Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 8 - Evidence - May 5, 2004 - Afternoon meeting
OTTAWA, Wednesday, May 5, 2004
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:05 p.m. to give clause- by-clause consideration to Bill S-17 to amend the Citizenship Act and 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.
[English]
The Chairman: Before we turn to our panel, we will proceed to clause-by-clause consideration of Bill C-17, to amend the Citizenship Act, a private bill that Senator Kinsella has introduced.
We have heard witnesses in this committee. I know from talking to members on both sides that it is the inclination of the committee to pass the bill today without amendment. Senator Kinsella, do you wish to comment at this point? It is not necessary. I am happy to proceed directly to clause-by-clause study.
Senator Kinsella: I simply wish to say that I followed this very closely. Although I was not personally present, I did get the blues of all the meetings. I thank my colleagues for the careful study they have given to the bill.
Senator Callbeck: I have a question to declare. I know that we are dealing with the lost Canadians between 1947 and 1977, so that it would be on the same basis as others after 1977. What about the people before 1947, when Canadian citizenship came in? If someone had British status and went to the United States and became an American, then their children are American citizens. If that child wants to become a Canadian citizen, what would happen?
Senator Kinsella: In that instance, one would apply for citizenship under the current Citizenship Act, which is bringing forward the Paul Martin citizenship act of the mid-1940s and the amendment of 1977. They simply would apply.
Senator Callbeck: Would they have to go through security checks?
Senator Kinsella: Yes. On the issue of security, because I know that arose here, as you know, I was the deputy minister for a number of years when I was at Secretary of State, and Citizenship was then under the Secretary of State, and the registration centre was in Nova Scotia. Each of us has the opportunity to get a certificate of citizenship. A security provision has always been there, and it remains. It is section 20 of the Citizenship Act. If there were a security clearance problem, that section would deal with it.
Senator Callbeck: However, it is not there for people from 1947 on. The security check and the check on their criminal record are not there.
Senator Kinsella: Section 20 of the Citizenship Act does indeed apply to anyone seeking the certification of Canadian citizenship. The concern was raised here that someone might be a criminal or a security threat. If you turn to section 20 of our current Citizenship Act, it is very clear that if an applicant constitutes a threat to the security of Canada, that is examined, and there is no grant of citizenship.
Senator Callbeck: If it were before 1947, but now, with this new legislation, it would not be examined.
Senator Kinsella: All this section does is put those born in Canada on the same footing as those born after 1977. There is no change.
Senator Callbeck: My question concerns those before 1947. I cannot get it clear in my head whether we are discriminating against that group.
Senator Kinsella: We had no citizenship prior to 1946.
Senator Callbeck: No.
Senator Kinsella: We were British subjects.
The Chairman: I think I can clarify the problem. The bill does not deal with the issue being raised, which is what do you do if you were born a British subject. It deals with people who were born in Canada to parents who were not necessarily Canadian subjects and citizens and who may never become Canadian citizens. It takes the position that most other countries raise, which is that if you were born in the country, you are automatically a citizen of that country, regardless of what your parents do. That is where the gap has been.
To put it concretely, when I was working in the United States, my daughter, my oldest child, was born. She is automatically, by virtue of being born on American territory, an American citizenship. By virtue of being born to Canadian parents and because we registered her with the Canadian government, she is also a Canadian citizen. That equivalent never existed in Canada. Senator Kinsella's bill proposes to deal with that.
What do you do with people born before 1947 in Canada? There was no such thing as a Canadian citizen in those days. You were a British subject, as my parents were and I suspect your parents were. That is not actually covered by this bill, nor was it ever intended to be covered. This deals with the anomaly that it was possible for an individual to be born in this country and subsequently deported because their parents did not bother to become Canadians and thereby have them become Canadian citizens, whereas in any other industrialized country they would automatically be citizens independent of what their parents did.
Senator Morin: These parents did something special, though, just for the record. They renounced their Canadian citizenship. It was not just passive, like the example of the United States. It went up to the Supreme Court, and the Supreme Court acknowledged that the parents have the right to do that on behalf of their children.
The Chairman: Which most other countries would not do.
Senator Morin: I realize that, but it is not just a passive issue. The parents did something very special. They renounced their Canadian citizenship.
