore does not believe regulations and guidelines need to be changed to accommodate the needs of individuals with episodic or recurring conditions. Because the determination of disability for CPP is based on the functional limitations that prevent a person from working, and not simply on a medical diagnosis or prognosis, the adjudication process is able to take into consideration the short- and long-term impacts of recurrent or episodic medical conditions on the client’s ability to function in the workplace.[372]

The Committee strongly rejects this view, and it recommends:

 

 

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That the eligibility criteria for Canada Pension Plan — Disability (CPP-D) benefits be modified so that persons living with a mental illness are no longer required to demonstrate that their illnesses are severe and prolonged, but only that their illness has been diagnosed and that they are unemployable and need income support.

That the Government of Canada review how to coordinate better Employment Insurance (EI) sickness benefits and CPP-D, and examine how to eliminate structural barriers (i.e., financial disincentives) that limit opportunities to return to work.

That the Government of Canada grant authority to the CPP to permit it to sponsor research on, and the testing of, new approaches that could target people with episodic disabilities, particularly episodic mental illness.

That the Government of Canada explore ways to provide incentives to employers who hire persons living with mental illness, including the possibility of offering them CPP premium “holidays”.

 

8.5.4.2 Employment Insurance (EI)

Individuals with mental illness may also be eligible to receive EI benefits as a source of temporary income replacement.  Some concerns have been raised, however, with respect to EI:

§         In terms of EI eligibility, employees who are dismissed because of “misconduct” or quit “without just cause” are not eligible for EI benefits.  Due to stigma, individuals with mental illness in the workplace often conceal their illness.  When they experience difficulty on the job, they may be fired or may quit as a result of their illness, but would not be in a position to claim EI benefits because they have not previously disclosed their illness.

§         When a person applies for EI sickness benefits, he/she is required to obtain a medical certificate indicating how long the illness is expected to last.  The unpredictable nature of mental illness makes it difficult to provide this kind of medical information.

§         Individuals with mental illness and addiction share the view that EI should exempt individuals with recurring illnesses or disabilities from fulfilling the additional number of insurable hours required of those who are considered new to the labour force.  In their view, without this exemption, individuals with mental illness are unjustly disadvantaged.  Few are able to meet the eligibility criteria in terms of the total number of insurable hours required of new workers.

In his brief to the Committee, Dr. Sunil V. Patel, then President of the Canadian Medical Association, recommended that the federal government review CPP(D) and other federal income support policies to ensure that mental illness is on a par with other chronic diseases and disabilities in terms of the benefits available to affected persons.

The Committee is of the view that the criteria for EI sickness benefits should be modified so that persons living with a mental illness can qualify more easily for EI.  Given the enormity of the surplus in the EI Account,[373] this change would not represent an undue burden on the public purse.

Therefore, the Committee recommends:

 

 

38

That Employment Insurance (EI) sickness benefits be modified so that persons living with a mental illness can qualify more easily.  Specifically, for persons living with a mental illness, the number of hours to be worked since the last claim should be reduced.

 

8.5.4.3 Disability Tax Credit (DTC)

The Disability Tax Credit[374] is a non-refundable tax credit that can be used by persons with disabilities to reduce the amount of income tax they have to pay.  A person can transfer the credit to his or her spouse, or to another supporting person.  It is intended to help persons with disabilities bear the additional costs of living and working generated by their disability.  The basic credit is worth $1,037.76 per year.

Qualifying for the DTC is not an easy task.  In order to be successful, a person must have a severe and prolonged (i.e., minimum of one year) impairment that markedly restricts his or her ability to perform a basic activity of daily living.  The definition of “basic activity of daily living” is highly restrictive, and does not include working, housekeeping, recreational or social activities.[375]  Also, the amount of tax relief is small.  Therefore, the Committee recommends:

 

 

39

That the eligibility criteria for the Disability Tax Credit (DTC) be modified so that persons living with a mental illness can qualify more easily, and that the amount of the DTC be increased.


CHAPTER 9:
ADDICTION SERVICES

9.1        INTRODUCTION

One of the biggest challenges for addictions in the health system is that ministers have to choose between MRIs and junkies, to be blunt.  There is no political traction…—Michel Perron[376]

In Canada, the treatment of addiction, like that of mental health, is not a “system.” Its evolution has been fragmented, chronically underfunded, and has occurred in the shadow of stigma and government inattention. Yet, there are few Canadian families who have not been touched by addiction.[377] Over the course of its hearings, the Committee heard much about the devastation caused by addiction: family breakdown, financial losses, child prostitution, crime, homelessness, domestic violence and child abuse, concurrent health problems, road and industrial accidents, job loss, birth defects, brain damage and suicide. The connection between addiction and these consequences often goes unrecognized because of stigma and denial. When people with addictions come to the point where they need and will accept help, they and their families have a hard time finding services; even when successful, they often face long waiting lists. Lengthy wait times mean those who might otherwise be helped, withdraw further into addiction with a resulting increase in the human and social consequences.

 

 

 

Mental health and addiction services operate in separate spheres. The idea that some people with a substance abuse problem might also have a mental illness and that those living with mental illness might also be addicted has taken time to emerge. However, research has revealed that 30% of people diagnosed with a mental illness will also have a substance abuse problem in their lifetime, and 37% of people who abuse alcohol (53% who abuse drugs) also have a mental illness.[378]

Consumers and families are frustrated trying to get help from mental health services or from addiction services.  But when mental illness and an addiction are present together, there is the added burden of being shunted back and forth as professionals argue over which problem constitutes the “primary” diagnosis.

I’ve gotten help for each individual thing but to get help for (both), like at the same time, you fall between the cracks and if one of your disorders is worse than another and then one doctor thinks you’re seeing somebody else, basically nobody’s helping you, nobody follows up, you kind of disappear.
—Anonymous[379]

The Committee acknowledges that it has not been able to devote as much attention to substance use issues as it intended when it embarked on its study of “mental health, mental illness and addiction.” The Committee recognizes that this report concentrates primarily on mental health issues and is acutely aware that it only scratches the surface of many substance use issues that deserve a much fuller treatment.

There are, of course, many areas of overlap between mental health and substance use issues, not least of which involve people living with both mental health and substance use disorders. Because of the importance of substance use issues in general, and of this overlap in particular, this chapter of the report is devoted to these issues. Moreover, there is an important recommendation in Chapter 16 (National Mental Health Initiatives) that the federal government inject an additional $50 million per year in concurrent disorder programs.

9.2       THE HUMAN FACE

A strong consumer and family self-help and advocacy movement has arisen in support of mental health services. With regard to addiction, too, self-help has had a pervasive presence with a long history — but within a culture of anonymity and independence, and with little government funding. This may explain why so few people with addictions, or their family members, testified before the Committee or submitted briefs.

Clean and Sober Thinking (CAST) is an unfunded addiction consumer organization based in Peel Region Ontario. CAST meetings provide support at a crucial time for an addict on the cusp of change. When someone in the soul destroying world of addictions decides to reach out, the fear is all-encompassing. The window of time in which a response is needed is brief and urgent. There is no comfort like that which is given by those who have been there — or in the case of a CAST meeting — those who are there. In Ontario, there is a whole culture of funded consumer initiatives for the mental health sector. There are no funded consumer initiatives for people with addictions.  —Tom Reghr[380]

The testimony available to the Committee gave only a small glimpse into the pain caused by addiction.

I speak personally because my daughter, who has schizophrenia, is on crack.  […]  How can we expect a person with a serious mental illness whose cognitive abilities are affected, who has little or no motivation or insight, who lives a sort of hand-to-mouth existence every day, how can they ever manage to quit? The interventions, and resources and treatment facilities are hopelessly inadequate. The general attitude is to wait until they are ready to quit. Well, they do not want to quit.  —Joan Nazif[381]


More people than we know are addicted to gambling — writing bad checks, lying, stealing, skipping work — all to feel the high of the instant gratification. But unlike other addictions, it is often hidden. There is no wavering gait, no slurred speech, no needle tracks. For three years, none of my friends knew I gambled. I went alone, and usually late at night. Playing the slots…at any cost, was my number one obsession.  —Anonymous


The pain pill addiction stripped me of my dignity and cost me a great deal. Aside from taking money from my family, I borrowed and stole the trust and faith they had in me. Nothing became as important as the high. I had to take more pills just to try and recapture the elusive feeling. The pills only exacerbated the struggles I was facing. I could finally see what had been only too clear to many others — my life was a mess. I was financially broke and my spirit was on overdraft.  —Barry Strader[382]

The addiction field lacks powerful voices, a vacuum that has left only policy makers and health providers to speak for anonymous clients. However good their advocacy, there is no substitute for direct testimony from people who are, or have been, “there.” Individuals and families living with mental illness have successfully made the case to various provincial and territorial governments that the contributions of self-help organizations are so important that they must be funded. That this has not been done for addictions sets up inequality of representation between two groups, both of whom have crucial expertise to offer and important work to do.

Therefore, the Committee recommends:

 

 

40

That a portion of the funding for peer support in the Mental Health Transition Fund (see Chapter 16) be made available to develop and sustain self-help and peer support groups for people and their families living with addiction (including problem gambling).

 

9.3       FAMILIAR CULPRITS AND THE DAMAGE THEY CAUSE

While the production and trafficking of illicit drugs grabs headlines, legally available substances — alcohol[383] and prescription medication — have the greatest and most far-reaching impact on Canadians’ lives and health, principally because of their pervasive presence and common usage.[384]

When you look at the idea of somebody who is addicted, you tend not to look at alcohol. If you do, it is a person sitting in an alleyway with a brown paper bag.  You do not look at it as being the drinker inside the home; you do not look at prescription drugs and those kinds of things. The sensationalized reporting [on illicit drugs] does not help because what is in the news are the sensational stories, not the day‑to‑day lives of people.  —Senator Cordy[385]

Prenatal exposure to alcohol is now considered to be the leading cause of birth defects in North America. The magnitude of the problem of abuse of legal substances in Canada is often ignored because of stigma and denial. Nonetheless, the facts are clear:

§         13.6% of all Canadians are considered high-risk drinkers.[386]

§         In any given year, it is estimated that 8% of all hospitalizations and 10% of the total number of days in hospital are attributable to substance abuse.[387]

§         Prenatal exposure to alcohol is now considered to be the leading cause of birth defects in North America.[388]

§         In 2000, a total of 981 people died in alcohol-related vehicle crashes in Canada (including pedestrians and off-road vehicles).[389]

 

 

§         Canadians are among the highest per capita users of psychiatric medications in the world. Canadians are the second-highest users of sedatives and the fourth-highest of prescription narcotics.[390]

§         It is estimated that 20% of Canadians over 60 are long-term users of pain-killers.

§         Women are 50% more likely to abuse medication than men. Aboriginal populations are particularly at risk for non-medical use of prescription medication.[391]

 

§         Abuse of legal substances (including tobacco) accounts for $11.8 billion in annual productivity losses in Canada, or 1.7% of the gross national product (GNP), a cost that works out to $414 for every man, woman and child in Canada.[392]

Ballpark, it would be 90 per cent of deaths caused by drugs are from alcohol and tobacco.  If you look at disability and quality of life, it would probably be more like 95 per cent. The analysis done by the World Health Organization globally, including looking at economically developed countries such as Canada, shows this very clearly.  —Tim Stockwell[393]

The reality is that the vast majority of Canadians who are addicted use legally available substances. Many people are cross-addicted, meaning that they use alcohol and medication in a variety of combinations. Addiction is a health problem in which incidence can be affected by monitoring interventions (in relation to prescription drug use, for example,) and public awareness of the dangers.

Therefore, the Committee recommends:

 

 

41

That treatment resources targeted at addictions include addiction to legal substances such as alcohol, tobacco, and prescription medications, and to behaviors such as gambling.

 

9.4       A NEW THREAT — PROBLEM GAMBLING

The prevalence of problem gambling has risen significantly over the past 25 years. In Ontario it is estimated that 3.8% of citizens (340,000 people) have moderate to difficult problems related to gambling; an additional 0.9% are severely addicted.[394] In 1999-2000, the net profit from gambling (after prizes and other expenses) to governments at all levels was $5.7 billion.[395] By 2004, that profit had risen to $6.2 billion, more than the net profit to government of tobacco and alcohol combined ($5.9 billion).[396]

British Columbia, Manitoba, Quebec, Alberta, Ontario and Prince Edward Island have “responsible gaming” programs related to problem gambling. Ontario’s commitment is 2% of gross revenues from slot machines in charitable casinos and at racetracks, the largest allocation to a problem gambling strategy anywhere in the world. In a recent review, however, it was found that the fund has not been fully disbursed (only $21.7 of the $36 million allocated was released in 2003-2004). Fewer (5,900) than the expected number of problem gamblers (8,600) sought treatment.[397]

Experts fear that most of the problems related to gambling remain hidden because of shame and stigma, but that they will emerge in due course and in overwhelming numbers. One indicator of what is to come is that high school students gamble at two to four times the rate of the general public — the problem gamblers of tomorrow.[398] 

Canadian governments at all levels depend on revenues from gambling; it is likely that investment in gambling facilities will be increased. But the social, economic and health impacts for Canadians are just beginning to emerge and must not be ignored or minimized. 

