Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology

Issue 5 - Evidence -  Thursday, April 1, 2004 - Afternoon

OTTAWA, Thursday, April 1, 2004

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 3:05 p.m. to study on issues arising from, and developments since, the tabling of its final report on the state of the health care system in Canada in October 2002. In particular, the committee shall be authorized to examine issues concerning mental health and mental illness.

Senator Michael Kirby (Chairman) in the Chair.


The Chairman: Honourable senators, we have with us today via teleconference from Columbus, Mr. Michael Hogan, chair of the U.S. President's New Freedom Commission on Mental Health. We also have with us here in Ottawa Mr. William Emmet, the co-ordinator for the U.S. Campaign for Mental Health Reform. I thank both of you for taking the time to be with us. I will give you a brief background on what we are doing.

About 18 months ago, this committee released a report that we had been working on for almost three years on the major changes that were needed to the Canada's acute care system, the hospital and doctor system. Many of the ideas were appropriately machine-gunned by the right and the left at the time we put the report out to the extent that we frequently describe ourselves now as being the ``coalition of the extreme centre.'' On all of the truly controversial issues — waiting lines, funding, how money should be raised and so on — the committee reached unanimous consensus despite the political sensitivity of the issues.

Having concluded that, we decided to move on to the issue of mental health. We are very much in the early stages of this study and it will shortly go into a period of hiatus because this country is about to have a general election.

Nevertheless, we are following the pattern of our previous study. We will produce this fall what we would call an options paper that will set out a series of public policy options addressing the mental health issue. We will then conduct an extensive set of hearings in the first half of 2005 to gauge reaction across the country both from experts and the general public on the various options. We will then produce recommendations for reform in the second half of 2005. That is our schedule.

We wanted to get input from the two of you early on because of the kinds of things that we have read about regarding the issue in the United States and some of the progress that you are making. It will not surprise you to learn that we found that in terms of the acute care system, we did not copy much from the United States for many reasons. When you begin with a universal publicly funded system, there is really relatively little one can learn from the American experience other than perhaps how you make hospitals more efficient and we did use some of that information.

On the mental health issue, however, we do not have a national policy. It would appear that there are virtually no provincial policies. The mental health system has been the orphan of the health care system in Canada for a long time. We are determined, both through the report and then through the strong advocacy of recommendations, to get to the point where it ceases to be the orphan.

We are very early in this development. Any input you can provide will be extremely helpful. I would hope that as we go down the road we may well be in touch with you again simply because this is an issue on which we could learn from each other. I very much appreciate your taking the time to be with us.

We will begin with opening statements from the two of you, starting with Mr. Hogan and then turn to questions.

Mr. Michael Hogan, Chair, U.S. President's New Freedom Commission on Mental Health: Honourable senators, I will try to be succinct because more may come from the questions than from my presentation. It is an honour to have the opportunity to talk to you. I have just enough knowledge of health care in Canada to be dangerous. I do want to acknowledge a debt to one of my mentors, Dr. Hugh Lafave was a leader in reforming mental health care in Saskatchewan in the 1960s. Subsequently, he came to work in New York State where I learned a tremendous amount at his knee.

I will tell the story quickly of this president's commission that was established to look at mental health care in the U.S, not because I believe there is a complete fit in the health and mental health care systems of these countries. However, there is enough in common, as you said, Mr. Chairman, to allow us to learn from each other.

There are some similarities. The existence of a strong, although fragmented state, in our case, provincial in your case, responsibility backed up — sometimes poorly — by federal programs. Both Canada and the U.S. also share — as do many western countries — a problem with respect to mental health care. That is, we have government-run care systems for those with the most serious illnesses, while many people get care in the mainstream health care system for their mental illness. We do have some things in common.

I will go through these slides as quickly as I can. As I have indicated, this commission was established by the President. The last time a President's commission looked at mental health in the U.S. was a quarter century ago under President Carter.

Turning to the second slide, there is a quote from the executive order that charged this commission to look at improvements that will enable adults with serious mental illness and children with severe emotional disturbance to live, work, learn, and participate fully in their communities. Implicit in that charge was, I felt — and still feel — a direction to the mental health system to lift its sights beyond maintenance care toward the kind of treatments and supports that would help people achieve the life that they want.

I will not dwell on this, because honourable senators already know — or your study will take you into this subject — that the burden and impact of these diseases is quite extraordinary. This slide is taken from the World Health Organization, which looks at violent deaths worldwide and finds that deaths as a result of suicide are essentially equal to murder and war put together across the world. We do know that 95 per cent of suicides are precipitated by mental illness, sometimes with alcohol or drug use as well. This is a different measure of the impact on society of these conditions.

Also, WHO data in this case is specific to the U.S., Canada and Western Europe. It looks at the proportion of disability that is attributable to different categories of illnesses. We see a tremendous amount of disability is caused by mental illness. In part, because these conditions tend to come on when people are young and, in many cases, impair their functioning for decades. The impact goes on far longer than it would be for other illnesses that are thought of as more serious, like cancers, for example, that would tend to come on late in life.

The work of this commission was helped considerably by the fact that the Surgeon General of the United States, in 1999, completed a review of essentially all of the science of mental illness and of mental health care. The Surgeon General's report is a resource document that may be of some use to your committee. This slide shows the fundamentals of mental illness as documented in that report. These are conditions that affect many people, which, if treated well and early, have quite good outcomes.

However, most people get no care at all, and the care they get is apt to not be good enough. For example, in respect of people who are treated by their family doctor for depression, we know — in the States anyway — the depression tends to be under-detected and under-treated. We have this paradox of good treatments that are, at least in theory, available, but poor treatment that leads to high morbidity and mortality.

A problem that I believe that the United States and Canada both share is how the structure of our health care delivery systems is a part of the problem, which is why it is fortuitous that your committee has a broader scope than did our commission. One of the ways that I describe this problem is to ask people to think of another category of illness where we have a distinct care system run by government for the sickest people. We would not countenance that for any other major category of illness. Patients with cancer, heart disease or other health problems would get care in the same health care system. However, we have in the U.S., as you have in Canada, systems of care — if we want to be generous enough to call them that — at the state and provincial level that specialize in care for the most seriously mentally ill. I believe that, in and of itself, is a cause of the stigma. When people must rely on a care system run by government, it probably brings a certain amount of negative reputation to it.

This picture that I have included in the documents illustrates how our efforts to reform mental health care in the United States have been in some ways successful, and in other ways causative of other problems. This is a simplified description of what might be described as the theory in the United States over the last generation of how mental health care would be organized. We would have a federal agency, a Department of Mental Health within the state government, a CMHC or mental health centre at the community level — and this mental health centre would coordinate a wide array of services to the individual consumer, knit them together through a case manager.

This view was developed in the United States about 30 years ago. One of the things that followed, when we were going through the period known as deinstitutionalization, was that the federal government was not a good supporter of these needed care programs for people with serious mental illness. Therefore, now many of the mainstream federal programs — our Medicare program, which is, by and large, acute care for the elderly and for some disabled people, and our Medicaid program, which is a health-care and long-term care program for the very poor and disabled, as well as other government programs — got modified to provide at least some care for mental illness.