Senator Kinsella: Another way of looking at it is simply that the bill deals with the birth right of Canadians.
The Chairman: That is a better way to describe it.
Does any member of the committee want to propose any amendments? If not, I am happy to entertain a motion to dispense with proceeding through it clause by clause.
Senator LeBreton: I so move.
Senator Morin: I second that.
The Chairman: Is it agreed?
Hon. Members: Agreed.
The Chairman: Can I have a motion to report the bill back to the Senate without amendment?
Senator Fairbairn: I so move.
Senator LeBreton: I second that.
The Chairman: Is it agreed?
Hon. Senators: Agreed.
The Chairman: Carried. Thank you very much.
We will now turn to our panel on the subject of the mental health and addiction. We have before us today four witnesses: Mr. Kelly from the Ontario Federation of Community Mental Health and Addiction; and three representatives from the Centre for Addiction and Mental Health in Toronto, being Mr. Rush, Mr. Skinner and Ms. Bois. Our first presenter today is Mr. Kelly.
Mr. David Kelly, Executive Director, Ontario Federation of Community Mental Health and Addiction: Thank you for having us here today. We appreciate the opportunity to come forward and discuss these issues with you.
The federation represents 216 mental health and addiction providers in the province of Ontario — front-line service providers, consumer organizations, and hospital programs. These are all accountable to a volunteer board and provide a wide range of services — in a sense, a complete basket of mental health and addiction services in the province.
The federation envisions a community mental health and addiction system which is accessible, flexible, comprehensive, responsive to the needs of individuals, families and communities, shaped by many partnerships, respectful of human dignity and rights and accountable to those it serves.
We come before you at a time — and I do not use this term lightly — when a crisis exists within mental health and addiction services in the province of Ontario. To understand the crisis that the addiction mental health is facing it should be realized that the cause of mental health and addiction problems to the Ontario economy is enormous. Most of these stats can be applied right across the country.
The number of people affected by mental health and substance abuse problems is on the rise. The cost of managing these problems in the community is significantly lower than the alternatives. Members of the federation are unable to offer enough services to the many people who come to us for help. Despite these obstacles, the community-based addiction and mental health sector can demonstrate the success and effectiveness of their services.
To understand this crisis, we have to understand a bit about the background. Provincially funded mental health agencies have had no increase to their base budget since 1992. Operating budgets for addiction services have risen just 2 per cent in that time period. With inflation, using the federal government's inflation calculator, we conservatively estimate that the ability of organizations to respond to problems in the mental health and addiction field has declined by 20 per cent since 1992. We have some estimates that show the human resources within the sector of community- based mental health and addiction services has actually fallen by 28 per cent in the same time period. That means that there are 28 per cent fewer people providing those services in the community.
Faced with the rising costs and requirements to maintain a balanced budget, organizations have been forced to close programs, reduce services and limit access. At the same time, we have seen a dramatic increase in the requirement and need for those services.
The outcome is simple. We have longer waiting lists; increased use of other, more expensive, institutional services; and, increased stress on consumers of those services and their families and communities. We have increased pressure on other health and social services — most notably police and correctional services, emergency rooms and hospitals. We have increased pressure on emergency services.
Since about approximately 1986, there have been 18 studies in the province of Ontario outlining the need to build stronger and more comprehensive community services. Of the last two, the earlier one in 1993 was called ``Putting People First.'' This study envisioned a future with a comprehensive delivery of services in which people with mental illness and addiction would have better access to quality care from an appropriate mix of institutional community services, and for which all components would be integrated and coordinated. At that point, it was envisioned that community services would represent 80 per cent of the funding mix, while the institutional side would be at 20. We are obviously nowhere near reaching that targets.
In 1999, Ontario released ``Making It Happen,'' which reaffirmed the government's commitment to similar principles. It envisioned that services would be tailored to consumer needs. It also stated that consumer choice and access to services would be improved, and there would be continued investments and re-investments in mental health services to support mental health reform and increase the overall capacity. That same year, we had the release of ``Setting the Course,'' which was a framework for integrating addiction services. That report articulated two overarching goals: to ensure that each district of the province had the appropriate range of services and to ensure that clients had access to the appropriate services when they needed them.