Therefore, the Committee recommends:

 

 

42

That provincial and territorial governments commit a fixed portion of funds derived from gambling to evidence-based prevention, awareness and treatment programs for gambling addiction, and to gambling addiction research.

That Statistics Canada ensure that in addition to alcohol and drug use, the prevalence of problem gambling among the general population is measured and reported upon through regular survey work.

 

9.5       THE MOST VULNERABLE

As with other health problems, people who are poor, marginalized or otherwise disadvantaged suffer disproportionately from addictions and/or problem gambling. Children and youth, women and seniors have particular vulnerabilities that may not be recognized and, as a result, are not addressed.  

9.5.1     First Nations, Inuit and Métis Peoples

As described in Chapter 14, Aboriginal people attribute their mental health and addiction problems to a history of colonization that assaulted their culture and created a pervasive atmosphere of despair.[399] Constant relocation of communities and the removal of children from families to residential schools disrupted traditional connections to family and community; whole generations were dislocated and traumatized. The effects are a weakened cultural identity, poverty, dependence on social welfare, and a profound sense of grief.[400]

First Nations, Inuit and Métis peoples suffer a host of health problems, not the least of which is addiction.

In Labrador alone, as the man was saying from the reserve, there have been an awful lot of suicides of young people. This is not limited to Labrador, but happens in St. John’s and all over the province from depression. There are also a lot of suicides in this province from those video lottery terminals and…from overdoses with drugs....  —Harold Dunne[401]

 

9.5.2    Women

Women differ from men in many respects, including their responses to substance use. For example, women are more likely than men to develop cirrhosis of the liver with less consumption of alcohol over shorter periods of time.[402] They are also more likely to be victims of domestic assault, child abuse and sexual violence; women who have suffered such experiences are more likely to develop substance abuse problems.[403] Because of the risk of birth defects, women of child-bearing years who are drinking or using drugs are of particular concern.

 The system would benefit from more outreach services (educational seminars in places where high risk women gather naturally). These services not only help identify pregnant and parenting women but they are encouraged to begin treatment. Outreach is also critically needed for other populations like elderly women, youth, the chronic or severely addicted woman who is often homeless, and women offenders. These women frequently do not or cannot access services and we need to reach out to them with understanding and sensitivity.  —Nancy Bradley[404]

 

9.5.3    Seniors

Up to 18% of hospitalized seniors are there because of alcohol abuse. Older adults use more prescription medication and, as a result, are particularly vulnerable to adverse drug reactions and interactions, and drug dependence.

In addition, problem gambling may be on the increase among seniors. An Ontario study found that 6.4% of seniors who gambled were at risk of addiction, with 0.1% already gambling at problem levels. A Manitoba study found 1.6% of seniors who gambled were at risk of addiction and 1.2% were already problem gamblers.[405]  In all of Canada, there are only 12 specialized addiction treatment programs serving approximately 1,250 seniors annually.[406]


9.5.4    Children and Youth

Youth are most affected by mental health and addiction problems.[407]  Research has shown that early evidence of substance abuse in children and youth is a predictor of subsequent criminal behaviour.[408] Some problem gamblers reported beginning to gamble as early as age 10.[409] Children and youth are also vulnerable to emotional, physical and sexual abuse by substance-using caregivers.[410]

When it comes to early diagnosis…it is much easier to take care of the children before they get older. Early diagnosis…I know especially in addictions, can definitely save a life and a lifetime of heartache for not only the youth but so many others.  —Dave Rodney[411]

Failing to address the impact of addiction and problem gambling in vulnerable populations, particularly youth, costs Canada a great deal in both human and economic terms. In a “pay me now or pay me later” scenario, the neglect of these groups is paid out over time in ever-rising social and health care costs.

Therefore, the Committee recommends (in addition to those recommendations specific to Aboriginal peoples in Chapter 14):

 

 

43

That the Government of Canada conduct an assessment of the outcomes of existing programs dedicated to addiction problems for First Nations, Inuit and Métis peoples. 

That the results of this assessment be shared through the Knowledge Exchange Centre to be created as part of the Canadian Mental Health Commission (see Chapter 16) with a view to identifying successful treatment models and expanding these programs to improve access and reduce wait times.

 

 

That the provinces and territories develop and implement evidence-based outreach, and primary and secondary prevention programs for at-risk populations — women, children and youth, seniors, and those affected by Fetal Alcohol Spectrum Disorders.

 

9.6       GOVERNMENT RESPONSIBILITY

Addiction must also be considered within the context of government regulation and taxation related to the sale of alcohol and the prevalence of gambling (including provincial lotteries), both of which are significant revenue sources.[412] Powerful corporate interests are also involved in alcohol as well as gambling. Years of government inattention have left advocates frustrated by the low investment in prevention, health promotion and treatment for people who have been harmed, relative to the large amounts of money collected in taxes and gambling profits.[413]

…we have to acknowledge the elephant in the room that no one seems to be tackling, which is that notwithstanding the need for looking at meaningful taxation processes for alcohol, volume content and the like, the government already collects a tremendous amount of revenue from this product and it is not earmarked for the right purposes.  Although it may go to other good purposes, at the end of the day we should acknowledge openly that the government continues to encourage activities that they know will cause harm, such as gambling.  —Michel Perron[414]

 

9.7       NEW IDEAS THAT WORK

Notable strides have been made in helping people with addiction and mental health problems. These advances have been implemented in a number of locations in Canada and are showing either promising or positive results confirmed through research. They can be built upon to create a stronger, more integrated addiction and mental health system.


9.7.1     Integrated Treatment for Concurrent Disorders

Substance abuse can mask the symptoms of a mental illness but, for those who are known to be mentally ill, it makes psychiatric symptoms worse.  As a result, people with concurrent disorders[415] generally have more complex problems and are more difficult to help because they often exhibit more disruptive behaviours, are less accepting of treatment and are more prone to relapse[416] than those whose mental illness is not compounded by addiction or vice versa.

Both the mental health and addiction “systems” have been slow to acknowledge even the existence of concurrent disorders.[417] Typically, people with them cycle back and forth as clinician-specialists try to decide which problem to treat first.

When concurrent disorders have been recognized, treatment has tended to fall into one of three categories: partial treatment — focusing on one of the problems, assuming the other will abate over time; sequential treatment — starting with one problem and resolving it before treating the other; or parallel treatment — where separate services treat both problems at the same time.[418]  The results have been less than satisfactory, primarily because of the disconnect between the two treatment systems and their differing philosophies. People just got lost.

Literature on best practices recommends that mental health and addiction programs screen clients for both problems and, when problems are discovered, those affected should be fully assessed to ensure their proper treatment. It also calls for integrated treatment - both problems are treated simultaneously[419] by the same team, using compatible techniques and philosophies.[420]


9.7.2    Community Reinforcement and Family Training (CRAFT)

The CRAFT approach is an alternative to some of the more confrontational interventions or strong tactics used by frustrated family members to persuade a loved one to enter treatment. It is a teaching model, most often accompanied by a workbook, in which aspects of cognitive behavioural therapy are employed to help families and friends develop ways to keep themselves safe, analyze under what circumstances substance abuse is most likely to occur, utilize positive reinforcements for both themselves and the addicted family member, and adopt healthier lifestyles. Research has shown that this minimalist intervention is highly effective in engaging in treatment people with addictions, including problem gambling; a 64% success rate has been achieved for people with drug and alcohol problems, and seven out of ten problem gamblers have been brought to treatment.[421]

The more the family is involved, whoever they consider their family to be, the better they will do.  —Nancy Bradley[422]

 

9.7.3    Harm Reduction

Harm reduction is intended to reduce the health and social impact of alcohol and drug use without asking that users abstain. Abstinence may be a long-term objective, but the short-term goal is to promote safe use. The features of harm reduction are: pragmatism — people are going to use drugs and alcohol and some will use them to excess; humane values — the dignity and rights of the user are respected; focus on harm — it’s not how much a person is using, it’s how much harm it is creating; and hierarchy of goals — the most important needs are attended to first.[423]

 

9.7.3.1  Needle Exchange Programs (NEPs)

In Canada, the first unofficial needle exchange program (NEP) opened in Toronto in 1987. More were established officially in Toronto and Vancouver in 1989. Today there are 30 programs operating in Canada. All prisons administered by Correctional Service Canada provide bleach to inmates for needle sterilization, but despite repeated recommendations for the implementation of NEPs, no correctional jurisdiction in Canada provides sterile equipment to inmates.[424] 

NEPs operate under an exemption in the Canadian Criminal Code and the Food and Drugs Act that makes the distribution of “drug paraphernalia” legal as long as the goal is to prevent HIV infection. Initially, the federal government shared the costs with provincial governments. Programs are now run under a variety of funding models, including federal and provincial/municipal partnerships. The cost of one needle exchange kit is slightly more than $1.

Many fears regarding these programs have been expressed but, according to the evidence, have not materialized:

§         Needle exchange programs do not lead to a proliferation of dangerous needles discarded in the community — in fact, more needles are turned in than given out.

§         Needle exchange programs have not attracted drug dealers to the community where the site is located.

§         Police do not object — the Canadian Association of Chiefs of Police has passed a resolution in favour of the National AIDS Strategy, including needle exchange programs.[425]

 

9.7.3.2              Supervised Injection Facilities (SIFs)

Supervised injection facilities (SIFs) include needle exchange but also offer safe places to use drugs and receive emergency medical care, basic health services, counselling, and referrals to other agencies, plus education and participation in social support networks among others living with addictions. SIFs typically have a number of house rules that relate to safety — for example, no alcohol, no violence, no “dealing,” local users only, and no one under 18 years of age.

The one SIF in Canada is in Vancouver. It functions as a scientific research project to be evaluated over three years. It was established under Section 56 of the Controlled Drugs and Substances Act, which allows the federal Minister of Health to issue an exemption from the provisions of the Act for specific medical or scientific purposes. Ninety percent of those who use the Vancouver SIF are Hepatitis C Virus positive, and 28-30% are HIV positive. Five hundred safe injections per day are provided at the site.[426]

 

9.7.3.3              Wine and Beer in Shelters

Some homeless people report that they will not enter shelters because they cannot bring their bottles with them; alternatively they binge just before entering, a cause of fights and injuries to staff and other residents. In response to violence in shelters and deaths on the street by freezing, staff in a few Toronto locations have started to introduce an approach to harm reduction that entails giving those living with alcohol addiction a drink of beer or wine every hour or two during their stay.

The Annex Harm Reduction Program, a satellite of St. Michael’s Hospital in Toronto serving the men who live in Seaton House,[427] now offers medical treatment and referrals to addiction treatment and housing. The preliminary results of an evaluation show that alcohol-related accidents and injuries are declining, that the men now drink safer forms of alcohol (instead of Lysol, mouthwash or rubbing alcohol), and that they receive better medical care. Some have reduced their drinking; others have entered treatment, while still others are in stable housing and have jobs.[428] 

In Ottawa, the Shepherds of Good Hope Shelter has established a harm reduction program with a Supporting Community Partnerships Initiatives (SCPI) grant. It serves 10 people at a time, 24 hours a day, seven days a week and has a waiting list three times as long. The program offers a glass of homemade wine once an hour, progressively diluted over time. Evaluation has shown fewer emergency room visits, hospitalizations and ambulance calls as a result. Graduates of the program have obtained stable housing, stayed out of jail and entered treatment for addiction.[429]

 

9.7.4    Drug Treatment Court (DTC)

In 1998, the federal Department of Justice funded one drug treatment court (DTC) in Toronto and another in 2001 in Vancouver. These courts identify low-risk offenders whose main problem is drug abuse and who would benefit from treatment rather than time in jail. Offenders, including youth, are offered drug education, employment training and mental health treatment if they openly take responsibility for the offences they have committed. Sentencing is often confined to community service hours; alternatively, charges may be withdrawn if treatment is completed in a positive fashion. In May 2003, the federal government committed $23 million over five years to expand DTCs.[430]

 

9.7.5    Day Detox and Home-Based Detox

The most cost-effective strategy for responding to early-stage alcohol problems is a single session of advice from a primary care physician with follow-up by a nurse.[431] Advances in research relating to detoxification services have shown also that people with physiological dependence on alcohol or drugs can enter a successful detox program that offers them nursing support in their own homes or on a day program basis.[432] The idea of Community Alcohol Teams was developed in the United Kingdom and elsewhere because of long waiting lists for inpatient beds.  Studies of the relative costs showed that hospital-based care cost roughly 10 times more than community care with little difference in outcomes.[433] It should be noted, however, that homeless populations still require some form of residential detox service.