The result has been this patchwork quilt where we have all these different federal agencies that have some responsibility for mental health care. They tend to work through the corresponding agency at the state level. There is probably some analogue to this in the federal and provincial relationship in Canada. The entities at the state level and then at the local level that are responsible for care are different bureaucracies and different systems, creating the situation where the person with mental illness and the family has to navigate what has become a terribly complicated system; and they must do this, by and large, when they are at their worst.

One of the challenges is that this is a complicated, intergovernmental relationship that has been established over time. It is probably too complicated to just reform our way out of it. That is a challenge we had to deal with. In a sense, the diagnosis that this commission came up with for mental health care is that we have a system in our country, coordinated by states. The states use very different approaches and nobody has figured out a perfect solution. To some extent, as I know is true in Canada, the state's approach to mental health is dependent on the politics and the geography of that state.

We have a specialty system that is not really oriented to recovery. We tend to get people late and keep them in maintenance care. We do not use the best science. At the same time as we have this problem, we have a growing problem of mental health care not being available for people in other settings. In the schools, we have a big problem now with mentally ill people not getting care and ending up in prisons. The system has become a narrow maintenance system that is not very effective across the range of responsibilities and populations. That led this commission to say that we viewed our system as being in shambles.

The logic of what our group proposed was to try to sidestep the notion of reform or reorganization. We had a sense that reform had gotten us into this mess, and we had to have a different language or concept. We ended up being galvanized around this notion of transformation. We do not know exactly what it means, but we think that this transformation means that actions are necessary at many levels. It is not just a federal problem such that the wisdom will flow out of the national capital and local people will adapt. We need local action as well and we need small and large actions, not just large and unachievable actions. For example, creating a situation wherein individual patients and families are more empowered in their own treatment sounds like a small change but, in the long run, it may be more potent or revolutionary than larger changes. We propose the idea of national vision for mental health care and the establishment of national goals, which we hope would serve to motivate and organize people as well as the stock and trade of any group such as this.

An idea or organizing principle for mental health in Canada as well as in the United States and probably around the world came to this commission in a talk from former First Lady Rosalyn Carter, who is the honorary chair of the last national commission in this country. She reflected with us on what has changed in mental health over the last generation. Ms. Carter said that in reflecting on that, there was one thing that we have going for us today that did not exist a generation ago. One thing has changed that is more significant than anything else: we now understand today that recovery is possible for any individual with a mental illness.

This is a simple but powerful statement that has several meanings in the mind of our commission. First, it is possible for people to get better even if we might have thought years ago that they were ``hopeless cases.'' Second, even if people have a serious illness that may affect them for a decade or longer, they can achieve a good quality of life with the right kind of support. Recovery is not necessarily just a miracle cure but it can be a case of coping well with a devastating illness. Third, recovery for people in the mental health system is beginning to imply hope as a core ingredient of our approach to care, as opposed to a notion that is more passive and oriented to maintenance.

In our report, we proposed to the President that a commitment to a future where recovery or resiliency, especially for children, are the expected outcomes, not just extraordinary outcomes as portrayed in the story of Dr. Nash in the book and film entitled, A Beautiful Mind. We have to expect, with a diagnosis of mental illness, that recovery is the outcome and not something extraordinary. This would have to be supported in part by access to care that is early and good as opposed to late and bad.

I will end by listing the six goals that we propose as a framework for thinking about how to approach mental health care in the U.S. I will name a few although we made 19 formal recommendations. A couple of them might be salient for members of the committee to consider. Two of the recommendations relate to plans, the first being at the level of the individual consumer. We do not know exactly how to do this, but we believe we need to move in the direction of care being more individualized and geared to a personalized effort so that the family and the individual have greater input and control of their care plan. That does not imply total control but rather a genuine partnership with professionals, as opposed to simply getting a diagnosis and taking the medicine.

The second recommendation may have an analogue in Canada — the notion of moving toward state responsibility for mental health that would be defined somewhat more broadly than it is now. In the United States now, all states would have some entity in government responsible for mental health care. In some cases, such as Ohio, it is actually a free-standing department with its director reporting to the governor. In a number of states, it is a branch or bureau of a health agency. Generally, these agencies have a relatively narrow purview over programs for children and adults with serious mental illness. We have proposed an approach that would turn on incentives between the federal and state governments for the state to take a broader approach to mental health care and think about the mental health of children in the schools, of people who may have been arrested and might be more appropriately given community care, provided they do not represent a danger to others, as opposed to incarceration.

The federal government, through the partial provision of incentives and resources, could encourage this state plan. States would have to step up and make the choice to do it. That approach may have some utility in Canada.

The Chairman: I will make just one observation in respect of your chart about your fragmentation of services after reform. I think our situation is so complicated that I do not even think we could draw the chart. That is how awful it is.

Mr. William Emmet, Coordinator, U.S. Campaign for Mental Health Reform: Honourable senators, it is an honour to be here. I hope that we can have a dialogue that will be beneficial to Canada as well as to the United States. I will say also that it is an honour to follow Mr. Hogan in making a presentation to you. He has done such wonderful work during the course of the campaign and indeed back through his career as a commissioner in Ohio and Connecticut and working with the advocates.

I pay compliments to Mr. Hogan because I think my presentation will echo his in many ways, at least in terms of the themes so I hope you will bear with me on that. That will be instructive because the themes emerging in the United States may be of some use to you here in Canada.

The campaign for mental health reform is a unified mental health advocacy effort that is unprecedented in the United States. Typically in the past, various advocacy organizations, provider associations, professional guilds, and other agencies have often pursued their unique and often competing interests and not worked together very effectively. The campaign, with 16 member organizations, was organized when we anticipated the report of the New Freedom Commission on Mental Health. We were organized specifically to support and build on the recommendations of the President's New Freedom Commission and to ensure that United States mental health policy would reflect on-going advances in the field.

As I began think about making this presentation to you, I realized that a brief survey might be in order. I looked at what has happened over the last several presidential administrations. During his administration, former President George H.W. Bush signed the Americans With Disabilities Act in 1990. Critically, and against some opposition, the drafters of that legislation included psychiatric disabilities among the disabilities covered by the law. As a result, the particular rights of people with psychiatric disabilities are protected by the law in a way that they were not protected prior to the ADA. These include the right to accommodation for one's disability in the place of employment or education and the right to appropriate housing for people with disabilities in the community.

The United States Supreme Court handed down an important ruling on the applicability of the ADA in 1999. In the Olmstead decision, the court interpreted the ADA to mean that states must provide services in the most integrated setting appropriate to the needs of qualified individuals with disabilities. The effect of this ruling has been to force a number of states to reassess the programs they offer for all people with disabilities and to consider how they allocate resources for these populations. In some states, this has worked to accelerate activities that go as far back as the 1960s to make community placements available for people with psychiatric disabilities. The ADA dealt with rights but it did not look at the nature of the services to which people have a right.