Unfortunately, the reality is much different than our visions were. Almost half of the people who need mental health or addiction services in Ontario must wait for eight weeks or more. That is an eternity in the lifetime of a person, family or community struggling with a serious mental illness or an addiction. A significant number of programs within the federation, 18 per cent, indicate a waiting time of a year or longer for service. Eighty per cent of the federation have identified that they need to close programs temporarily to cope with fiscal pressures. Twenty-five per cent have closed programs permanently. Three quarters of our federation members have lost staff to higher paying jobs outside the sector. Often when people leave, we cannot afford to replace them. We obviously cannot compete with salaries outside our sector.
Since, 1996, 12 per cent of residential addiction treatment capacity has been lost in Ontario and withdrawal management has seen a similar loss in capacity. To give you an idea of some of the impact, it now takes four months to be assessed for an addiction service in some areas of the province of Ontario; five months for admission to a day or evening treatment program; and six months for admission to residential service.
For someone on the road to recovery, who needs to access these services, that four-month period can obviously spell incredible cost to our society through the use of emergency rooms and interaction with the judicial system. Costs are escalated by that delay.
We have reached a point where we have seen our services shrink. I want to give you an idea of some of the problems that are being faced in different parts of the province of Ontario.
The first is about an addiction service in Northwestern Ontario. In June 2003, the only addiction psychiatrist in Northwestern Ontario who licensed prescribed methadone announced he was leaving the community. Ninety-six people depended on him for that service. Fortunately, community organizations often pull together and are able to stretch resources. They came together and put a band-aid on that program to keep it flowing.
However, the program is threatened approximately every six months because it has never been completely funded. It had one-time funding of $50,000, which is expiring, I believe, at the end of this month.
The absence of a comprehensive methadone maintenance program in Thunder Bay — you may have seen recent reports that Thunder Bay has one of the highest addiction rates in Canada — results in increased street trafficking and increased crime. Pharmaceutical break-ins were three times higher in 2003 than in 2002, with 80 per cent of the break- ins resulting in the theft of opiate and narcotic medications. There has also been an increase in incarcerations, multiple emergency visits, multiple inpatient admissions to general and psychiatric hospitals. The absence of such a program has also resulted in increased length of stay and withdrawal of management services — commonly known as ``detox'' — and longer waiting lists for withdrawal management beds for non-methadone users as those methadone users stay in the system longer.
To provide yet another example of some of the problems that we are facing as a result of lack of funding flowing to organizations, I will talk about a community mental health housing program in Southern Ontario. This program serves 30 of the most severely disabled people in the province. The program entered into a unique partnership contracting with another service provider for nursing care required to address residents' unstable medical conditions. Prior to their admissions to the program, all the residents had been in long-term, inpatient psychiatric hospitals. Many of them had tried other housing repeatedly, but none had been able to manage in other housing until they entered this program.
Ranging in age from 41 to 69 years of age, the program clients have been ill for 27 years on average. In addition to their psychiatric diagnoses, nine residents have diabetes; eight have a history of addiction; six have a developmental delay; six have been ordered into treatment by the Ontario Review Board; five have arthritis; three have Chronic Obstructive Pulmonary Disease; another three have seizures; and one resident has cancer.
Despite the severity of their conditions, residents have faired remarkably in the supportive housing complex. The program estimates that it saved more than $4.4 million in in-hospital costs in 2002 alone. They are on what would be estimated as the high-end cost for per-day support to residents at $59 a day for supportive housing. That is the high end. Some programs go down to as little as $5 to $10 a day. Compare that with $80 to $90 a day for a hostel bed; $117 per day in a long-term care facility, $137 per day for incarceration; or $500 per day in a psychiatric hospital. Starving the community mental health and addiction services increases costs on many other levels.
I want to talk about the effectiveness of services for a second to give you an idea. We can clearly demonstrate how community-based mental health and addiction services effectively save our health care system and our society incredible amounts of money.
The cost of hospital care is significantly greater than care in the community. Across Ontario, fewer than 50 per cent of mental health consumers receive the appropriate level of care. For example, 76 per cent of the people in Whitby who need community mental health services and 63 per cent of those in the northeast region are receiving less help than they need. These figures come from the Health Systems Research and Consulting Unit. It is the lack of alternatives, settings and supports — not the level of functioning — that puts and keeps putting individuals in the hospital. To avoid the over-provision of this most expensive and restrictive type of care, it is necessary to develop a full range of community supports.