One example in the service I provided in the U.K is that we had one community nurse supervising as many home‑based detoxifications for problem drinkers as the general hospital, which had been the other major service provider in the area, did in one year.  —Tim Stockwell[434]

With the exception of the treatment of concurrent disorders and the CRAFT program, the emerging trends in this section remain controversial, particularly those related to harm reduction. Society judges harshly those it thinks have made bad choices. Harm reduction challenges perceptions because it is an adult-to-adult model that focuses on keeping everyone, including society as a whole, as safe as possible while preserving dignity and hope for those affected.

Given these advances, the Committee recommends:

 

 

44

That the Government of Canada include as part of the Mental Health Transition Fund (see Chapter 16) $50 million per year to be provided to the provinces and territories for outreach, treatment, prevention programs and services to people living with concurrent disorders.

That family physicians be trained, through medical school and professional development curricula, on diagnostic guidelines for Fetal Alcohol Spectrum Disorders (FASD).

That family physicians be trained in the use of brief intervention and interview techniques to recognize problem substance use leading to addiction.


9.8       STEPS TO INTEGRATION

9.8.1     Build on Commonalities

Historically, mental health and addiction services have developed separately — each with its single focus. Addiction and mental illness are both enormously complex problems. Services for each must address a multiplicity of factors and contend with a host of personal and social consequences. Outcomes are uncertain even when the best of supports and treatments are in place. The two sets of services rest on differing philosophies relating to causes, effects and how to help. But there are signs of convergence, not the least of which are the emergence of literature on best practices and treatment of concurrent disorders, and the establishment of some joint services.

In my experience over the past 13 years, I have found that the “my turf” attitude has diminished to some degree.  I have talked to people in the community who have said that there might be battles at the provincial level, but at the community level, everyone gets along fairly well.  —Jeff Wilbee[435]

 

9.8.1.1  Recovery

Recovery has been a beacon of hope since the 1935 inception of the most famous self-help movement, Alcoholics Anonymous. Recovery is well defined in the addiction world — as a lifelong process of living well in the face of challenges. In the last 20 years, led by people living with mental illness, the mental health system has begun to embrace recovery[436] as its defining concept. That concept, however, has yet to fully inform professional treatment philosophies.

 

9.8.1.2  Self-Help and Peer Support

Although founded on self-help, addiction services have been professionalized over time. Substance abuse specializations have developed in higher learning centres, together with professional accreditation and certification. Most addiction services now have strong professional leadership. The modern mental health system began with a medical specialty, psychiatry, that, over the last century, has spawned a number of other mental health professions such as psychiatric nurses and social workers. Relatively speaking, the self-help movement in mental health is new and has had to advocate strongly for its place in the largely professionally driven system. Happily, providers in both addiction and mental health services have come to understand and value self-help and peer support, while still acknowledging the need for a professional presence.

We still have peer professionals, and I do not think anyone can provide a sense of hope for change for a consumer group better than people who [have] gone through the system themselves. I do not think anyone can navigate or advocate better. There will always be a place for that, but the ratio is changing [peer support versus professional care] because of the type of service we are delivering.  —Greg Purvis[437]

 

9.8.1.3  Non-Medical Community-Based Services

Addiction services, evolving out of self-help, have a historical commitment to a community-based, non-medical approach. While individuals must, from time to time, seek medical interventions and/or psychiatric assessment, diagnosis and medication, it may be said that, as a whole, services for people with addictions are intent upon remaining non-medical in nature and community-based.

Community mental health services evolved as a result of the deinstitutionalization that began in the late 1960s. Throughout Canada, governments have continued to close psychiatric inpatient beds. Although investment in community services has been too slow to materialize, the commitment from policy makers and from the field to building a system based mainly on non-medical community supports and services is solid.

 

9.8.1.4  Broader Determinants of Health

Community mental health services evolved as a result of the deinstitutionalization that began in the late 1960s.Managers and providers of mental health and addiction services are deeply aware of the importance of broader health determinants in preventing problems in the first place, and/or in lessening the effects of problems once they emerge. Safe and affordable housing, employment, education, adequate income supports, and freedom from violence are crucial to the health and well-being of all Canadians; they are life-sustaining for people living with mental illness and addiction.

 

9.8.1.5  Early Intervention

Identifying problems early, and then intervening in the least disruptive and life-altering manner possible, is acknowledged by both service sectors as crucial. Healthy pregnancies, assisting at-risk parents to acquire skills, a focus on early childhood development, and helping children and youth with emerging substance abuse problems, all save lives and/or prevent a lifetime of dependence on a variety of expensive health and social programs.

Early intervention in psychosis is perhaps the most hopeful integrative treatment approach to emerge in mental health. Young people at risk, identified early and given lower doses of medication over shorter periods of time, can avoid hospitalization, loss of education, unemployment, and the loss of social and family supports.

Senator, you asked about pieces that are missing.  What struck me immediately was the number of times I have read and heard presentations at conferences about childhood trauma, abuse and addiction.  What I am about to say is not just about how to improve the treatment system but how to decrease the demand for the treatment system.  An increased effort to deal with damaged children will have as much impact on the addiction treatment system as anything done directly in the addiction treatment system.  —Jon Kelly[438]  

Competition between the addiction and mental health care sectors for scarce resources makes no sense. It only entrenches differences and discourages collaboration. However, there is reason to believe that numerous commonalities have emerged over time. It is now time for addiction and mental health services to begin to build integrative mechanisms based upon their shared interests, views and, above all, the benefits to affected people that will accrue. 

 

9.8.2    A Step-by-step Approach

British Columbia’s policy document entitled Every Door is the Right Door proposes to develop a collaborative model of health system responses that spans the domains of population health, health promotion, harm reduction and building community capacity.  The model is intended to assist local health authorities to plan, implement and evaluate an integrated and evidence-based system for people with addictions and mental illness.[439]

Alberta’s document, Building capacity: A framework for serving Albertans affected by addiction and mental health issues, aims to improve access and services for people with concurrent disorders through service partnerships and shared care, typically psychiatrists providing consultation to primary care physicians. The framework also emphasizes information, prevention and early intervention for those whose conditions are not yet severe.[440]

 

[The CCSA] position is quite clear. We fully support a new model for the coordinated delivery of mental health and addiction services to Canadians, and we believe that where appropriate, such a model requires a careful and strategic integration of approaches to treatment of mental health problems and addictions.  —Michel Perron[441]

9.8.2.1  The Quadrant Model

This model is well-known among service providers in the addiction field. It has been endorsed as a “thinking tool” that helps conceptualize integration in a way that respects the differences between the mental health and addiction fields while, at the same time, offering opportunities for integration that can be acted upon fairly swiftly.[442]

 

 

 

High

Quadrant 3

A high level of addiction problems with a low level of mental illness

 

SPECIALIZED ADDICTION CARE

Quadrant 4

A high level of addiction problems with a high level of mental illness

 

SPECIALIZED INTEGRATED CONCURRENT DISORDER CARE

 

 

Low

Quadrant 1

A low level of addiction problems with a low level of mental illness

 

PRIMARY CARE

Quadrant 2

A low level of addiction problems with a high level of mental illness

 

SPECIALIZED MENTAL HEALTH CARE

 

           Low             

                                         High          

 

 

People with a combination of a low level of mental health and addiction problems (Quadrant 1) are by far the largest segment of society who will seek help most frequently from a primary care physician. The quadrant model proposes that addiction and mental health services become concurrent disorder capable, meaning that those services must be able to recognize and respond to both mental health and addiction problems. Only those who fall into Quadrant 4, the number of whom is not large, require concurrent disorder specialized services.

The quadrant model does not value one service system over another. Nor does it presuppose the amalgamation of administration and services over the two fields, or the elimination of specialized programs. Integrative mechanisms could be built locally to include: service agreements among mental health and addiction agencies; designation of local “lead” organizations that take on the role of intake, assessment and referral; communication tools that facilitate the secure exchange of personal health information; and the use of distance technology to bring mental health, addiction and specialized services to remote or under-serviced areas.

9.8.2.2 A Shared National Focus

The addiction field has had the benefit of a National Drug Strategy (May 2003), a national survey of Canadians’ use of alcohol and drugs (the Canadian Addiction Survey, November 2004) and the ongoing leadership of the Canadian Centre on Substance Abuse. A National Framework for Action on Substance Use and Abuse is currently being created through a broad consultation process culminating in a national addiction conference held in June 2005.[443]

On 7 June 2005, the House of Commons passed a motion calling for, among other things, a national strategy on mental health.[444] This motion paves the way for the creation of a National Mental Health, Mental Illness and Addiction Strategy which must incorporate, but not subsume, ongoing national activities in the field of addiction.

9.8.2.3 Taking the Long View

The experience in other jurisdictions where integration has begun shows that it is a difficult process despite the commitment of people in the field. Creating a closer relationship between the addiction and mental health systems will take time, leadership and money, but the first steps must be taken without delay.

If people have the freedom to talk, discuss and disagree on the process and work their way through it, then that will breed far more grassroots buy‑in. […] Once the awareness-raising happens, and people begin to get their heads around it, we will need resources and opportunities for them.  Without those, it would be much ado about nothing.  The resources must be available in your back pocket before you step forward into consciousness-raising.  Otherwise, you are setting people up to disagree, and for it not to happen.  Also, you need to build in outcomes, measure the outcomes, and feed them back to the field. Nothing will increase the buy-in more in the field of mental health and addictions for a change in process than positive outcomes. People want to succeed and do well by their clients.  —Greg Purvis[445]

Addiction services in Canada are fragmented and chronically under funded, resulting in inadequate responses to the needs of those living with addiction and their families. The culture of separateness between mental health and addiction services has added to the frustration. But a number of important commonalities can be utilized as logical starting points for integration. Committee members were told that the preferred approach to integration is to preserve that which is unique in each field, while building on common values, dialogues and obvious points of agreement.

Therefore, the Committee recommends:

 

 

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That the Canadian Mental Health Commission (see Chapter 16) actively partner with national addiction organizations, and work toward the eventual goal of integration of the addiction and mental health sectors.

9.9       CONCLUSION

Advances in scientific knowledge have produced interventions that show positive results for people with addictions. The Committee’s witnesses emphasized particularly the need for integrated treatment for people with both mental health and addiction problems — concurrent disorders. We support this direction.

Testimony was notably absent from people living with addictions, and from their families. The Committee commends for their courage those who did step forward. We are committed to building a strong consumer and family presence within the addiction sector.

Testimony before the Committee made overwhelmingly clear the problems associated with addictions to legally available substances coupled with long waits for help. We call for sustained investment to mitigate the effects of the misuse of legal substances on the health and well-being of Canadians.

Gambling is a significant revenue source for governments, but many people are gambling at problem levels and are not seeking treatment in the numbers expected. This hidden problem is only beginning to emerge; it must not be ignored, nor must its lack of visibility lead to a false sense of complacency. Governments must help those who are harmed by gambling.

 

 

The Committee was persuaded by arguments in favour of harm reduction. These varied approaches, which have been demonstrated to relieve suffering, have often been developed by direct services workers who use their ingenuity to solve the problems they and their clients face daily.

Vulnerable populations — Aboriginal peoples, youth, seniors and women — suffer disproportionately from the effects of addiction and problem gambling. We were particularly affected by the preventable tragedy of Fetal Alcohol Spectrum Disorders. The Committee calls for effective outreach and prevention strategies focused specifically on those who are most at risk.

The Committee was impressed with the level of agreement among witnesses in support of the eventual integration of the mental health and addiction sectors. We heard that the differences and debates that can preoccupy service providers and policy makers do not make much sense to people with addictions and their families. All they want is help — now. Fortunately, the Committee heard that there are many points of agreement between addiction and mental health services that can be built upon as integrative mechanisms.