Proceeding with the survey, the next great leap forward in our nation's understanding of the needs of people with mental illnesses came during the administration of President Bill Clinton. He held a 1998 White House conference on mental health, signalling the administration's strong interest in the issue. More important was the report of the United States Surgeon General, which Dr. Hogan mentioned a moment ago. It was issued in 1999 by Mr. David Satcher, the Surgeon General at the time.

This comprehensive report compiled what was then known about mental health and the causes and treatment of mental illnesses. It brought in numerous experts and sources. The report remains today a great foundational document for mental health policy in the United States, referred to by consumers, families, providers, administrators and policy- makers as the most balanced and inclusive survey of the issues.

The great message of the Surgeon General's report is that while there is much yet to learn, we know a great deal about services and treatments that improve the lives of people with mental illnesses, yet tragically, our treatment systems fail to make these effective services accessible to the majority of those who need them.

During the presidential campaign of 2000, then-governor George W. Bush pledged to address the state of mental health care in the United States. Reminded of his pledge after his victory, President Bush, in 2002, named Dr. Hogan to chair the commission charged with studying mental health service delivery in the nation and making recommendations to improve it. Acknowledging in its interim report that the system is in shambles, the President's New Freedom Commission on Mental Health pointed the way to transformation of the system to one that rests on the belief that recovery from mental illness is indeed possible.

The six goals for transformation of the system laid out by the commission in its final report are actionable, as Dr. Hogan said, at the local, state and federal levels. While the commission report is intentionally short on detail, it does provide a very useful and farsighted framework for getting at the central problem that was identified by the Surgeon General in his report — that is, we know what services work but we make it very difficult for those who need them to get them.

As you know from your studies of broader health care, many Americans receive health care as a benefit of employment. Typically, however, coverage of mental health care is more limited than is true for coverage of other types of health care. Thirty-four states, approximately, have passed laws that provide for some degree of parity but the federal government has yet to act in a meaningful way to ensure that those companies who are self-insured must provide coverage for mental health conditions similar in scope to coverage for other illnesses. In any case, mental health benefits under these private insurance plans are tightly managed. Again, it is very unlikely that most who are covered will have access to the services they need, as a result.

Approximately 43 million U.S. citizens are not covered by private insurance. For the portion of this population with mental health care needs the nation's publicly funded mental health system is the only option other than receiving no care at all. The public mental health system is a $23-billion system. It serves approximately 6.1 million people annually in all 50 states, four territories and the District of Columbia. In the United States, responsibilities for public mental health care are shared among the three levels of government, as Dr. Hogan pointed out. The system has evolved considerably from the time it was almost entirely based on institutions operated by the states. Today, the number of hospitals and the populations of those state hospitals have been significantly reduced but more than 40 years after President Kennedy first signed legislation creating community mental health centres, the goal of access to comprehensive services in the community remains elusive in many places.

Both the President's commission and the Surgeon General made it clear in their reports that there are pockets of excellence in the provision of mental health care services in the U.S. However, they also pointed to the fact that identifiable segments of American population — minorities and people who live in rural areas for instance — receive markedly poorer services or no services at all. Both reports noted the rise in the use of evidence-based practices but they also called attention to the 12- to 15-year lag in the implementation of research-based interventions. They found that poor or ineffective treatment remained the rule in many parts of the country.

Dr. Hogan and the commission certainly cited fragmentation of mental health care as the major impediment to availability of consistent high-quality services in communities across the country. The commission noted that fragmentation is largely the result of our nation's patchwork financing of services. Today, funding comes from local, state and federal sources, again illustrated very well by Dr. Hogan.

Federal funding comes through a variety of departments and agencies but the major federal funds specifically earmarked for mental health services — the Mental Health Block Grant — typically constitute about 1 to 3 per cent of a typical state's overall spending on mental health services. On the other hand, Medicaid is the fastest growing source of funds spent on mental health services in the states. As a medical entitlement program it covers only certain approved services, however, and it requires matching contributions from the states that are increasingly difficult for the states to make in these tight budgetary times. Too often lost in the mix is sufficient funding to meet the rehabilitative needs of adults and children with mental illnesses.

The inability of parallel systems to communicate with each other is costing many jurisdictions. The mental health system is not coordinating well with its counterparts in housing, employment, education, general health care, criminal justice and on down the line. Fragmentation has many consequences. At a minimum, it results in a system that is very difficult for people in need of services to understand or navigate. Many are unaware of available services; others are frustrated by the system's confusion and simply stay away.

The costs of these failed connections and consequent untreated mental illness are enormous. Approximately 16 per cent of the 2 million American men and women in jails and prisons at any one time have a diagnosable mental illness. Perhaps 30 to 40 per cent of our nation's homeless persons have a diagnosable mental illness and some estimates range much higher. Nearly 30,000 people take their own lives each year, and over half a million people visit hospital emergency rooms due to self-inflicted injury. As revealing as these data are, they do not show the loss of hope and productivity suffered by adults and children with untreated mental illnesses, or the burdens so frequently carried by their families.

A major recommendation of the President's commission is the development of mechanisms for comprehensive state- wide planning for mental health service delivery. Significantly, funding for grants to help a number of states begin this process is proposed in President Bush's budget, now before Congress. Despite large cuts proposed in some other mental health programs in that budget, advocates are supportive of this initiative because it is an attempt to address the problem of fragmentation that seems to be one of the root causes of the ineffectiveness of our system.

That is just a brief survey. It has been encouraging to see mental health service delivery and policy studied seriously in recent years by the Surgeon General and the President's commission. It is particularly helpful to see the identification of effective evidence-based practices now under way in the U.S. and to note the emergence of new thinking for organizing and financing mental health services. We still feel, however, that the consequences of our nation's failure to recognize the benefits of effective mental health services are poorly understood by American policy- makers. The stigma remains an immense barrier to this understanding and many productive lives are being lost as a consequence.

On behalf of the campaign for mental health reform, I certainly wish you success in your efforts and again, thank you for the opportunity to have a conversation with you.

The Chairman: I thank you both for your comments.

I have two questions that have begun to trouble us a bit. One has to do with the structure of the system. You both point out the importance of having both the consumer and the consumer's family involved in decisions, which would be an ideal in a much more individualized design to the program. At the same time, to the extent that you move in that direction, you also move away from what most people would think of as a system in the sense that you are introducing a degree of individualization. In this country the more individualized you get and the less broad the system from a public policy standpoint, the worse it is.

It seems to me there are inherently conflicting elements here. One is the clear desire for national set of goals instead of provincial goals and a clear set of programs, all of which by their very nature historically in this country would be very non-individualized. People would be forced to fit into the designs of the program. I should like to know if either of you could comment on that.

The second issue that has come before us repeatedly is the need to deal with the very early identification of issues, particularly with children. That occurs largely within the school system. We have a not insignificant problem in the sense that constitutionally, the federal government has no jurisdiction whatsoever with any part of the education system. Health departments provincially do not deal with the education system either. It operates very much like an island unto itself.