Supportive housing can demonstrate a 60 per cent reduction in the total length of time consumers spend in a hospital. We have a program in Metro Toronto that can demonstrated a reduction in total hospitalization costs from $1.3 million to $176,000 for 56 people receiving comprehensive case management services. There is a huge array of support and statistics that demonstrate the effectiveness of mental health and community-based programs.
As we are getting short on time, I will point out to one other document in our package entitled, ``Generating New Revenue to Support Addictions Services.'' We know we cannot just come forward with the problems. We have to be innovative and creative to address these needs — particularly in Ontario where we are facing a current deficit.
This proposal is subtitled, ``A Behavioural Insurance Model.'' I urge you to look at it as an innovative way to support, as part of a package of supports, addiction programs. It is not the only solution. It revolves around a one cent per standard drink behavioural surcharge, which would generate approximately $40 million in new revenue per year for addiction services. It is based on what the Ontario government did with the gambling to address problem gambling. Under that policy there is a 2 per cent surcharge on their gross revenues from slot machines and charity casinos. That money is put into treatment and prevention services for problem gambling.
The Chairman: Thank you.
Our next presenter is Mr. Rush.
Mr. Brian Rush, Research Scientist, Social Prevention and Health Policy, Centre for Addiction and Mental Health: Thank you for the invitation for this presentation. I want to talk about co-occurring mental health and addiction problems, two problem areas are often seen as independent. I will show you why this ``double trouble'' is important and needs your attention.
Over the last two decades the co-occurrence of addiction and mental health problems among people seeking treatment and support has emerged as an important issue for those who plan and fund mental health and addiction programs as well as those people who provide direct service. Concern about concurrent disorders have been fuelled by research that looks at two things: First, the prevalence of this co-morbidity and the degree to which the populations overlap. Second, the implications of co-morbidity for the course, cost and outcome of treatment and other support services.
In response to this growing concern, Health Canada commissioned the Centre for Addition and Mental Health, CAMH, to bring together the current knowledge and develop best practice guidelines for the treatment and rehabilitation of people with concurrent substance abuse and mental disorders. We combined our research synthesis with the advice and input of experts and other key stakeholders in the field. We also spoke to consumers across Canada who have experienced the consequences of these co-occurring disorders. While I will not speak to it today, I will leave you with copies of this best practices report commissioned by Health Canada.
What do we mean by ``concurrent disorders?'' In general, this term is used to refer to people who experience the combination of mental health problems and substance abuse problems. Technically speaking, in diagnostic terms, it refers to any combination of mental health and substance use disorders as defined within DSM IV, a diagnostic manual for physicians and psychiatrists.
Why is this combination so important? My job here, with Mr. Skinner and Ms. Bois, is to show you why it is important to think of mental health and addictions within the same policy framework and with the same breath. You cannot disentangle addictions here and mental health there. You may look at me and say, ``Well, I do not know anybody who would do that.'' I will convince you in a moment that this is what has happened in Canada over the last 30 or 40 years. We have evolved to two completely separate systems of care. For those people who are experiencing both problems, no one really wants them. They are falling through the cracks because they do not belong anywhere. It is the highest need population.
This is important for three reasons. First, the overlap between mental health and addiction problems is extremely high. More importantly, today's health professionals do not recognize it. Second, the overlap is associated with a high number of very serious health and social consequences. The overlap is also associated with poor outcome when you go to treatment. Third, there are long-standing systemic and professional issues between mental health and addiction services that have contributed to poor coordination and continuity of care.
How common is this overlap between mental health and addiction problems? We examine this question from two perspectives. First, how common is the overlap in the general population? Second, how common is it for people who are coming for treatment?
For the general population, we have studies from most developed countries and many developing countries, population surveys and epidemiological studies looking at addictions and mental health problems. I want to acknowledge that Statistics Canada commissioned a survey that has been completed. We are waiting for the data, which we expect will be very good information on the prevalence of mental health and substance abuse problems and the way in which they are combined in Canada. I can speak to one excellent study in the U.S., but we have the data coming very soon for analysis in Canada.