CHAPTER 10:
SELF-HELP AND PEER SUPPORT

10.1      INTRODUCTION

Self-help provides emotional support and practical help.  It is the kind of help you cannot duplicate in a doctor’s office.  No one can say better than somebody living with, through and beyond a mental illness, “I understand how you feel.  I am on a quest for recovery with you.”  —Linda Bayers[446]

Over the course of its extensive public hearings, the Committee heard regularly from people living with mental illness or addiction, and their families, who are disappointed by their lack of access to services and disheartened by the paucity of hope that they feel characterizes mental health and addiction care in Canada.  While acknowledging that professional help is valuable, people and families living with mental illness are turning more and more to self-help and peer support as a substitute for, or as an adjunct to, hospital, community and professional services.

The best-known self-help program is Alcoholics Anonymous (AA), which began operation in 1935.  Only a few years later (1937), Abraham Low, a physician, founded Recovery Inc., focused specifically on the needs of people with mental illness, headquartered in Chicago.  Today, it maintains its strictly volunteer tradition all over North America (www.recovery-inc.org).  Similarly, GROW, founded in Sydney, Australia, in 1957, supports thousands of members based on its version of a 12-step program and a philosophy of “caring friendship and mutual help” (www.grow.net.au). 

In Canada, the first alternative mental health service based on people living with mental illness helping one another, called the Vancouver Mental Patients’ Association (MPA), was established in 1971.  It remains in operation (now calling itself Motivation, Power and Achievement - MPA) (www.vmpa.org).

 

PROFILE

National Peer Support Program for current and former Canadian Forces Members (www.ossis.ca).  This unique program, launched in February 2002, is part of the Operational Stress Injury Social Support Project.  It has served 1400 individuals and family members since opening, with referrals coming at a pace of one per day.  Across 12 sites, it employs 20 trained Peer Support Workers, each of whom has experienced a stress injury.  A professional team is available for consultation if required. Family members have six sites across the country.  The role of the Peer Support Workers is two-fold:  To help others heal from an operational stress injury and to pay attention to their own self-care.  This non-medical model has been presented to audiences in Canada, Australia and Berlin.  The program’s goal is “to provide the best possible peer support to the men and women of the Canadian Forces, who continue to participate in an ever-growing number of demanding operations around the world” (General Ray Henault, Chief of Defence Staff, 2002).  Says Lt. Colonel Stéphane Grenier, Project Director, “Peer support saves lives everyday.”

 

 

10.2      THE MOTIVATIONS BEHIND SELF-HELP AND PEER SUPPORT

People living with mental illness, and their families, point to the many negative messages from society and from professional caregivers that impede healing and recovery.

In today’s society, the stigma of mental illness plagues us still.  We feel this stigma everyday of our lives… from being overlooked for promotion at work... to being harassed by medical insurance companies who question the validity of our illnesses so they no longer have to pay disability benefits… to sitting in emergency waiting rooms for hours on end, sometimes leaving in despair… because we are not high priorities.
 —Frank Dyck[447]

10.2.1   Finding a Place to Belong

People living with mental illness say that the most devastating impact on their lives came not from the illness itself but from the way others began to treat them.  Prejudice and discrimination take many forms: disregard for the person’s rights, ostracism, loss of friends, sometimes rejection by family members and, in many instances, loss of housing and employment.  Thirty-four percent of respondents participating in the Committee’s e-consultation reported that they or others they knew had been turned down for a job or fired because of a mental illness, and 21% had been denied housing by a landlord.[448] 

We know when we break a leg we go to the emergency room.  But if we are having a panic attack or thinking of harming ourselves, we don’t know where we should go.  We are told to go to the emergency room, but they see no wounds and we are dismissed.  —Anonymous

Families also bear the brunt of stigma.  Making matters worse, people and families living with mental illness may internalize these negative social attitudes and blame themselves for their own marginalization.  People living with mental illness state that there is also “prejudice and discrimination in the mental health system itself” — the system to which they turn for help when they are most vulnerable.[449]  Twenty-two percent of respondents to the Committee’s e-consultation reported that they had been treated with disrespect by medical personnel or had a physical ailment ignored because of their mental illness or addiction.[450]  Not surprisingly, research shows that two-thirds of people suffering from addiction or mental illness simply do not seek help.[451] 

 

 

Self-help and peer support counteract stigma by providing people a place where they are safe and welcome.  This is particularly important for client groups that have been poorly served by the mainstream mental health system:

Over time, it became clear that it might not be possible, and perhaps not even desirable, to promote cultural sensitivity within the conventional mental health service providers, with a view to these agencies at some point undertaking the responsibility to deliver this type of healing alternative.  […] [Healing circles] are rooted in ceremonies and traditions that can only be performed by those from the Aboriginal community who possess a depth of knowledge and who are recognized within that community as being capable of leading healing circles. 

[…]

Over the life of the project… the majority [of clients] use the healing circles alone as their preferred method of recovery.  —Tarry Hewitt[452]


10.2.2   Counteracting the Powerlessness of the Patient/Client Role

The Committee was told that playing the role of patient or client is debilitating in itself because the focus is on illness and disability.[453] Being dependent on help from those who claim exclusive expertise and who, by definition, are in a superior position, further erodes the self-esteem of the person who is defined as the patient or client as well as their ability to act effectively in their own interests.  Over time, people can lose hope and fully embrace passivity.  Experience has taught them that their views are unwelcome, someone else knows better, and it is easier (and in some instances, safer) to cease to struggle and let others make decisions.

It is very hard to ignore [professional] feedback or to put it aside as just one person’s opinion when it comes from a health professional, and it is really hard to stand up in the face of authority and say, “I want more,”…particularly because you are a mental patient… —Helen Hook[454]

10.2.3   Finding Hope in a Sea of Hopelessness

People living with mental illness have often been told that they will not complete their education and will never hold a job or work.  For many years, researchers characterized mental illness as generating an inevitable downward spiral — both in function and in social status.  The prognosis was bleak:  permanent disability, isolation and poverty. 

 

The opinions of people living with mental illness have too often been reinterpreted as a manifestation of denial or as “part of the illness,” disallowing them a credible role in their own care and life decisions.  Pejorative labels such as non-compliant, manipulative, difficult to direct, hard to serve, attention-seeking or interfering (for family members) have discredited assertive behaviours and have further silenced people.

People living with mental illness state that their expression of healthy human emotions such as sadness, fear and anger is often medicated as opposed to validated.[455]  The elements of human growth and pleasure are transformed into therapeutic interventions, such as bibliotherapy, art therapy, music therapy, horticultural therapy, interpersonal relationship therapy, and social network therapy, etc.  These interventions may be helpful but they constitute professionally mediated encounters that recast normal activities in terms of treatments.    

The range of supports that currently exist for those who are deemed unable to work includes a monthly pension with subsidized medications, subsidized housing for the fortunate, and a support network of health professionals and programs for free.  I would suggest that many individuals are trapped and left unmotivated to plan and execute an exit strategy from this cycle of learned helplessness.  —Raymond Cheng[456]

 

10.2.4   An Antidote for Identity Theft

Persons living with mental illness are asked to accept their diagnosis as reality and to develop insight into their illness and disability, so much so that they feel their identities as parents, siblings, employees, students, athletes, artists — as individuals — are erased or, at the least, diminished.  People are spoken of as addicts, schizophrenics or depressives.  They have become their illness.[457]  

Some argue that their personhood has been invaded, conquered and colonized in much the same way countries have been defeated and occupied by a foreign power.

 

10.2.5   Reclaiming One’s Own Story

People and families living with mental illness often have to tell their stories over and over again to a variety of disconnected professionals.[458]  Even more problematic is loss of control over their own histories.  Many feel that reinterpretation of their experiences in the unfamiliar language of medical or rehabilitation terminology does not describe adequately the personal reality of that experience.  These “translations” can overlook the context of their lives, concentrating on their conditions rather than acknowledging what is wrong with their individual situations.[459]  Experiences of abuse, racism, oppression, marginalization, homophobia, sexism, childhood trauma, violence in relationships, loss and grief, poverty, bullying, unemployment and other stressful life circumstances can be ignored or, if included in the “translation,” fail to lead on to interventions that take them into account.  Positive factors such as a supportive family, a particular talent, or dedication to culture and community can also be missed when the “translator” concentrates narrowly on assessment, diagnosis and medication. 

In the course of my work, I hear stories of abuse, abuse perceived in the eyes of patients and I feel the force of their outrage at how they have been treated.
—Ron Carten[460] 

 

 

10.2.6   Meeting the Need for Information

Accurate and complete health and service information is essential to the role of full partner in one’s own care or that of a loved one.  People living with mental illness, and their families, have told the Committee that they lack access to even the most basic information.  For example, 33% of respondents to the Committee’s e-consultation said services could be improved simply if more information was made available.[461]  Sixty-six percent of families identified information as a pressing need.

What does a diagnosis of mental illness mean?  What will the medications do?  Where can I get community services?  How do I get help for a loved one with an addiction? What are my rights? 

Rushed professionals may offer few answers or communicate in a way that is hard to understand.  As a result, people and families living with mental illness believe there is no substitute for conversations with a peer and exchanges of information among those who have “been there.”

…if you have a health problem, go to a self-help group.  You will find out information because self-help group members are information junkies surfing the Internet day and night for information on how to get better and how to recover. They provide emotional support and practical help. They are cheerleaders. They say, “You can do it because I did it.”' Where else can you do that when you are feeling hopeless? There is no place else on planet earth where you can get that kind of help.   —Linda Bayers[462]

The Committee recommends:

 

 

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That programs be put in place to develop leadership capacity among persons living with mental illness, and their families.

That the Knowledge Exchange Centre (see Chapter 16) contribute to building this capacity by facilitating electronic access to information and technical assistance for people affected by mental illness and their families.

 

10.2.7   Having a Voice

People with experience of the mental health system frequently report that they are the voice least heard, both as individuals and at the systems level.  Advocacy means “to give voice to.” That is the fundamental purpose of a number of self-help organizations speaking on behalf of people who are or have been in the mental health or addiction system.  Having a say in matters that most affect you is essential to everyone’s sense of well being and citizenship.  Groups that are entirely made up of the people for which they speak are uniquely empowering. They constitute a vital resource for communities that typically are talked about but seldom talked to.

 

10.2.8   Finding Recovery

The hopeful and optimistic concept of recovery[463] has emerged from the consumer movement and in response to negative treatment experiences in the formal mental health and addiction system. Utilizing experiential knowledge hard won through their own struggles, people living with mental illness have initiated a new dialogue that has begun to influence government policy and is slowly making its way into professional literature. Self-help and peer support groups are the incubators of individual recovery and a key sustaining force behind the broader acceptance of recovery as the guiding principle for all that occurs in the formal system.    

 

10.2.9   Summary

Professionally defined identities based on illness and disability can overwhelm individuality and become the way persons living with mental illness, and their families, are known — by caregivers, by society, by the media and by themselves. Social and systemic forces coalesce to present them a bleak future — unproductive, lonely and hopeless.  Self-help supports the concept of recovery and responds to the full tapestry of people’s individuality.  Illness is only one part — perhaps even the smallest part — of a rich life fully worth living.

10.3      SELF-HELF AND PEER SUPPORT IN CANADA

Self-help constitutes people helping people — those who have “been there” sharing the common experiences of life-transforming events.  A primary benefit of self-help is affiliation, “the great relief of knowing you are not alone.”[464]  In Canada, self-help and peer support have evolved in three ways.

 

10.3.1   Volunteer Organizations

Historically, self-help organizations have not received formal funding. The members have themselves defined the ways in which they support and sustain each another.  Self-help or mutual aid (as it is also known) is based on the defining feature that all members are equal — all are experts on their own lives, no one knows more than anyone else and no one has all the answers.[465]  Individual life experiences are the “knowledge base,” and encouragement and hope the “methodologies” by which empowerment occurs and healing takes place.

Peer support is when a group of individuals who have experienced the mental health system come together regularly in a safe and comfortable environment to share each other’s stories, be empathetic, and take the  time to understand people.  —Raymond Cheng[466]

Peer support is also a form of self-help that includes one-to-one relationships between people who have had similar experiences.  Like self-help, it is a system of “giving and receiving help founded on key principles of respect, shared responsibility, and mutual agreement of what is helpful.”[467] 

Peers see one another as individuals with stories to tell, rather than as “patients,” “clients,” or “cases” to be managed.[468]  Peers may be further along in their own recovery than those they help — but mutuality of experience is always foremost.  They spend time with the newly diagnosed, the freshly discharged and those in crisis.  They offer information, resources and the reassurance that comes from sharing their own stories. 

In preparation for their role, peers will likely have attended orientation or training programs to equip themselves with basic information on how to be most helpful;  but they are volunteers, spending their own time with others whose journey, they hope, will be made easier by their presence.