Dr. Hogan talked about incentives. Have you any thoughts on how you get rid of the barriers that do not have anything to do with mental health but have to do with the education system being an island unto itself and the acute care being an island unto itself? The mental health system, which is not a system at all, is floating out there in never- never land. Have you any comments on either of those issues?

Until we begin to address those broad systemic questions, it will be difficult to get a handle on concrete solutions as opposed to putting ourselves in the position of being in favour of good deeds. One thing that caused our last health care report to be pilloried when it was released was precisely that we were very concrete. People are now turning to that document because we had concrete proposals. We are determined to be as operational as possible.

Dr. Hogan would you share your thoughts on those fairly simple questions?

Mr. Hogan: I would agree with what I hear as the premise of your first question. Individualizing the financing of care is likely to increase fragmentation and move away from an equitable and plentiful approach to that care. My response is a little bit of an equivocation. I would say that a broad approach to care must be the foundation. Within that broad approach to care, the place where the patient's involvement is really critical is in the negotiation of a plan of care. That negotiation of a plan of care ought to be a partnership. There is a balancing act there.

One should not individualize the financing of care. There should be a broad equitable program. However, there should be encouragement, incentives and supports for physicians and other caregivers to treat consumers and patients as informed co-participants. One thing that we have learned about recovery is that we do not have cures for these illnesses. We can provide treatments, but then people have to learn how to live with the illness and how to accommodate the illness. That works much better when they feel that they are a part of the game and not being treated as an afterthought. That would be my response to your first point.

You are absolutely right about the imperative of early intervention. Our commission spent a considerable of time focusing on that. We are now starting to understand that the cause of many problems for children can be in their mother's depression, as an example. The mother's illness makes it much harder for her to play with her baby and allow the baby to connect those emerging neuro-pathways that allow us to grow up self confident with the ability to develop relationships and to succeed in life. We would do much for later mental health and school success if we did a better job of identifying and treating depression in mothers.

One of the ``model programs'' the commission recommended we look at is one called the ``Nurse-Family Partnership,'' which was developed a number of years ago in upstate New York. This program involved nurses working with very poor at-risk moms to help them be better parents and address their issues. That effort, which is not a mental health program at all, has had very positive mental health outcomes and resulted in lower school dropout rates and less juvenile delinquency for those kids 15 or more years later.

I would agree with you about the necessity for and the challenges in creating partnerships among schools and health care and mental health providers. In my state, Ohio, we have been working very hard to do this. Our efforts have ended up being largely on a voluntary basis of bringing together the people that are the champions of this approach. We are finding a tremendous movement in that regard. It is by no means complete. Much of it comes from our understanding that, as mental health professionals, we cannot walk into a school and tell a principal that we are from mental health and we are here to help. That is a giant turn-off; it is not relevant to them. However, if we say that we have some skills in helping children with problems including problems of learning, they tend to be very receptive. We can then create a good partnership.

Our approach is to encourage people to think about what might be described as the social, emotional and behavioural side of growing up as a part of the process of schooling. We then encourage our mental health care workers to spend some time in the schools — not to treat kids, but to be available as a resource. That is a bit of an oversimplification.

Mr. Emmet: The answer to both of your questions, at least theoretically, lies within the first stated goal of the New Freedom Commission report, which is that mental health is essential to health. That is obviously a theoretical position and does not give you an operational answer.

I will give you an example of what we as advocates think about when we look at consumer and family choice in services. Many providers are now looking at the field of developmental disabilities. There have been some efforts made in the United States to offer clients of those services a menu of options from which they can choose services that are appropriate for them. Now we are trying to determine of there is an analogue to that in mental health care. Is there a way to do that that makes sense and does not cause the problems Dr. Hogan referred to respect of individualized financing of mental health services, but does give some choice to consumers and families.

With respect to children's issues, there are a number of screening tools and instruments emerging across the country and are being found to be effective. Dr. Hogan talked about the way in which to introduce those to the schools. It is not mental health moving in to say that they can help. Rather, it is a joint enterprise to try to create an environment in which kids can learn. Screening for mental health issues is one of those approaches. It is like screening for hearing problems or other issues that may prevent kids from effective learning.

The Chairman: I am intrigued by your comment that including mental health in the American Disabilities Act began to get mental health issues broader into the public policy sphere. You just said you are beginning to ask yourself the question of whether the policies and programs that deal with the disabled can treat mental illness as a disabling illness as opposed to a sick illness for which you go into an acute care hospital. Have you been able to learn anything from either the public policy approach or the practical approaches to disabilities?

Mr. Emmet: Absolutely. Dr. Hogan described clearly the fact that mental illness is kind of stuck in between health care and disability. We navigate from one to the other as it suits our purposes. However, if you begin to look at mental health in the paradigm of the public health model, and look at ways to prevent mental illnesses from becoming disabling, it fits into the public health paradigm. There is some intersection there. Does that make sense?

The Chairman: Yes.

The Chairman: Do you want to add to that, Dr. Hogan?

Mr. Hogan: No, I do not think so.

Senator LeBreton: Dr. Hogan, you talked about the fundamentals of mental illness. At one point, you quoted Rosalyn Carter, saying there has been a big change in thinking. I agree with that.

You also talked about the paradox of good treatments being available but not being accessed. Are these low rates of access a result of the stigma, or is it because there is really no entity in government responsible for coordinating and pulling together all the various facets of mental health care? Is the stigma still a big barrier to people seeking access to help; or is it system failure; or both?

Mr. Hogan: The short answer is it really is all of the above. When our President gave his talk kicking off this commission, he posited that there were three big things keeping people from getting the care they needed. The first was stigma, in fact — and we know that still is an issue. The second was the problems in insurance coverage, which are, to some extent, related to the peculiar way in which we handle health insurance coverage in the United States. The third barrier he described was the problem of fragmentation.

His inventory was good. However, it is even more complicated than that. It depends somewhat on the kind of condition that one has. For someone with depression, for example, the very fact of the disease may make them less able to recognize their problem; and it may sap their motivation to do anything about it or to seek help. We also know that for most illnesses, until they get very severe, to come to the attention of public authorities, for example, people are probably most likely to go to their paediatrician or family physician. The training, at least in the United States, that physicians get, and the amount of time they have to work with patients to identify a problem, are inadequate to the task of identifying these sometimes complicated problems where you have to really talk to a person about their behaviour to assess what is going on.

Stigma is a problem. Access to health care generally is a problem. Physicians and others such as teachers are not as able to identify these problems well. Then, after all those problems you get into the supply being adequate.

There is this paradox of how there are many more services now than there were a decade ago, and the people who are lucky enough to use them do well. However, the fact that there are all these services has made things much more complicated at the community level, so families do not know where to turn when a problem is emerging. That is the challenge of fragmentation. It is a complicated problem, and I may have muddled it because I think your description was really quite clear.

Senator LeBreton: Mr. Emmet, you talked about deinstitutionalization. We have the same problem in this country, taking people out of controlled mental health facilities and more or less putting them on the street. Has deinstitutionalization contributed to the problem, and then extrapolated down to even higher numbers of people suffering from mental illnesses? Where do these people go, in the United States context, or do they fall into the same pattern they have in this country whereby a lot of them ending up in our penal institutions?