One of the best current studies comes from the U.S. The researchers found that for those people with any substance use disorder, 43 per cent have a co-occurring mental disorder. Almost half the people with a substance abuse problem in the community also have some other severe mental health issue. This fits well with the data we have from one good survey in Ontario. In the mid-1990s we measured a 55 per cent overlap. This pattern is duplicated in almost every epidemiological study around the world.
We also know that the people experiencing these problems together in the community are in fact the most likely to come forward for treatment. For example, survey respondents in one study show that those people with an alcohol use disorder are five times more likely to come for help if they are also experiencing drug problems and depression. You have probably heard many other people speak to this around the prevalence of depression in society today.
It is safe to assume that people engaged with helping services in the community come forward with these severe problems because of the added stress — they have compounded problems as a result of the overall mix. You cannot separate out an addiction problem from a mental health problem. In day-to-day life they are dealing with many problems.
If we look at the prevalence of the overlap for those coming forward for treatment in mental health services — psychiatric hospitals, community mental health clinics or emergency services — the amount of the overlap depends on which of those kinds of services we look at. It is not uncommon for the overlap to be estimated as high as 50 to 75 per cent. We have just finished one major evaluation project of community mental health services in Toronto, Ottawa and Kingston, where the overlap is estimated between 15 per cent, at the lower range, and 45 per cent, depending on the difference in population and services provided.
Among the homeless populations in Ottawa and Toronto — people with mental illness and who may be living on the street — the overlap is over 50 per cent if not higher. Among clients coming forward for alcohol and drug treatment, some studies show that about 75 per cent — if not 100 per cent — are also dealing with very serious mental health problems.
It is also important to recognize the degree of overlap that you find in a research study. If I go out and conduct a study in one or more centres and deliberately look for the co-morbidity, I will find much more than has been turned up by routine detection and assessment procedures within the centre itself. I will give an example. There were 75 patients admitted to an in-patient psychiatry unit. They come through the emergency department of the hospital and from there they go into the regular in-patient unit. The psychiatrist in the emergency department made four substance abuse diagnoses out of 75 patients admitted. The hospital staff — the second point of referral — made 29 diagnoses among the 75 people. A week later, a research group conducted a full diagnostic interview with each of the patients in which they count disorders separately for different drugs. They found 187 diagnoses, including alcohol, cocaine and heroin.
This is not an unusual study. The real lesson here is that services, in this case a mental health centre that is well- respected in the community and an in-patient psychiatric hospital, are simply not looking for addiction. They are not trained to look and it does not occur to them to look.
Yet, the co-morbidity is the number one factor predicting poor outcome. Those of us who work in the field feel an almost ethical obligation to look for co-morbidity because we know it is so important in predicting the course of care and the outcomes that will be achieved.
The second reason this is so important concerns the relationship between the co-morbidity and health status, treatment outcome and service utilization. Two to three decades ago, there was a major deinstitutionalization movement in the mental health system. People came out of hospitals. We found we could support them in the community with the appropriate medication. In theory, though as Mr. Kelly has mentioned, we were also supposed to provide a lot of support services to go with this. In reality, it has not happened.
We found that young men in particular — they are generally the first in the community to be afflicted with schizophrenia — were encountering a range of drugs in the community, back in the 1960s, and were simply unable to manage. Research showed early in the deinstitutionalization movement that involvement in alcohol and drugs was the number one factor predicting poor adjustment in the community. Therefore, we have known for some time how the overlap in the problems can affect people trying to manage in the community.
Since then, the research has gone on to show that concurrent substance abuse in mental health is associated with a high risk of relapse and hospitalization, suicide, incarceration, homelessness and family problems — the list can go on so long that you can start to tune it out. This is a list health and social consequences that virtually covers the spectrum — child abuse and neglect, domestic violence, the risk of violence and being victimized, HIV and AIDS, and functional difficulties including unemployment, work instability and chronic problems managing in day-to-day life.
In respect of co-morbidity, think of dealing with problem X — depression, for example, — and add in severe alcohol abuse. The problem is compounded. The effort to manage one's life is doubled or tripled. I someone who is managing schizophrenia is introduced to cocaine, the impact of everything is doubled and tripled.