We stress that we are not professionals but people who have lost a loved one through the act of suicide.  Through our own stories, we help others share their grief and find a path to recovery. —George Tomie[469]

 

10.3.2   Paid Peer Support

Some peer support workers are para-professionals employed by mainstream mental health or addiction service providers (hospital or community-based) working in Assertive Community Treatment (ACT) teams or outpatient counselling programs.  Others may work in non-medical, community-based environments as staff hired for the life experiences that qualify them for the job, not for their professional expertise and qualifications. 

Paid peer support workers can have many titles — Peer Advocate, Peer Counsellor, Peer Tutor, Case Manager Aid, System Navigator, Consumer Advisor, Peer Outreach Worker (www.mentalhealthconsumer.net) — the variety is bounded only by the limits of imagination.  Unlike volunteers, they have been formally trained in the role.  Many peer support programs include peers as members of mobile crisis teams and staff in safe houses and have been established out of the need to deal with psychiatric crises out-of-hospital.[470]

 

PROFILE

The Gerstein Centre is a 24-hour non-medical crisis centre located in downtown Toronto. It hires people based on life experiences to provide mobile crisis services, short-stay safe house residential care and telephone crisis counselling. Its philosophy: the environment and support offered are individualized, responsive to the needs and wishes expressed by the service user, and respectful of the autonomy, dignity and ability of the service user. It is the oldest program in Canada of its type and, this year, celebrates its 15th anniversary.

 

10.3.3   Paid Peer Support Workers in Stand-Alone Consumer and Family Organizations

In 1991 the Ontario government established the Consumer/Survivor Development Initiative (CSDI) with an initial investment of $3.1 million (now $4.5 million).  CSDI has since evolved into the Ontario Peer Development Initiative (OPDI).  The philosophy that underpins the program is one of peer-to-peer support. 

These funded organizations were not to provide such services as counselling or case management in the way professional organizations did, but to build upon the culture of mutuality and experiential knowledge that is at the centre of self-help.  The resulting Consumer Survivor Initiatives (CSIs) employ peers in roles that include economic or community development, one-to-one peer support, social activities, peer education, advocacy and website communications.

PROFILE

The Ontario Peer Development Initiative (www.opdi.org) (OPDI) evolved from the Consumer/Survivor Development Initiative in response to the need, expressed by CSIs, for technical support.  The organization offers assistance in board and organizational development, conflict resolution, along with membership and resource development.

 

 

 


10.3.4   Summary

In Canada, as elsewhere, self-help and peer support programs have grown in an ad hoc fashion.  Although some have been funded by governments, most exist independently of one another on shoe-string budgets and struggle for survival.  But survive they do — on passion, commitment and dedication.  Paid peer support has emerged in isolated pockets supported by provincial/territorial funding.  As a new and tenuous addition to the mental health and addiction system, the future of self-help and peer support programs remains insecure.

We believe that the largest group of service providers are families, and that self-help groups are a significant support to persons with mental illness.  Self-help groups have demonstrated their effectiveness in Manitoba.  They are adjuncts to the mental health professionals for both patients-clients and families. 

Self-help groups must continue to be part of the system and spend their time assisting their members, as opposed to spending time and resources in fund-raising.  Services should be devolved to them.  Their individual approaches must be protected.  —Annette Osted[471]

The Committee recognizes the value of self-help and peer support organizations and is aware of the financial difficulties facing many such organizations across the country.  Therefore, the Committee recommends:

 

 

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That funding be made available through the Mental Health Transition Fund (see Chapter 16) that is specifically targeted at:

·         Increasing the number of paid peer support workers in community-based mental health service organizations.

·         Providing stable funding to strengthen existing peer development initiatives, build new initiatives (including family groups), and build a network of self-help and peer support initiatives throughout the country.

That the federal government lead by example, building on innovations such as the National Peer Support Program for current and former Canadian Forces members and support, with appropriate levels of funding, self-help and peer support programs for the client groups that fall under the jurisdiction of the federal government.

10.4      RESEARCH INTO SELF-HELP AND PEER SUPPORT

Testimony from persons living with mental illness, and their families, credits self-help and peer support for being effective and, in many cases, virtually life-saving.

I have no shame.  I owe my life to the OSISS group (Operational Stress and Injury Social Support).   —Corporal Clement[472]

Studies that evaluate the effectiveness of self-help and peer support are emerging.  The research that is available has tended to be descriptive or has surveyed members’ satisfaction.[473]  But in the United States, an evolving body of research documents the outcomes of peer support programs,[474] and there are some recent Canadian studies noteworthy for their scientific rigour.

Nelson et al. examined four Consumer Support Initiatives in Ontario offering educational events, advocacy opportunities and social networking in addition to peer support.[475]  When members joined these peer support groups, almost 40% were in unstable housing, one-third had been admitted to hospital in the past nine months and 25% reported the distress of psychiatric symptoms.  After 18 months, they experienced fewer hospitalizations and fewer visits to emergency rooms than a control group of non-members.  They had more stable housing, were experiencing fewer symptoms, and reported more friendships, all leading to an overall improvement in their quality of life. Qualitative data showed that members valued peer support as a safe place to recover and grow, protected from the negative judgments of society and the indifference of their communities.

Forchuk studied cost savings attributed to peer support.[476]  Using a randomized cluster design, she examined the experiences of 390 patients in 26 hospital wards in southwestern Ontario.  She found that peer support, in combination with inpatient follow-up until a discharged patient was connected to community services, saved $12 million in bed costs in one year.  “Treating just one lonely person would pay for a part-time volunteer coordinator through reduced hospital and emergency costs.”

A study of Consumer/Survivor Initiatives, also in Ontario, found that with peer support, members used fewer mental health services (hospital days dropped from 48.36 to 4.29, and crisis service contacts went from 3.54 to 0.81).  Members also increased their social and community supports.[477]

In light of these findings the Committee recommends:

 

 

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That research be undertaken to:

·         quantify the benefits of self-help and peer support to participants,

·         identify savings to the health care system that result from peer support initiatives, and

That a portion of these savings be redirected to support further self-help and peer support initiatives.

 

Further to research on outcomes, there has been substantial effort in Canada to conceptualize how consumer and family knowledge can shape thinking related to clinical treatment, community service, and government policy.  In an important reworking of the Framework for Support document for the Canadian Mental Health Association,[478] authors offer an idea called the Knowledge Resource Base which they argue is critical to the advancement of the understanding of mental health, mental illness and addiction.  In addition to traditional sources of knowledge that include evidence derived from social science (such as the outcome studies referred to above) and medical/clinical knowledge (studies of brain function, for example), the Knowledge Resource Base also includes experiential knowledge (the day-to-day lived understanding of illness as offered by persons living with mental illness, and their families) and the wisdom that comes from custom, tradition and history (honouring diversity and including other ways of healing).

I believe that peer support should be promoted and funded for people who have a personal experience with mental illness.  Only individuals who have a mental illness truly understand what it is like to live with a mental illness.  Because of that, we have a tremendous ability to help one another that the professionals just cannot match. 

Families also need peer support so they can support one another and help navigate the system and advocate for their loved ones. 

We would be more able to help one another if we had financial resources as so many people are also living in poverty or with very limited incomes.  Transportation, communications by phone or internet is often not available to the individuals, themselves.   —Anonymous

 

10.4.1   Summary

Research focused on self-help and peer support is relatively new, but the findings are promising.  The theories that underpin the few studies that have been done and the methodologies employed are expanding the research horizon in new and innovative ways. 

Importantly, people living with mental illness, and their families, are participating in the formulation of questions as well as in data collection and analysis and the dissemination of findings. Such knowledge transfer practices are taking mental health and addiction in evolving and promising directions. 

Conceptual work, such as that evidenced by the new edition of Framework for Support, provides a rich discourse that is inclusive of consumer and family participation and establishes the value of their role in the creation of new knowledge. 

Therefore, the Committee recommends:

 

 

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That the Canadian Institutes of Health Research (CIHR) support research into self-help and peer support, and that in determining which research projects to fund the CIHR utilize a review process that welcomes and understands the types of participatory methodologies that persons living with mental illness, and their families, prefer and find effective.

 

10.5      NEW VOICES

Self-help and peer support, while a welcome addition to the array of treatment and community services, challenges traditional thought in a variety of ways.  People living with mental illness have their own perspectives regarding the causes and treatment of mental illness and addiction.  Families speak out about lack of access to services, their exclusion from the treatment of their loved ones, and the failure of governments to enact laws that permit involuntary treatment.[479] 

 

10.5.1   Service Delivery

Forty-one percent of respondents participating in the Committee’s e-consultation stated that their experience with service providers was negative.[480]  Twenty-three percent described lack of respect as their worst experience, while others said misdiagnosis and inappropriate treatment (22%), delay in treatment (20%), physical violence (16%), denial of treatment (14%) and forced hospitalization (10%) constituted the worst.  In the second phase of the e‑consultation, persons living with mental illness, and their families, also distinguished between availability of services (hard to find) and their accessibility (the services are there, but there are too many barriers to getting access to them).[481]

 

 

 

While acknowledging the contributions of professionals, persons living with mental illness say that they are often not listened to or treated as whole people.  Their lives become a series of unconnected problems to be managed only in ways that fit the various professional specialties. People living with mental illness, and their families, also reported to the Committee that they felt themselves to be objects to be “handled” rather than human beings sharing relationships with their health care professionals.

The safety of self-help groups has allowed people to speak out and to publish their views.  Their personal experiences add power to these narratives.  As a result, professionals, policy makers, administrators and the public are being challenged to alter their traditional views about people with mental illness and addiction and the way services intended to meet their needs are structured and delivered.

Back home I can remember my own personal experience wanting to start a self-help centre and, I should note, wanting to do it in French.  There was a lot of opposition to that because they said, “There will not be any professionals around.  Can you really do that by yourself?” 

But we were deaf, we were stubborn, we never listened, and 18 years later I am here right now, and today that concept is accepted.  Thus in that sense things have improved in that we have finally come to terms with the fact that mental health clients can do things by themselves, and for themselves, and they can have their own initiatives. —Eugene LeBlanc[482]

10.5.2   Recovery

Rather than using the language of diagnosis, symptoms, funding patterns, service utilization and economic burden, those living with mental illness speak of hope, recovery, connection, story-telling, healing journeys, loving attention, dignity, friends, spirituality, empowerment and the transformative power of crisis.[483] These are sophisticated ideas that are not easily measured and managed; they do not fit comfortably in a system that prefers standardized procedures, uniform measures of accountability and homogeneous evidence-based best practices. 

Families, while more supportive of psychiatry and medication than are those undergoing treatment, also advocate for services that lie outside the medical circle of care — for example, affordable housing, income support and work.

The focus is on wellness and not illness, on ability not disability, on becoming at ease with one’s limitations and not remaining diseased within one’s limitations, on focusing on the beginning of the recovery process and not on remaining stagnant within one’s misery.  —Joan Edwards-Karmazyn[484]

Despite their increasingly prominent role, people living with mental illness, and their families, do not feel generally that they are being heard; and there is evidence that this is so.[485]  While it is true that recovery, as a defining construct, has appeared in mental health literature (it has had a much longer history in the addiction field), its revolutionary potential is not well understood, nor has it been widely acted upon. 

 

10.5.3   Summary

New voices and views are often not taken seriously because those who advance them may be expressing somewhat diverging points of view. They may not agree with one another and the language they use may not be typical of the mainstream.  However, with respect to people and families affected by mental illness and addiction, these disparate voices offer the opportunity for a richer, more nuanced dialogue among all stakeholders.  They also provide a route to improved measures of accountability. 

 

 

The “customers” of the Canadian mental health and addiction system say that they cannot find services when they need them and that, when they are lucky enough to find help, they are often unhappy with the services they do receive.  These criticisms are not vague or insubstantial.  They point exactly to what is wrong.  This valuable information must serve to improve the targeting of future government investment and the oversight of outcomes.  Therefore, the Committee recommends:

 

 

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That accountability measures for mental health and addiction services include not just process issues such as numbers of visits, hours of counselling or dollars spent, but also address outcomes, such as respect, preservation of dignity, as well as a focus on hope and recovery, since these figure amongst the things that persons living with mental illness, and their families, value most.

 

10.6      CONTRADICTIONS AND CHALLENGES

As self-help and peer support continue to grow and become more adept at competing for government and other funding, they are challenged to remain true to their roots while, at the same time, being buffeted with the complicated demands, strings and “administrivia” that accompany money.