Mr. Emmet: It is too simplistic to say that people left the hospitals and wound up in the penal institutions. First, deinstitutionalization has been going on for some time now, and we see that the people who are entering the criminal justice system are very different people today.

In many ways, deinstitutionalization was a great success. There were many people who did not belong in the institutions, and they did leave and start living productive lives — or at least far better lives than they had in the institutions. The problem over time has been that people who formerly would have gone to institutions have not been able necessarily to get the services they need. Therefore, they have wound up being homeless or being involved in the criminal justice system. Many of them have wound up, in fact, in the community mental health system doing pretty well. It is a more complex equation than just that.

Senator LeBreton: I did not mean to suggest that. However, did that not create a problem for the system because many of these people did not belong in these institutions, as you quite rightly pointed out? Most of them went back into the care of their families, but did that not then create a whole other set of problems in the communities?

Mr. Emmet: Absolutely.

Senator LeBreton: What have they done in the United States to try to address that gap?

Mr. Emmet: One of the results of deinstitutionalization was the rise of the family movement, and the rise of the consumer movement in the United States. That was a positive by-product because it created an advocacy base for improved services for people with mental illness. It did not solve the problem for many people because, frankly, the funding was not there for the community services that were promised for people coming out of the institutions.

The problem of closing down the institutions and turning to a community system is something that Dr. Hogan could speak to very well. It has created a whole different set of problems in the financing of mental health services at the state level. I do not know whether that is fair to kick the question back over to Dr. Hogan, but —

Senator LeBreton: I saw him react when I asked the question, so I will do just that.

Mr. Hogan: I do not know how this has played out in Canada. One of the challenges in the United States is that it was easier to budget for the bricks and mortar and payroll of the institutions than it has proved to be to budget for this complicated, decentralized care system. I have a sneaking suspicion, that is buttressed by some data, that mental health funding over time has fared poorly in that it is harder for governors and legislators to keep their eyes to this very decentralized, dispersed system. It was easier to fund the institution because you had a certain number of beds to staff, and a negotiated labour contract for which you had to cover the costs. When it got turned over to local government, it became a little bit out of sight, out of mind. That may be the complaint of a bureaucrat who does not believe that he is getting enough money, but I think there is some truth to it.

We have not figured out how to make community care, in a sense, as solid as the hospitals were. I would underline one point that Mr. Emmet made: None of us in the field would argue for a minute that we ought to go back. The system of institutions failed to touch most people. Those whom it did touch were confined very expensively and they did not get better. They received ``three hots, a cot and health care,'' but they were never able to get a life. We cannot go back to that situation but we have not yet solved the problem of creating a care system that is well organized and robust enough to do a good job.

I will go back to something Mr. Emmet said. I do not know how this has been in Canada but by and large in the United States, services for people who have mental retardation are probably, on average, better than are the services for people with a mental illness. Part of that is because of the arcane ways in which our federal Medicaid program funds services more generally for the developmentally disabled. The community services for people who are mentally retarded in this country tend to be better organized, have a clearer advocacy and have more money. Partly due to the disability, folks with mental retardation need to be constantly tended to, whereas people with a mental illness are apt to be more physically and mentally independent. Thus, mental illness is a more complicated problem, in a way.

If it is as true in Canada as it is in the U.S. that things are better in some ways for the mentally retarded than for the mentally ill, some of the ways that services are organized might provide a model. That would not be the actual service delivery but rather the organization and financing of the services.

The Chairman: Anecdotally, I am sure it is true that people who are mentally challenged in Canada do, in fact, receive better service than many others with different mental illnesses. That could be partly because the problem has been recognized for a longer time.

Senator Keon: Mr. Hogan, this is a tremendously interesting area that you are focusing on right now and we have much in common with you. You said in your remarks to not individualize financing. We are committed to a single payer. By the same token, a single payer is giving us big problems when it comes to the big institutions. The single payer is bureaucratic, inefficient, et cetera. Many of us are pushing for a downsizing of that component of our system and, we hope, a sophisticated reorganization of our primary care systems that would allow us to deliver primary care, public health and mental health through the same community clinics.

In Canada, because we are committed to the single payer, we might be able to achieve this. We have to draw the line between the single payer and a paralyzing bureaucracy. I would like to hear your thoughts on how we might glean efficiencies in the community by organizing the community in such a way that, for example, sparsely populated regions could receive one-tenth of a public health officer, one-tenth of a mental health officer and 80 per cent of a family practitioner, be that a nurse practitioner or physician. Would you respond to that, please?

Mr. Hogan: That is a complicated and intelligent question. Some of what I might say may not transfer well. As you were talking, I thought about the limited amount that I know from this fellow that I mentioned, psychiatrist Dr. Hugh Lafave, who worked in Saskatchewan in the 1960s. I heard from him and others about what, at that time, was deemed to be quite successful in mental health reform long before anyone in the United States. The foundational elements of that reform were: first, a strong health care system that provided access to basic health care services, including hospitalization for mental illness as required on a par with hospitalization for any other illness; second, clinics where people could receive medical care; third, a strong reliance on family care, whether the natural family or a family that could be engaged to provide housing and a little oversight for people; and fourth, social workers to organize all of the above. It was quite a simple approach that blended elements of good health care with some of the special requirements for caring for people with mental illness. That is one comment that I would make in response to your question because it is wise to see your single-payer system as the first line of defence for mental health care and to beef up the expectations on that system to diagnose people and to provide routine care for many conditions.

Having said that, for people with the more complicated illnesses such as bipolar disorder or schizophrenia, I believe there is no evidence and no logic suggesting that a single health care system can adequately provide the appropriate care. Their illnesses are so complex and have dimensions of rehabilitation and other things that extend beyond the capacity of the health care system. The notion that you would begin with an emphasis on mental illness in the health care system and then look to complement that with what might be described as a specialty program for some people does make some sense to me.

There are some models in the United States but our health care system is so different. However there are some very good models that would fall under what has generally become the distasteful term of ``managed care,'' whereby a company or in some cases a government is engaged, usually at a capitated rate, to provide a specialty care — for example, for a population of people with mental illness — in consultation and cooperation with primary care. The notion of managed care that has a specialty orientation to mental illness working in concert with a unitary health care system works exceptionally well where it is done well.

I might refer you to a gentleman by the name of Dr. Saul Feldman, Chairman and Chief Executive Officer of United Behavioural Health in San Francisco. It is a large, private company that works under contract with employers and, in some cases states, to coordinate care.

An additional one-liner about this issue is that managed care, funded adequately and done well, seems to be the best approach. The trouble is, often it is not funded adequately in the States and, if it is done poorly, it becomes a disaster.

I may be rambling somewhat but I come back to this notion of relying on the single-payer system as the first line of defence but then recognizing there has to be some kind of specialty entity that takes responsibility for mental health care. That entity has got to work in partnership with the primary-care system and has got to well-manage care for people with more complex illnesses.