Without question, outcomes associated with mental health and ongoing community support are negatively affected by substance abuse. The converse is also true. The outcome of substance abuse is negatively affected by psychiatric impairment. This seems to be particularly the case among opiate addicts, alcoholics and people who abuse cocaine.
Coexisting mental disorders increase the probability of leaving treatment early, which in turn has a negative impact on outcome. Early dropout from treatment can be explained by the fact that many of these clients encounter difficulties engaging in treatment and establishing therapeutic alliance. In effect, they do not trust the system. They have been pushed around the system so much that it is difficult for them to engage. In fact, a person with a mental health problem who is making an application for supportive housing, will not talk to you about their substance abuse because it puts at risk the housing they so desperately need.
If they do remain in treatment, the amount of attention and length of treatment required by these individuals often exceeds the services normally planned by the program. Given the higher risks of relapse, higher likelihood of re- entering more expensive services, and the high likelihood of leaving services prematurely, effective assessment and treatment of people with concurrent disorders will reduce health, social and correctional service costs.
Clients of substance abuse treatment services who are diagnosed with psychiatric disorders also use more health services generally and are more often readmitted to treatment. The frequent use of expensive hospital and emergency services and the persistence of mental health and substance use disorders over time contributes significantly to the extremely high economic cost associated with treatment and ongoing support for these individuals.
Finally, in your study of the mental health field and addiction services in Canada, you need to look at this subpopulation with mixed co-occurring disorders because the services that are provided are not planned and integrated in a way to maximize outcomes. There is widespread agreement that individuals who have co-occurring mental and substance abuse disorders have typically had to seek treatment and support from two very separate service delivery systems. This is particularly true for people with substance abuse problems who also have severe and persistent mental illnesses or personality disorders. Most analysts agree that historical barriers between the two systems are at the heart of many of today's problems experienced by consumers with concurrent disorders who are trying to access the help they need.
Many factors account for the historical separation of the two systems of care. For example, the needs of the population seeking mental services changed dramatically as a result of the deinstitutionalization movement in the 1960s. People were receiving services in the community. At the same time, we also saw the rapid growth in the availability of alcohol and illegal drugs in the community. The ``double trouble'' phenomenon began to emerge, and the systems of care and support that were originally designed from a single problem perspective have been playing catch-up for the past 25 to 30 years. As the problems have integrated, the services have moved further and further apart. It makes no sense at all.
Today, it is generally agreed that having two systems of care for people with such an overlap in their constellation of needs has had more negative than positive effects on continuity of care and consumer outcomes. Having two separate systems of care has usually meant parallel or sequential services being delivered across two separate systems: ``We will deal with you here, and then we will refer you there.'' The problem is that the person may never go, and no one will know.
Poor outcomes are thought to result from three important systemic factors: compounded feelings of stigma, competing perspective on what is the most important problem, and the additional burden of having to retell their story when they move into another program.
Examples of conflicting approaches to treatment are abstinence versus harm reduction goals and philosophical differences in the use of confrontation techniques. The acceptability of psychoactive medication that helps manage the symptoms of mental illness remains controversial in some substance abuse services.
In the worst-case scenarios, the delivery of two separate systems of care and support has meant the individual — often the person with the most severe constellation of problems — is simply referred to the other side. Such referral has also meant little or no case management to ensure contact has been made and that the person has been successfully engaged in the system. Dropout rates from concurrent but poorly coordinated programs can run as high as 60 per cent.
The poor coordination of services is particularly evident in testimonials and the personal stories of consumers participating in the focus groups that we held in the course of our national best practice project. I want to finish with a quote from one of the consumers who spoke to us in the group: She said,
I have gotten help for each individual thing but to get help for, 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 is helping you. Nobody follows up and you kind of disappear in there.
She is referring to co-morbidity and this was a common theme that arose in the groups.
I summarize these three reasons for the problem at the end of my presentation. The overlap is extremely high; the impact on outcome is extremely poor; and we have two quite the separate systems of care trying to manage very intermixed and very integrated sets of problems.
Mr. Wayne Skinner, Clinical Director, Concurrent Disorders Program, Centre for Addiction and Mental Health: I have included a little information guide that we have just recently produced for your information as well. I want to commend the committee for including this topic in your considerations on mental illness and thank you for the opportunity to be here today.