 

10.6.1   Paid Work Versus Unpaid Volunteerism

Self-help and peer support are based on independence as a core value. This argues that one of the main reasons their members experience success and satisfaction is that such groups are free to provide help in their own creative ways without direction from the “outside,” whether from funders or anybody else.  Nevertheless, having work to do is important and highly valued. Therefore, having the opportunity for a paid career as a peer support worker or on the staff of a funded self-help or peer support program is a very worthwhile goal to be pursued.

I want to be clear that [peer support] opportunities cannot be token ones.  They deserve to be paid positions and paid at a wage that is a life-worth-living-wage; not a living wage, a life-worth-living-wage [emphasis added]. —Becky McFarlane[486]

Once self-help and peer support work is recognized as a paid profession, the door opens on all sorts of possibilities that offer the potential for considerable benefit: credentialling of peer support through formal education, emergence of sub-specialties, formation of associations, and regulation through codes of ethics and disciplinary boards.  The danger to be avoided is that such traditional “structures” might transform self-help and peer support into something different, removing from them the fundamental reason for their effectiveness — the participation of their members solely on the basis of their lived experiences.

 

10.6.2   Funded (With Strings) Versus Unfunded (Poor But Free)

The accountability requirements that accompany funding by government and many granting bodies are onerous.  Just completing applications is skilled, labour-intensive work. Mainstream organizations often employ staff specifically to satisfy their funders’ demands for reports.  The burden of data collection increases steadily, and mainstream programs are required to keep extensive electronic and paper records describing their service activities in relation to expenditures, all the while complying with security measures and privacy legislation. Self-help and peer support groups, by their very nature, do not ask for private health information; some do not even ask participants for their names or addresses.  Their tradition is an oral one and their most valued activity, storytelling, defies conversion into data elements.

Many prominent self-help and peer support groups are effective without external funding (AA being the prime example).  But there are also numerous examples of self-help organizations that compete successfully for grant money, receive government funds and raise funds through soliciting private donations. 

But most live perpetually on a shoe-string budget without the means to mount the initiatives needed by their members or to maintain a presence at important decision-making tables.  Many such groups have difficulty acquiring funding because they challenge the very system through which the money tends to flow.  Some decide not to pursue government funding because of the pressures that may then be applied to change their ways of doing things.  Whatever the reason, lack of funding often contributes to the marginalization of self-help and peer support groups and ensures that, funded or unfunded, their voices are drowned out by the power of professional interests.

All of those initiatives have one thing in common:  They are undervalued, under-funded and, because they do not fall within the prevailing cultural framework of clinical and unionized services, they are not a priority for governments and are often seen as an afterthought.  In many instances, tokenism is very much enshrined in the mental health system.  —Eugene LeBlanc[487]

 

10.6.3   The Limits of Best Practice Research

Concepts such as best practice have not served self-help and peer support well. The approach to models — of programs, of practice, of logic, of evaluation — that is common among professionals, does not translate well to the informality of the self-help culture. On the one hand, this has meant that not enough research has been done on the merits of self-help and peer support. On the other, because much traditional research has tended to discount the voices of people with direct experience of mental illness, it has cut itself off from the key source of information required to be able to assess outcomes of mental health interventions.

People living with mental illness, and their families, like many marginalized groups, have legitimate grounds for being suspicious of many traditional research methods, and for looking with greater favour on non-traditional methodologies such as participatory action research or underutilized ones such as qualitative methods. With the increased incidence of government funding, however, some groups are grappling with defining best practices, hoping that by adopting the methods of the professional culture they will gain respect and compete more effectively for funding.   

The value of self-help and support groups in recovery has been very well documented.  […]Financial support for promoting and funding this important area is much needed. The self-help movement is growing, but could do so at a much faster pace.   —Susan Kilbridge-Roper[488] 

 

10.6.4   Summary

There is no doubt that tension exists between the informality of self-help and peer support and the formality of professional research methods and literature. In response to questions such as,

§         can and should peer-run support programs be classified, evaluated and understood by the same measures that govern services provided in the traditional mental health system, and

§         would standardization of services supplant the healing bond of peer-to-peer relationships rendering them units of time at billable hours.[489]

it is very likely that peer support programs may not be able to reach their full potential if  they do not embrace certification and accountability mechanisms.  Therefore, the Committee recommends:

 

 

51

That accountability requirements that are established for self-help and peer support groups do not impose an overly onerous burden on these groups, and that measures be taken to ensure that these groups are able to meet these requirements.

That consumer and family-led certification and accreditation processes for self-help and peer support programs be developed and funded to ensure quality, and to sustain the unique contribution of self-help and peer support initiatives.

 

10.7      SUSTAIN AND PROTECT

While mainstream organizations assert that a lack of funds compromises their ability to be effective, marginalized groups often hear the opposite — that funding will spoil them.  People living with mental illness, and their families, have fought their way onto the mental health and addiction stage, step by difficult step, making on the way valuable contributions to the ways in which we think and speak about mental illness and addiction.  The ideal of recovery comes from their ranks, as does the transformative reorientation of mental health and addiction treatment, supports and services toward the goal of recovery.

How do you live day and night with a mental illness?  Does it not make sense to talk to people who are living day and night with a mental illness? It makes perfect sense to me.   —Linda Bayers[490]

Indeed there are contradictions and disagreements among individuals and families affected by mental illness and addiction, but this is hardly unusual.  It is also true that the skills and attributes necessary to recover from a mental illness or addiction — or, as a family member, to support yourself, a loved one, and to navigate the system — are not the same as those required to lead complicated non-profit organizations; but then again, health professional education does not encompass much in the way of administration or management expertise. Usually, at least in the health professions, such skills are learned on the job. 

For decades, professional organizations have had substantial funding. They have built infrastructure (computers, software and trained financial and informatics staff) to meet their accountability requirements.  Consumer and family self-help and peer support organizations must begin almost from scratch because of their history of no, or limited, funding.

Self-help and peer support groups (and the research that focuses on them) point out that the solutions they offer to people and families suffering from mental illness and addiction are more cost-effective than professional help.  This assertion can hardly be disputed, given that they are providing help for free or at minimal cost.  There is a danger that if such groups are excused from conforming to standard accountability procedures because of their lack of infrastructure, self-help and peer support will simply become more deeply entrenched as poor cousins, outside the circles of real power where the important decisions are made. 

In case these fears seem trivial, it should be noted that the Australian mental health strategy, praised internationally for its focus on the involvement of consumers and their families and its values of hope and recovery, has encountered serious difficulties in sustaining its implementation.  For example, funding for the National Resource Centre for Consumer Participation, despite excellent capacity-building work, was withdrawn in September 2004; it no longer exists.

The Committee believes that the rewards of investing in self-help and peer support outweigh the risk that their cultures may be altered in unpredictable or negative ways.  The key is to balance financial support with independence and the capacity to meet the necessary accountability requirements. 

The rise of the self-help movement in mental health and addiction heralds a significant change in the traditional power relations in our systems of care. With sufficient and regular funding, combined with ongoing government commitment and protection, its full benefits will be realized.

I believe that self-help initiatives such as consumer/survivor projects and many other self-help resources for mental health and addictions need to be formally recognized and acknowledged to be very effective and less threatening recovery solutions.  As a result they require funding which is appropriate — and not shamefully lacking — for the excellent work that they do.   —Anonymous

 

 

Therefore, the Committee recommends:

 

 

52

That existing and new consumer and family organizations be funded at an annualized, sustainable level.

That broad-based coalitions be funded and built among self-help and peer support organizations so that they do not continue to exist in isolation but are able to form networks with one another.

 

10.8      CONCLUSION

The informed perspective of persons living with mental illness, as well as that of their family, is invaluable. Their organizations must be supported through stable, adequate, annualized funding. They must also be included in public education, research and knowledge transfer activities and thereby support the growth and development of the structures and skills that enable all organizations providing services to people and families affected by mental illness and addiction to operate effectively.


[298]   5 July 2005, /en/Content/SEN/Committee/381/soci/25ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[299]   Standing Senate Committee on Social Affairs, Science and Technology. (November 2004) Report 1 — Mental Health, Mental Illness and Addiction:  Overview of Policies and Programs in Canada, Chapter 6, section 6.1, p. 107.

[300]   5 July 2005, /en/Content/SEN/Committee/381/soci/25ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[301]   5 July 2005, /en/Content/SEN/Committee/381/soci/25ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[302]   5 July 2005, /en/Content/SEN/Committee/381/soci/25ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[303]    Dewa, C. S., Lesage, A., Goering, P., and Caveen, M. (2004) Discussion Paper: Nature and Prevalence of Mental Illness in the Workplace. HealthcarePapers, Vol. 5, No. 2, p. 18.

[304]   Ibid., p. 20.

[305]   5 July 2005, /en/Content/SEN/Committee/381/soci/25ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[306]    Vézina, M., Bourbonnais, R., Brisson, C., and Trudel, L. (2004) Discussion Paper: Workplace Prevention and Promotion Strategies. HealthcarePapers, Vol. 5, No. 2, p. 34.

[307]   Canadian Psychiatric Association. (2005)  Mental Illness and Work. http://www.cpa-apc.org/MIAW/pamphlets/Work.asp.  

[308]   5 July 2005, /en/Content/SEN/Committee/381/soci/rep/report1/repintnov04vol1-e.pdf.

[309]   See Chapter 6, Children and Youth.

[310]   Archambault, E., Cote, G., and Gingras, Y. (2003) Bibliometric Analysis of Research on Mental Health in the Workplace in Canada. Cited in research conducted for the Committee by Neasa M. Martin and Associates, June 2005.

[311]   Goldner, E., Bilsker, D., Gilbert, M., Myette, L., Corbiere, M., and Dewa, C. S.  (2004) Discussion Paper: Disability Management, Return to Work and Treatment. HealthcarePapers, Vol. 5, No. 2, p. 77.

[312]   Ibid., p. 86.

[313]   Neufeldt, A. H. (2004) Discussion Paper: What Does It Take to Transform Mental Health Knowledge into Workplace Practice? Towards a Theory of Action. HealthcarePapers, Vol. 5, No. 2, p. 123.

[314]   Standing Senate Committee on Social Affairs, Science and Technology. (November 2004) Report 1 — Mental Health, Mental Illness and Addiction:  Overview of Policies and Programs in Canada, Chapter 6, section 6.1, p. 107. See also Dewa et al. (2004), p. 13.

[315]    Standing Senate Committee on Social Affairs, Science and Technology. (November 2004) Report 1 — Mental Health, Mental Illness and Addiction:  Overview of Policies and Programs in Canada, Chapter 6, section 6.4, p. 113.

[316]   Dewa et al. (2004), p. 22.

[317]    Standing Senate Committee on Social Affairs, Science and Technology. (November 2004) Report 1 — Mental Health, Mental Illness and Addiction:  Overview of Policies and Programs in Canada, Chapter 6, section 6.3, p. 110.

[318]   Global Business and Economic Roundtable on Addiction and Mental Health. (2006) Employers Getting Started — The Road to Mental Health and Productivity, Module Three: The Demographics and Distribution of Mental Illness: Mostly an Economic, Business and Labour Cost — Health Care Costs Less Than Productivity Loss.

[319]   Standing Senate Committee on Social Affairs, Science and Technology. (November 2004) Report 1 — Mental Health, Mental Illness and Addiction:  Overview of Policies and Programs in Canada, Chapter 6, section 6.3, p. 110.

[320]   Dewa et al. (2004), p. 19.

[321]   Standing Senate Committee on Social Affairs, Science and Technology. (November 2004) Report 1 — Mental Health, Mental Illness and Addiction:  Overview of Policies and Programs in Canada, Chapter 6, section 6.3, pp. 110-111.

[322]   Global Business and Economic Roundtable on Addiction and Mental Health. (2006) Module Three.

[323]   Global Business and Economic Roundtable on Addiction and Mental Health. (2006) Employers Getting Started — The Road to Mental Health and Productivity, Module Two: The Building Blocks of Productive Capacity in a Brain-Based Economy — Setting the Stage for Mental Health in the Workplace.

[324]   Ibid.

[325]    Ibid.

[326]   Vézina et al. (2004), p. 39.

[327]   Ibid., p. 34.

[328]   Ibid., p. 36

[329]   Ibid.

[330]    Vézina et al. (2004), pp. 39-40.

[331]   Global Business and Economic Roundtable on Addiction and Mental Health. (2004) Roundtable Roadmap to Mental Disability Management.

[332]   Neufeldt (2004).

[333]   Gnam, W. (2004) Researcher Response: Research Priorities Are Critical. HealthcarePapers, Vol. 5, No. 2, pp. 91-94.

[334]    Bender, A., and Kennedy, S. (2004) Discussion Paper: Mental Health and Mental Illness in the Workplace: Diagnostic and Treatment Issues. HealthcarePapers, Vol. 5, No. 2, pp. 54-67.