Senator Morin: I would like to recognize the remarkable contribution the United States has made in the field of innovation and research in mental disease. We have profited from this in Canada and, I think, throughout the world. This is to follow up on the comments that the chair made at first, concerning the fact that we have a universal health care system but we all strive to practice quality American medicine here in Canada and elsewhere in the world for sure.

I would like to address the matter of costs and cost containment. As you know, in this country we are worried about the sustainability of our universal health care system. Mr. Hogan, did you put a dollar sign on your reforms? If I understand correctly, you are now spending over $100 billion in direct costs for mental illness in the States. How much more would that have cost if we implemented your reforms?

Mr. Hogan: That is a very good question. Considering that we were charged by this particular president, we were encouraged to be not particularly expensive or explicit about expense with respect to innovations. We did not put a price tag on them. In fact, the president's executive order encouraged us to look first for economies and efficiencies although they did not slap our wrists and tell us to avoid recommending anything that costs money. A number of recommendations we have made will cost money. We did not put a price tag on the costs of the reforms.

I am not sure if this is explicit or implicit in our report, but we know from national data in the United States, that we spend more on the costs that are attributable for not providing mental health than we do for providing that care. That is out of sync with the rest of health care. For example, with respect to cancer or heart disease we spend more to treat it than we spend on the costs that are attributable to not providing that treatment.

The biggest single expenditure attributable to mental illness in this country is disability payments for people who have become disabled by mental illness. We send them a cheque every month. It is not adequate enough to live on. Essentially we make a deal with them that they have to stay disabled in order to get that cheque, which is a terrible situation. If we were to provide better care to them and help them get a job — it might not be a full-time, 40-hour job — everybody would be much better off.

I do not want to beat around the bush too much. We did not cost out many of our recommendations. We tried to be moderate about them. We worked with this notion in mind that mental illness costs us more via non-treatment than via treatment in this country.

Senator Morin: I would like to talk about managed care. I realize that managed care has had bad press recently. I was very happy to hear that there are specialized health maintenance organizations, HMOs, which function well. What is your impression of more general types of HMOs, Kaiser Permanente, for example, in treating mental illnesses? What is the record of cost containment in these areas?

Mr. Hogan: The good HMOs who have tended to focus on these issues as a part of their general responsibility, have done a very good job with respect to those mental illness that can be cared for in a clinical setting: many cases of depression; many cases of attention deficit disorder for children; anxiety disorders. Therefore, Kaiser or the program in the northwest part of the country that used to be called Puget Sound have done excellent work in this regard. Those examples would tend to buttress my notion that reliance on the primary care system is a very good place to start, but it is not sufficient for those with complicated disorders.

Senator Cook: I come from Newfoundland, where a family unit is still very much a caring community. I do not mean siblings or whatever; I mean the social framework of a community. In your system, have you entered into partnerships with NGOs? I am speaking specifically of churches. In my community, and the faith that I belong to which is the United Church of Canada, we have programs within the community for the homeless and we embark on all kinds of innovative things.

We have something like a couple of hundred people now with mental disorders — some of whom are psychotic — who are living in sheltered housing, where the agency takes the risk and the government puts the money up front and the consumer pays. We have had some good successes with that to the point where some of the members of the communal living, manage their own system and they sit on the greater board. We encourage them to hone their coping skills and eventually they are able to move on notwithstanding that jobs are always a challenge.

Through that process, the medication has always concerned us. It is easy to get another prescription. It is far more difficult to work yourself through the system where you are not dependent on that and you build your own self-esteem. Have you done any work of that nature?

Mr. Hogan: My comment would be that we have tended to become, in the United States, far too sophisticated to do things like that, that work much better. The pace of life goes faster, families live in the suburbs, and mom and dad are both working to try to make ends meet. We do not have enough of that social fabric in many locations. There is not much that I am aware of that I could teach you at all about any of that. Frankly, it sounds like a better approach than what we have, much of which is trying to determine a better way to spend people's money. It is a wonderful approach.

We do know, for example, that pastors — there was some research on this a number of years ago — come in contact or have more ``mental health contacts'' than all mental health professionals put together. That is where people will often go if they are having troubles. In the mental health system, we do not tend to work all that well with the faith community and with others.

Senator Cook: I should add, for the benefit of my colleagues, that although it is under the umbrella of the church, which ultimately takes the risk, it is very much a community-based board with consumers of mental health sitting on that board. It is a partnership.

In my province, about 30 years ago, we deinstitutionalized our one mental hospital and went to a community-based program, sadly, without enough social supports from the government, but we managed. Out of that need came what we have today. We still have many people who are consumers living alone in boarding houses with few creature comforts. However, we have opened social centres and have gone from a place where it just was a place to be warm or watch TV to getting grants for literacy programs where student nurses come in to do part of their affiliation. It is all done within the community and not a lot of money is spent. It is coordinated. We run about 140 people through our one social centre each day — which is a pretty good average. Eventually, they are able to move on, but they will always go to that centre because that is their family.

I would like to see such a program housed in community health, because they have various needs, too. They get earaches, toothaches and other aches other than coping with their mental illness. We should be creating an environment in our society that addresses the total person.

Mr. Emmet: We do have a significant amount to learn from that type of structure.

In the United States, we are finding that specific communities — that is to say African Americans or the Latino- Hispanic population — really do not avail the public mental health system in great numbers. We know that there is a great deal of stigma involved. We do know, however, that they work through the churches and different community organizations to try to address their problems.

We need to understand how to make appropriate services available to those populations through their existing community structures rather than have them break down those structures that work for them in so many ways and accept the mental health system as it has been conceived to this point. We could learn a great deal from what you are doing in Newfoundland and elsewhere.

Senator Cook: If you meet peoples' needs where they are, the silos will not go up. Adequate funding for NGOs is an opportunity to care for people when they are at a most vulnerable point.

Mr. Emmet: In the United States, we do talk a great deal about meeting peoples' needs where they are. Assertive community treatment is a program that is meant to meet people where they are — in coffee shops, in their apartments and in social settings that are comfortable for them. We talk a great deal about that. Whether we are able to achieve that on a grand scale, I am not sure.

The Chairman: Mr. Hogan, given the industrialized nature of Ohio and the problem that you commented on a minute ago, are you attempting to do, as Mr. Emmet suggested, even pilot projects that attempt to meet people where they are or, as Senator Cook put it, in the community setting? Or are you, like our health care system, very much driven to institutions of some form?

Mr. Hogan: As Senator Cook was talking, I was thinking that there are a number of things that we are doing that take a step back to that kind of approach. There is no doubt that the core of our system of care is clinics. These are clinics that are generally operated at government expense by community not-for-profit organizations.

One significant development in Ohio and in a number of the States is something similar to what Senator Cook described. In most of our counties we have at least one or, in some cases, multiple organizations that are run by people recovering from mental illness. In many cases, these started as something that was small and informal and might have been thought of as a drop-in centre that was open a few hours a day. In some communities these things have become quite robust. They have become mental health support programs that offer a good deal of compassion and learning from the school of hard knocks. People who have been on a road to recovery can work with and support other folks that are earlier in that process. Some of these organizations run their own housing programs and employment programs. They are tremendously effective. In many cases, they operate at very low cost.

They also have a side benefit of providing employment to people recovering from mental illness as well. These have not reached the point of being an alternative to the clinic, but they are a critically important supplement.

In some communities, about 4 to 5 per cent of all of the budgeted resources annually will go to programs run by mental health consumers for mental health consumers. They are a variant on what Senator Cook described, but quite an effective one.

The Chairman: Do you find opposition to that idea within your department? In the Canadian context, the minute we try to move outside the bureaucracy into this kind of decentralized more sensitive, local-based initiative, the bureaucracy, which feels that it is losing control. They want to know who is in control, how it will be done — a standard litany of issues pops up.

I suspect that we would get huge resistance to that were one to try to do that, which is absolutely no reason not do it. I wonder if you suffer the same kind of bureaucratic problems that we do.

Mr. Hogan: We do, to some extent. We may get a little less of that resistance in part. In Ohio, the community mental health care is orchestrated through a local board at the county level. In some cases, multiple county jurisdictions can come together and have one board. This board operates as a creature partly of the state, because it is established under state law, and partly as a creature of sponsoring counties. The local county commissioners appoint the members of the board. In our system, these boards are enjoined with running care programs. They are in charge of planning; they purchase care. They purchase services from community entities that tend to be not-for-profits. Nobody really has a monopoly on this.

Yes, all those resistances can occur. The consumer movement has been happening here for a good 20 years. It possesses certain momentum and logic that cannot be refuted. There are tensions. Many of these organizations experience struggles and growing pains. It is tough to run a small business, and it is probably tougher to run a small business when all of the employees and board members are struggling with a mental illness. That is just the way it is.

However, they also have so much experience and so much commitment that they make it work. They achieve wonderful results. It is a hard thing to do, but its value for us has been far beyond the dollars that are spent.

Senator Trenholme Counsell: To what extent have you seen an increase in the teaching the latest information to doctors, nurses, social workers, and teachers so that these very important people in our communities are knowledgeable of all of the advances that have taken place? Progress over the last decade or two has been so tremendous.

I have a feeling that the professionals who are in contact with people are not, perhaps, getting enough education. I would like to hear your opinion on that.

Mr. Emmet: My sense is that we have not seen an increase at all. The teaching of psychiatrists, social workers and others about serious mental illness and the new evidence-based practices, in fact, is a real hole in our system. That is something that we need to work hard to improve.

Among teachers, as you mentioned, there may be a thirst for learning about behavioural disorders and what they can do about it, but I do not think the training is up to the need at all.

Senator Trenholme Counsell: In the case of teachers, I think there is a great need to be up-to-date on learning disorders and on behaviour disorders — not that we expect them to diagnose or treat these problems. However, do you feel that the education in the United States has not kept up to date with the knowledge?

Mr. Emmet: There may be a few pockets where it has, but by and large, no.

Mr. Hogan: I agree completely with the thrust of your question, senator, and I agree with what Mr. Emmet has said. There is a definite lag here. To some extent, I think it is because our professions tend to control the content that is taught. They tend to control it both through the university training programs and also through the licensing examinations. Therefore there is always a lag time because people are stuck the way they were trained 20 years ago. It is a real problem for us.

Senator Trenholme Counsell: If the front line people — be they family doctors or nurse practitioners or social workers or people in emergency departments — have not been able to keep sharpening the pencil, so to speak, many opportunities will be missed.

I wanted to ask you about how much this is happening in the United States. I know that psychiatrists, for example, are developing excellent tools in some cases whereby family doctors and nurse practitioners could do that initial testing — to determine, for example, who might be bipolar and who is not. I have had very personal contact with this, and it is very important to identify the bipolar people — to determine that it is not just depression, or hyperactivity or this or that. It is crucial; it is life-saving.

Whether talking about a learning disability, or anxiety disorder or bipolar or schizophrenia, are these tools being developed fast enough, and are they being passed on to the people who need to be using them?

Mr. Hogan: They are not being developed quite fast enough and they are not being passed on fast enough either, in my view. I will mention another resource you may want to look at.

One of the more interesting screening tools— specifically for children — has been developed at Columbia University in New York City. They have a project or program there called ``Columbia Teen Screen.'' I do not know if they will ever achieve this, but their long-range goal is getting every 15- or 16-year-old in the country screened for these disorders once a year.

We do it for physical illness; if you have to play a sport, you have to go to your doctor. Yet, for adolescents, it is probably more important to check on their mental health and to find out if they are using alcohol or drugs — they tend to be very robust physically.

The screens are being developed. A problem is that it is hard to get the physicians to slow down long enough to be able to use these screening devices because they are working so hard and fast. We are trying to find out if the nurses who work in the doctors' office to do the screenings.

In general, however, we do not have a good answer to this. Your system might be a stronger one in which to emphasize screening, just given the strength of the overall health care system.

Mr. Emmet: I would like to add that I am very much in favour of the Columbia Teen Screen, but the problem is what will be done once the screening has identified a problem? It gets back to your workforce question. Are there the specialists out there who are trained in up-to-date practices that can deal with what comes their way? In many places there are not.

Senator Trenholme Counsell: My last question fits into this general line of inquiry. I work with a learning disabilities association. I advocate on their behalf and support them wholeheartedly. There is such a cry among parents and those who are the advocates in these associations for preschool testing of children for learning disorders. We know there is a big link between learning disorders and depression as well as other forms of mental illnesses as well.

Is this true in the United States too, that very little progress has been made on testing of preschool children for learning disabilities?

Mr. Hogan: I would say it is very true, yes. We have not made much progress.

Mr. Emmet: I agree with that.

The Chairman: I should just tell our witnesses that for better than a quarter of a century, Senator Trenholme Counsell was a family practitioner in a relatively small community.

Senator Keon: Given the enormous complexity of this whole area, I will try to simplify it and glean some help from both of you as we ultimately are faced with writing a report here.

Historically, in Canada, we had asylums or large mental health hospitals that functioned outside the health system. We are saddled with this dinosaur. Some people still think maybe it was still a rather good idea, but the majority of people now believe that mental health must be addressed within the structural framework of health. At least, that gets on to mental health and then someday, some wise people might be able to address the social aspects of this whole issue.

I do not mean to simplify this, but in both your opinions, should we be working toward the development of the mental health system within the context of the health system, and with no exclusion practically as it relates to mental health?

Mr. Emmet: I think we should be working toward inclusion of mental health in the health system, with the caveat that mental health is a specialty as are other branches of medicine. There needs to be the capacity to adequately address the needs of people who have acute mental illness and, specifically, the illnesses that we know under the diagnoses of schizophrenia, bipolar disorder and so forth today.

It does need to be in the context — ideally and ultimately — of the overall health system. However, there is always going to be a specialty component that needs to be carved out for mental health.

Senator Keon: Can you do that within the context of the health system, or do you need something outside?