[335]   Standing Senate Committee on Social Affairs, Science and Technology. (November 2004) Report 1 — Mental Health, Mental Illness and Addiction:  Overview of Policies and Programs in Canada, Chapter 6, section 6.5.2, p. 123.

[336]   Ibid., p. 124.

[337]   Harnois, G., and Gabriel, P. (2000) Mental Health and Work: Impact, Issues and Good Practices. Joint publication of the World Health Organization and the International Labour Organization, Geneva, p. 19.

[338]   Mental Health Works, CMHA Ontario. http://www.mentalhealthworks.ca/index.asp.

[339]   This section is drawn largely from: Standing Senate Committee on Social Affairs, Science and Technology. (November 2004) Report 1 — Mental Health, Mental Illness and Addiction:  Overview of Policies and Programs in Canada, Chapter 6, pp. 121-23.

[340]   Standing Senate Committee on Social Affairs, Science and Technology. (November 2004) Report 1 — Mental Health, Mental Illness and Addiction:  Overview of Policies and Programs in Canada, Chapter 6, section 6.5.1, p. 122.

[341]   Neufeldt (2005).

[342]   Standing Senate Committee on Social Affairs, Science and Technology. (November 2004) Report 1 — Mental Health, Mental Illness and Addiction:  Overview of Policies and Programs in Canada, Chapter 6, section 6.5.1, p. 123.

[343]   5 July 2005, /en/Content/SEN/Committee/381/soci/25ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[344]   Shankar, J., and Collyer, F.  (2002)   Support needs of people with mental illness in vocational rehabilitation programs — the role of the social network.  International Journal of Psychosocial Rehabilitation, Vol. 7, 15-28.

[345]   Lehman, A. F. (1995) Vocational Rehabilitation in Schizophrenia. Schizophrenia Bulletin, Vol. 21, No. 4, 645-656.

[346]   Marrone, J., and Gold, M. (1995) Employment Supports for People with Mental Illness. Psychiatric Services, Vol. 46, No. 7, 707-711.

[347]   Marrone, J., and Golowka, E. (1999) If Work Makes People Sick, What do Unemployment, Poverty and Social Isolation Cause? Psychiatric Rehabilitation Journal, Vol. 23, No. 2.

[348]   Ibid.

[349]   Bond, G. R., Drake, R. E., Mueser, K. T., and Becker, D. R.  (1997) Supported employment for people with severe mental illness: A review. Psychiatric Services, Vol. 48, No. 3, 335-346.

[350]   Crowther, R., Marshall, M., Bond, G., and Huxley, P. Vocational rehabilitation for people with severe mental illness. The Cochrane Database of Systematic Reviews 2001, Issue 2, Art. No.: CD003080. DOI: 10.1002/14651858.CD003080.

[351]   Ontario Peer Development Initiative. (October 2003) The History of OPDI. http://www.opdi.org/about_us.html#history.

[352]   Danley, K. (1996) Proceedings of the Conference on Psychological Disabilities in the Workplace.

[353]   The National Mental Health Consumers Self-Help Clearing House.

[354]   McReynolds, C. (2002)  Psychiatric Rehabilitation: The Need for a Specialized Approach.  International Journal of Psychosocial Rehabilitation, Vol. 7, 61-69. http://www.psychosocial.com/IJPR_7/approach.html.

[355]   Clubhouse History. http://www.telusplanet.net/public/club1/history.html.

[356]   This section is drawn largely from: Standing Senate Committee on Social Affairs, Science and Technology. (November 2004) Report 1 — Mental Health, Mental Illness and Addiction:  Overview of Policies and Programs in Canada, Chapter 6, pp. 116-118.

[357]   20 April 2005, /en/Content/SEN/Committee/381/soci/13eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[358]   Canadian Psychiatric Association. (1988) Insurability of the Psychiatrically Ill or Those With a Past History of Psychiatric Disorder.  Position Paper.

[359]   Government of Ontario, Ministry of Community and Social Services.  Who is Eligible for Ontario Works?  http://www.cfcs.gov.on.ca/CFCS/en/programs/IES/OntarioWorks/FAQs/OW-q-eligibility.htm.

[360]   Government of Ontario, Ministry of Community and Social Services. ODSP Handbook.  http://www.cfcs.gov.on.ca/CFCS/en/programs/IES/OntarioDisabilitySupportProgram/Publications/ODSP_handbook.htm.  

[361]   Government of British Columbia, Ministry of Employment and Income Assistance. BC Employment and Assistance Rate Tables — Disability Assistance — Effective 1 January 2005.   http://www.eia.gov.bc.ca/mhr/da.htm.

[362]   Government of Ontario, Ministry of Community and Social Services. ODSP Handbook.      http://www.cfcs.gov.on.ca/CFCS/en/programs/IES/OntarioDisabilitySupportProgram/Publications/ODSP_handbook.htm.

[363]   Government of Quebec, Emploi et Solidarité sociale. Basic Benefit.    http://www.mess.gouv.qc.ca/securite-du-revenu/programmes-mesures/assistance-emploi/prestation-de-base_en.asp.

[364]   Government of British Columbia, Ministry of Employment and Income Assistance. Fact Sheet — Earnings Exemption for Persons With Disabilities.         http://www.eia.gov.bc.ca/factsheets/2004/PWD_EarningsExemption.htm.

[365]   Government of Ontario, Ministry of Community and Social Services. ODSP Handbook.      http://www.cfcs.gov.on.ca/CFCS/en/programs/IES/OntarioDisabilitySupportProgram/Publications/ODSP_handbook.htm.

[366]   Government of Quebec, Emploi et Solidarité sociale. Basic Benefit.           http://www.mess.gouv.qc.ca/securite-du-revenu/programmes-mesures/assistance-emploi/prestation-de-base_en.asp

[367]   14 June 2005, /en/Content/SEN/Committee/381/soci/22eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[368]   This section is drawn largely from: Standing Senate Committee on Social Affairs, Science and Technology. (November 2004) Report 1 — Mental Health, Mental Illness and Addiction:  Overview of Policies and Programs in Canada, Chapter 6, pp. 118-120.

[369]   31 May 2005, /en/Content/SEN/Committee/381/soci/16eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[370]   Canadian Mental Health Association.  (27 November 2001)  Position Paper on Federal Income Security Programs, submitted to the House of Commons Subcommittee on the Status of Persons With Disabilities. http://www.disabilitytax.ca/subs/cmha-e.pdf.

[371]   /en/Content/SEN/Committee/381/soci/13evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[372]   Human Resources Development Canada. (November 2003) Government of Canada’s Response to “Listening to Canadians:  A First View of the Future of the Canada Pension Plan Disability Program,” p. 22.

[373]   In her November 2004 Report, the Auditor General indicated that the accumulated surplus in the EI Account had risen to $46 billion.  See:  Office of the Auditor General of Canada, November 2004 Report, Chapter 8.  http://www.oag-bvg.gc.ca/domino/reports.nsf/html/20041108ce.html#ch8hd3b.

[374]   For a more detailed explanation of the Disability Tax Credit, see:  Canada Revenue Agency, Disability amount. http://www.cra-arc.gc.ca/agency/resourcekit/individuals/benefits-dtc-e.html.  

[375]    “Basic activity of daily living” means one of the following:  perceiving, thinking, and remembering, feeding, dressing, speaking so as to be understood by a person familiar to you in a quiet setting, hearing so as to understand a person familiar to you in a quiet setting, eliminating (bowel or bladder functions), walking.

[376]   21 September 2005, /en/Content/SEN/Committee/381/soci/28ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[377]   Throughout this chapter, the term “addiction” is used for simplicity’s sake. It is recognized that harm due to substance use and abuse can occur without addiction being present: through binge drinking, intoxication and unsafe drug use that result in health problems, road accidents, falls and other adverse consequences. Substance use exists on a continuum with limited, safe use at one end and addiction at the other — but the potential for harm may occur at many points along this continuum.

[378]   Skinner, W., O’Grady, C., Bartha, C., and Parker, C. (2004) Concurrent substance use and mental health disorders: An information guide. Toronto: Centre for Addiction and Mental Health.

[379]   Rush, B. (undated) Concurrent mental and substance use disorders: Why is such “double trouble” so important? Submission to the Standing Senate Committee on Social Affairs, Science and Technology, p. 7.

[380]   Reghr, T. (September 2005) Brief submitted to the Standing Senate Committee on Social Affairs, Science and Technology, p. 2.

[381]   6 June 2005, /en/Content/SEN/Committee/381/soci/18eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[382]   Strader, B. (undated) Submission to the Standing Senate Committee on Social Affairs, Science and Technology.

[383]   Tobacco is also a significant factor in negative health consequences.

[384]   Tim Stockwell, Michel Perron, Greg Purvis, and Jeff Wilbee, 21 September 2005, /en/Content/SEN/Committee/381/soci/28ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[385]   21 September 2005, /en/Content/SEN/Committee/381/soci/28ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[386]   Canadian Centre on Substance Abuse. (March 2005) Canadian Addiction Survey (CAS): A national survey of Canadians’ use of alcohol and other drugs: Prevalence of use and related harms. Available at: www.ccsa.ca.

[387]   Single, E., Robson, L., Xiaodi, X., and Rehm, J. (1996) The costs of substance abuse in Canada. Available at: www.ccsa.ca.

[388]   Health Canada, First Nations and Inuit Health Branch. (2004)  Literature review: Evaluation strategies in Aboriginal substance abuse programs: A discussion. (2004) Available at: www.ccsa.ca.

[389]   Canada Safety Council. (2005) Alcohol-Crash Stats. Available at: www.safety-council.org/info/traffic/impaired/stats.html.

[390]   Rehm, J., and Weeks, J. (2005) Abuse of controlled prescription drugs. In Substance abuse in Canada: Current challenges and choices. Ottawa: Canadian Centre on Substance Abuse. Available at: www.ccsa.ca.

[391]   Ibid.

[392]   Canadian Centre on Substance Abuse, and Centre for Addiction and Mental Health. (1999) Canadian Profile 1999. Available at: www.ccsa.ca.

[393]   21 September 2005, /en/Content/SEN/Committee/381/soci/28ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[394]   Simpson, R.  Brief submitted to the Standing Senate Committee on Social Affairs, Science and Technology.

[395]   Canada West Foundation. (2001) Gambling in Canada 2001: An Overview. Available at: www.cwf.ca.

[396]   Skinner, W. (September 2005) Submission to the Standing Senate Committee on Social Affairs, Science and Technology.

[397]   Sadinsky, S. (March 2005). Review of problem gambling and responsible gaming strategies of the Government of Ontario: A report to the Ontario Ministry of Health and Long-term Care and the Ministry of Economic and Trade Development. Available at: www.health.gov.on.ca/ HYPERLINK "http://www.moh.gov.on

.ca" .

[398]   Youth Gambling International. (2004) Youth problem gambling. Available at: www.education.mcgill.ca.

[399]    Brant, C. (1993) Suicide in Canadian Aboriginal peoples: causes and prevention. In the Royal Commission on Aboriginal Peoples: The path to healing: Report on the national round table on Aboriginal health and social issues. Ottawa: Department of Supply and Services.

[400]   Mussell, B., Cardiff, K., and White, J. (2004) The mental health and well being of Aboriginal children and youth: Guidance for new approaches and services. Available at: www.mheccu.ubc.ca.

[401]   14 June 2005, /en/Content/SEN/Committee/381/soci/22eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[402]   American Liver Foundation. Cirrhosis:  Many Causes. Available at: http://www.liverfoundation.org/db/articles/1059.

[403]   Bradley, N. (September 2005) Submission to the Standing Senate Committee on Social Affairs, Science and Technology.

[404]   Ibid.

[405]   Spencer, C. (June 2005) Alcohol and seniors: Gambling issues for seniors — Links, programs, research and resources. (June 2005) Available at: www.agingincanada.ca.

[406]   Spencer, C. (June 2005) Presentation to the Standing Senate Committee on Social Affairs, Science and Technology.

[407]   Statistics Canada. (2002) Canadian community health survey: Mental health and wellbeing. Available at: www.statcan.ca.

[408]    Dowden, C. (2003) The effectiveness of substance abuse treatment with young offenders. Available at: www.canada.justice.gc.ca.

[409]   Youth Gambling International. (2004) Youth problem gambling. Available at: www.education.mcgill.ca.

[410]   Trocme, N., et al. (2005) Canadian incidence study of reported child abuse and neglect 2003: Major findings. Available at: www.phac-aspc.gc.ca/.

[411]    9 June 2005, /en/Content/SEN/Committee/381/soci/21eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.   