Mr. Emmet: I believe you can do it within the context of the health system. I believe that, theoretically, you can. In the United States, the issue is that it is not a tabula rasa. Parallel systems have developed over time, and whether we can get to a point where mental health can be appropriately merged into the health system, I honestly do not know. That is why, looking at the Canadian system, where the universal health care system is in place, it may be a more realistic goal.

Mr. Hogan: I would expand on that a bit. It seems to me that you have a stronger health care system in Canada than we have in the States. It is the logical first line of defence and it is reasonable to expect the health care system to take care of most people with most mental illnesses quite well if, and only if, there were some mental health experts stationed in that part of the health system — for example a psychiatric nurse or a psychologist or a social worker in the doctor's practice. The practitioners who do most of the their work in primary care will not have the time to be the experts in all of this. This is taking a step sideways to move forward but you can do most of this within the health care system if you have mental health experts within it.

It is my belief that you will still require some kind of specialty care program for people with complicated disorders such as depression that does not respond to medication, or a complicated bipolar disorder or schizophrenia. Those will have to come under a specialty program of sorts. Could that be a part of the health care system? I think it is possible but the program would have to be run by mental health people and you would have to determine the boundary between the two.

Implicit in your question but not explicit is another issue: the asylums. A mental health expert, whom Mr. Emmet and I know well in the United States, is fond of saying that ``less hospital care is probably good but if less is better it does not necessarily mean that none is optimal.'' There must be some hospital care for some of these conditions. In very few cases, should that be care that continues for years and years and years? That is truly the last refuge and not a good idea.

Separate from all off this is another complicated question that we will probably not address: What do we do about the mental health care of individuals who commit a crime? Both Canada and the U.S. have legal systems that have ultimately grown from British Common Law. Someone who commits a crime, but cannot be tried or found guilty due to insanity, will still need treatment or care. That treatment would probably categorize halfway between the criminal justice system and the mental health system. Such treatment would be considered a special case.

I tend to agree with the premise of doing this within the health care system, provided there are mental health people in primary care settings; there are a specialty programs for those with complex illness; and we set aside this question about what to do with people under the criminal justice system.

The Chairman: To follow up on issues under the criminal justice system, Dr. Hogan, are there people on your staff who deal with not the criminally insane but with the many people in the criminal justice system serving time in institutions?

Frankly, they are not treated to the extent that they are treated at all in Canada. It is minimal and borders on zero. That means they are released and our recidivism rate is high. I am not sure it is quite as high as yours but we are in the same ballpark. Appropriate treatment of mental illness in people who are incarcerated would reduce the recidivism rate dramatically.

I would be curious to know if my assessment is correct? Is anyone running good programs that would give you data to show that my presumption is right — that the recidivism rate would drop dramatically if we appropriately treated the mental illness of prisoners?

Mr. Hogan: I would agree in part and disagree in part. I would agree that you have to provide mental health care to those who are incarcerated. In Ohio, we have done quite a good job of that but we had to be sued to become motivated to action. In the end, we decided to have the mental health program in the prisons run by the prison system. They received a good deal of advice from us about how to set it up. They now run the program and do a pretty good job.

Receiving good mental health care in the prison, per se, will not be adequate to prevent recidivism because the illness will persist after the patient leaves the prison. You have to connect the person with mental health care on the outside once they leave. If you do that, then the recidivism rates go way down.

Mr. Emmet: I should like to point you to a source document that could be useful to you. It is called ``The Criminal Justice/Mental Health Consensus Project.'' It was coordinated by the Council of State Governments in the United States and can be found on line at This project brought together people from across the criminal justice spectrum as well as from mental health. Dr. Hogan was involved to some extent and the Director of Corrections in Ohio was very closely involved.

In that document and in the on-line version, there are numerous examples of programs that are chipping away at this problem whether at the front end through diversion programs such as police pre-booking diversion; or court-based programs that kick people into care and not into incarceration; or through re-entry programs that are specifically aimed at reducing recidivism.

There are data on a couple of programs in Chicago. The Thresholds Program shows a real reduction in recidivism for people coming out of jail to the residential-based program with all the services available. Much attention has been paid to such programs in the United States and the concept has picked up some traction at the state legislative level and at even at the federal level.

Senator Trenholme Counsell: To what extent is the specialization of psychiatric social workers proceeding? Is the training of many more nurses for the field of psychiatry, although they are needed for so many other health care systems, and the training of many more social workers to complement that effort, considered a sub-specialty, or super- specialty and developing to any extent in the United States?

Mr. Hogan: My sense is that there is probably a bulk-end requirement for both. Something about social work that is a good fit with mental health care is that there is an orientation to community care, to working in the community and recognizing that people have many different problems and to staying with people over time. From that point of view, the social work profession is ideally suited. The nursing profession is probably a little stronger in recognizing the medical side of this as well. There is a need for both. There are probably more social workers engaged in this than there are nurses in the U.S.

We have a problem in both areas is that there are social workers and nurses who did not truly receive enough psychiatric emphasis in their training. Nurses have their RN degree but they did not receive enough psychiatric training. However, in my opinion, the two professions are the foundation. We have to ensure they receive enough mental health training as part of their preparation. Our programs vary in providing that.

Mr. Emmet: We must also ensure they are paid enough to stay in the profession for any length of time.

Senator Trenholme Counsell: The training would have to be a specialization and it would take a number of months to acquire such expertise to become comfortable in the field. Not every social worker would want to take such a specialization.

Senator Fairbairn: I appreciate that the situation is probably about as difficult in the United States as it is in Canada in respect of assessments in schools and so on. However, there are programs of this nature in the prison system. To what degree are they being used in the United States? There are efforts here in Canada because it is never too late to try on learning disabilities. Does this take place within the system with any success in the United States?

Mr. Emmet: Are you talking of the juvenile justice system or adult?

Senator Fairbairn: I am talking about the justice system. Many of the people in the system, we are told, are there partly because they have gone through a life in which they have had these learning disabilities.

Mr. Emmet: I would say that it is something pretty spotty across country. I have been to jails where I have seen programs that are at least attempting to deal with this problem. I hear, anecdotally, from far many more places that these programs are not in place.

Mr. Hogan: I would agree with what Mr. Emmet said. The situation, although very uneven, may be somewhat better with respect to the treatment of mental illness because there is a constitutional expectation that there not be deliberate indifference to the treatment of illness. There is some obligation to treat mental illness in prison.

Learning disabilities would probably not be defined that way. I would guess that the interventions provided are probably, on average, a little less good than those provided for other mental disorders, which is not a very good commentary. That is just a guess. I agree with that it is very uneven, and there is no good model.

The Chairman: May I thank you both for coming. I have a request. In the last couple of hours we received many interesting references to organizations to contact. If you have any other thoughts in respect of people we should talk to, can you send us an e-mail? Perhaps there is a particularly good Web site to visit or report we ought to read.

As I said in my opening comments, we are very much at the early stages of this work. To the extent that you can help us find additional sources of information — either people, organizations or documents — it would be very helpful.

Thank you very much for coming.

The committee adjourned.

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