[412]   In 2002-2003, sales of alcoholic beverages totalled $15.4 billion in Canada, with beer accounting for $12.6 billion. Taxes on alcohol and tobacco accounted for 2.5% of all tax revenue. Source: Thomas, G. (2004) Alcohol-related harms and control policy in Canada. Available at: www.ccsa.ca.  In 1999-2001, net government revenue from gambling — across Canada — equalled $5.7 billion.  Source: Canada West Foundation. (2001) Gambling in Canada 2001: Overview. Available at: www.cwf.ca. In 2001, the average Canadian household spent $257 on government lotteries alone. Source: www.cbc.ca/background/gambling.

[413]   Ontario Federation of Mental Health and Addiction Programs. (2003) Generating new revenue to support addictions services: A behavioural insurance model. Available at: www.ofcmhap.on.ca.

[414]   21 September 2005, /en/Content/SEN/Committee/381/soci/28ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[415]   The term dual diagnosis is used in the United Kingdom and the United States.

[416]   Stuart, H., on behalf of the Concurrent Disorders Champion Group. (2002) Concurrent disorders: An integrated service delivery plan for southeastern Ontario. (2002) Submitted to the Southeastern Ontario Mental Health Implementation Task Force and the Southeastern Ontario District Health Council.

[417]   Rush, B. (undated) Concurrent mental and substance use disorders: Why is such “double trouble” so important? Submission to the Standing Senate Committee on Social Affairs, Science and Technology.

[418]   Negrete, J. (2003) Treating addiction in individuals with other mental illnesses. Submission to the Standing Senate Committee on Social Affairs, Science and Technology.

[419]   The one exception is that best practice guidelines (Rush, 2002) call for substance abuse to be treated first among people with mood and anxiety disorders — although integrated treatment is recommended for Post-traumatic Stress Disorder.

[420]   Centre for Addiction and Mental Health. (2002) Best practices: concurrent mental health and substance abuse disorders. Available at: www.cds-sca.com.

[421]   Ontario Problem Gambling Research Centre. (undated) Minimal treatment approaches for concerned significant others of problem gamblers. Available at:           www.gamblingresearch.org/printdoc.sz?cid=123.

[422]    21 September 2005, /en/Content/SEN/Committee/381/soci/28ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[423]   Thomas, G. (2005) Harm reduction policies and programs for persons involved in the criminal justice system. Canadian Centre on Substance Abuse. Available at www.ccsa.ca.

[424]   Ibid.

[425]   Canadian Centre on Substance Abuse. (February 2004) Needle Exchange Programs (NEPs): FAQs. Available at: www.ccsa.ca.

[426]   Canadian Centre on Substance Abuse. (July 2004) Supervised injection facilities (SIF): FAQs. Available at: www.ccsa.ca.

[427]   Seaton House is a shelter serving men.

[428]   Wysong, P. (November 2002) Homecare for the homeless. Medical Post, Vol. 38, Issue 40. Available at: www.medicalpost.com.

[429]   Alderson-Gill & Associates Consulting Inc. (2002) Evaluation prepared for the National Homelessness Initiative: Shepherds of Good Hope, Harm Reduction Program, Ottawa, Ontario. Available at: www.homelessness.gc.ca/projects/casestudies/docs/ottawa/shepherds_e.pdf

[430]   Citizens for Mental Health Association. (2003) Backgrounder: Justice and Mental Health. Available at: www.cmha.ca/citzens/justice.pdf.

[431]   Stockwell, T., assisted by Sturge, J. (September 2005) Brief to the Standing Senate Committee on Social Affairs, Science and Technology.

[432]   Brunemeyer, N. (March 2004) Addictions services redesign at Vancouver Coastal Health. Four Pillars News, Vol. II, Issue 1. Available at: www.city.vancouver.bc.ca/fourpillars/newsletter.

[433]   Hayashida, M., Altman, A., McLellan, A., O’Brien, C., Purtil, J., Volpicelli, J., Pahelson, A., and Hall, C. (1989) Comparative effectiveness of inpatient and outpatient detoxification of patients with mild-to-moderate alcohol withdrawal symptoms. New England Journal of Medicine, Vol. 320, No. 6, pp. 358-365.

[434]   21 September 2005, /en/Content/SEN/Committee/381/soci/28ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[435]   21 September 2005, /en/Content/SEN/Committee/381/soci/28ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[436]   See Chapter 3 for a fuller discussion of how “recovery” is defined within the mental health system.

[437]   21 September 2005, /en/Content/SEN/Committee/381/soci/28ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[438]   21 September 2005, /en/Content/SEN/Committee/381/soci/28ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[439]   British Columbia Ministry of Health Services. (May 2004) Every door is the right door: A British Columbia planning framework to address problematic substance use and addiction. Available at:     http://www.healthservices.gov.bc.ca/mhd/pdf/framework_for_substance_use_and_addiction.pdf.

[440]    Alberta Alcohol and Drug Abuse Commission. (July 2005) Building capacity: A framework for serving Albertans affected by addiction and mental health issues. Available at: www.aadac.com.

[441]   21 September 2005, /en/Content/SEN/Committee/381/soci/28ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[442]   Skinner, W. (September 2005) Submission to the Standing Senate Committee on Social Affairs, Science and Technology.

[443]   The National Framework has identified: Issues (increasing awareness of problematic substance abuse, reducing the problematic use of alcohol, preventing the problematic use of pharmaceuticals, addressing enforcement strategies and addressing Fetal Alcohol Spectrum Disorder); Supportive Infrastructure (sustaining workforce development, increasing access to services, implementing a national research agenda along with knowledge transfer, and modernizing legislation, regulatory and policy frameworks); and Key Populations (children and youth, people of the North, First Nations, Inuit and Métis, and offenders).

[444]   The motion reads as follows: “That, given a national strategy is needed now to reduce the growing human and economic costs of cancer, heart disease and mental illness; the House call on the government to fully fund and implement the Canadian Strategy for Cancer Control in collaboration with the provinces and all stakeholders, and given that Canada is one of the few developed countries without a national action plan for effectively addressing mental illness and heart disease, the government should immediately develop and initiate a comprehensive national strategy on mental illness, mental health and heart disease” [emphasis added].

[445]   21 September 2005, /en/Content/SEN/Committee/381/soci/28ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[446]   10 May 2005, /en/Content/SEN/Committee/381/soci/15evc-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[447]   Dyck, F. (2 June 2005) Speaking notes  prepared for hearings of the Standing Senate Committee on Social Affairs, Science and Technology.

[448]   Chodos, H., N. Pogue and T. Riordan. (2005) E-consultation on mental health, mental illness and addiction: Phase one.  Parliamentary Information and Research Service, Library of Parliament.

[449]   Standing Senate Committee on Social Affairs, Science and Technology. (November 2004) Report 1 — Mental health, mental illness and addiction:  Overview of policies and programs in Canada, Chapter 3, Section 3.4.1, p. 59 (Quote from Jennifer Chambers’ testimony).

[450]   Chodos, H., N. Pogue and T. Riordan. (2005) E-consultation on mental health, mental illness and addiction: Phase one.  Parliamentary Information and Research Service, Library of Parliament.

[451]   Standing Senate Committee on Social Affairs, Science and Technology. (November 2004) Report 1 — Mental health, mental illness and addiction:  Overview of policies and programs in Canada, Chapter 3, Section 3.2.1, p. 42 (Quote from Rena Scheffer’s testimony).

[452]   16 June 2005, /en/Content/SEN/Committee/381/soci/22evc-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[453]   Mead, S., D. Hilton, and L. Curtis. (Undated) Peer support: A theoretical perspective. Available at: www.mentalhealthpeers.com.

[454]   15 February 2005, /en/Content/SEN/Committee/381/soci/05eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[455]   Everett, B. (2000) Consumers and psychiatric survivors confront the power of the mental health system. Waterloo, ON: Wilfrid Laurier University Press.

[456]   17 February 2005, /en/Content/SEN/Committee/381/soci/07ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[457]   Estroff, S. (1989) Self, identity and subjective experiences of schizophrenia:  In search of a subject. Schizophrenia Bulletin, Vol. 15, No. 2, 189-196.

[458]   Standing Senate Committee on Social Affairs, Science and Technology. (November 2004) Report 1 — Mental health, mental illness and addiction:  Overview of policies and programs in Canada, Chapter 1, Section 1.1.1, p. 8 (Quote from Loise Forest’s testimony). 

[459]   Mead, S., and C. MacNeil. (2004) Peer Support: What makes it unique? Available at: www.mentahealthpeers.com.

[460]   Carten, R. (June 2006) Submission to the Standing Senate Committee on Social Affairs, Science and Technology.

[461]   Chodos, H., N. Pogue and T. Riordan. (2005) E-consultation on mental health, mental illness and addiction: Phase one. Parliamentary Information and Research Service, Library of Parliament.

[462]   10 May 2005, /en/Content/SEN/Committee/381/soci/15evc-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[463]   See Chapter 3, Section 2, for a full discussion of “recovery.”

[464]   Everett, B. (ed). (1994) You are not alone: A handbook for facilitators of self help and mutual aid support groups. Available through: Mood Disorders Association of Ontario.

[465]   Clay, S. (ed). (2005) On our own together: peer programs for people with mental illness. Nashville, TN: Vanderbilt University Press.

[466]   17 February 2005, /en/Content/SEN/Committee/381/soci/07ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[467]   Mead, S., D. Hilton, and L. Curtis. (undated) Peer support: A theoretical perspective. Available at: www.mentalhealthpeers.com.

[468]   Canadian Mental Health Association, Ontario, the Centre for Addiction and Mental Health, the Ontario Federation of Community Mental Health and Addiction Programs and the Ontario Peer Development Initiative. (March 2005) Consumer/survivor initiatives:  Impact, outcomes and effectiveness. Available at: www.ofcmhap.on.ca.

[469]   9 May 2005, /en/Content/SEN/Committee/381/soci/15evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[470]   Mead, S., and D. Hilton. (2003) Crisis and connection. Psychiatric Rehabilitation Journal, Vol. 27, No. 1, 87-94.

[471]   31 May 2005, /en/Content/SEN/Committee/381/soci/16eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[472]   Maple Leaf. (February 2005) Canadian Forces Newsletter.

[473]   For example, Corring, D. (2002) Quality of life: Perspectives of people with mental illness and family members.  Psychiatric Rehabilitation Journal, Vol. 25.

[474]   Campbell, J., and J. Leaver. (2003) Report from NTAC’s National Experts meeting on emerging new practices in organized peer support. Available through: U.S. Department of Health and Human Services.

[475]   Nelson, G. (2004) What was learned about members of CSIs in Making a Difference.  Available through: Centre for Addiction and Mental Health.

[476]   Forchuk, C. (2002) Therapeutic relationships: From hospital to community. Available at: Canadian Health Services Research Foundation, www.chrsf.ca.

[477]   Trainor, J., et al. (1997) Beyond the service paradigm: The impact of consumer/survivor initiatives.  Psychiatric Rehabilitation Journal, Vol. 21, 132-140.

[478]   Trainor, J., E. Pomeroy, and B. Pape. (2004) A framework for support. Third edition. Toronto: Canadian Mental Health Association, National Office.

[479]   See also Chapter 4, Section 4.3.3, for a related discussion of the power of Review Boards to order treatment.

[480]   Chodos, H., N. Pogue and T. Riordan. (2005) E-consultation on mental health, mental illness and addiction: Phase one.  Parliamentary Information and Research Service, Library of Parliament.

[481]   Ascentum. (June 2005) Final report on the online consultation by the Standing Senate Committee on Social Affairs, Science and Technology.

[482]   11 May 2005, /en/Content/SEN/Committee/381/soci/15eve-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[483]   Mead, S. (2003)  Defining peer support. Available at: www.mentahealthpeers.com.

[484]   14 June 2005, /en/Content/SEN/Committee/381/soci/22eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[485]   Canadian Mental Health Association, Ontario, the Centre for Addiction and Mental Health, the Ontario Federation of Community Mental Health and Addiction Programs and the Ontario Peer Development Initiative. (March 2005) Consumer/survivor initiatives:  Impact, outcomes and effectiveness. Available at: www.ofcmhap.on.ca.

[486]   15 February 2005, /en/Content/SEN/Committee/381/soci/05evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[487]   11 May 2005, /en/Content/SEN/Committee/381/soci/15eve-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[488]   9 May 2005, /en/Content/SEN/Committee/381/soci/15eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[489]   Campbell, J., and J. Leaver. (2003) Report from NTAC’s National Experts meeting on emerging new practices in organized peer support, pp. 31-32. Available from: U.S. Department of Health and Human Services.

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