My comments are from a clinical perspective. I want to raise the point that we need to think of people with concurrent disorders as people first. They have had to pay too high a price for their illnesses. Mr. Rush illustrated the difficulty of getting comprehensive care, but their lives are affected negatively in many ways. I would like to point to stigma. These clients often talk about ``double trouble'' and ``double jeopardy.'' That is an important issue. The fact that these are human problems that involve illness and suffering is a starting point for me.
It is also important to see these as the norm and not the exception. In some ways, that goes against the way the world is set up, as Mr. Rush has illustrated. We need to have systems whereby when one problem is detected, there should be a demand to prove that another problem is not present. That should be the default logic. We do not work that way in either the addiction or mental health system.
From a clinical perspective, an important point is that the effects of the disorders extend beyond those who are diagnosed with the illnesses to their families and others. We are in trying to work with families. There is a hidden burden of suffering that needs to be recognized. We need to address it as part of a health care strategy. It is not well recognized. I do not think the care systems that focus on the individual with the diagnosis have the tools to deal with this.
We also know that the person's best chance of getting a good response comes from having a resilient healthy that is healthy and supportive. Often these chronic illnesses make the family dysfunctional. It is important to think about that when are trying to develop community-oriented approaches to care — which are the most important approaches.
The impact of concurrent disorders is especially devastating on particular groups. The people of Canada's First Nations have very complex problems related to mental health and addictions. The prevalence of these problems is high there. Immigrant and refugee populations suffer from higher rates of concurrent disorders. People in the correctional system also deserve to be identified. Those individuals have alarmingly high rates of addiction and mental health problems. If we are concerned about their effective return to the community and the avoidance of recidivism addressing them must to be seen as a paramount concern.
We need to include the full span of people with addiction and mental problems when developing policies and practices to respond to issues related to concurrent disorders. Traditionally the mental health system has concerned itself with the severely mentally ill. Not surprisingly, that is the population for which we have the most best practice information. We need to move beyond psychosis and severe, persistent mental illness, which affects about 2.5 per cent of the population, to look at the mental health problems that pertain to the broader population. Those include mood and anxiety disorders, impulse control, and personality disorder problems. These are much more prevalent. Most mental health resources cannot extend themselves to those populations because their priority concern is with the severely mentally ill.
On the addiction side, the system has tended to focus on alcohol and illicit drugs, but now we are aware of the need to include tobacco and prescription drug use. We need to go beyond substance use disorders to consider problem gambling and other behavioural addictions and their co-occurrence with mental health problems. We need a broader frame when looking at the impact of these problems in the general population. That would help us develop better prevention and intervention strategies.
We need to set an expectation that everyone receiving care in either the mental health or addiction system is screened and assessed for concurrent disorders. That is not happening now. The index problem with which a person presents determines the resource that they will access. The full set of needs of an individual is not well defined. Dr. Rush gave a powerful illustration of that in his comments.
Evidence-based practices that that can help funders identify what interventions merit financial support and can guide clinicians toward best practice standards are emerging. It has been heartening at the ground level to see the interest in these best practices among clinicians. There is a great interest in learning and applying these because people doing the work understand that the approaches that we are deploying currently are not optimally effective.
We should set an expectation that programs delivering mental health and addiction services are either ``CD- capable'' or ``CD-specialized.'' CD-capable means a service that has the ability to identify, screen for, and offer a first level intervention to people with these problems. A CD-specialized program is one that offers specialized intervention for concurring problems. We have a number of programs at the Centre for Addiction and Mental Health that operate on that basis.
There is a great opportunity to develop a national training agenda to help health care to social service professionals to develop the skills to deliver more integrated and collaborative services. As I mentioned, it has been our experience that we are finding a great appetite for this kind of learning. Often agencies to do not have the resources to send staff for training, but where it is done, it is quite successful. I have an addendum that describes a way of looking at the two systems and ways in which they could work more effectively in working with concurrent disorders, and how training strategies could be developed to help them.
Finally, while the cost of mental health and addiction problems runs in the tens of billion of dollars in Canada each year, it is important to recognize that a number of behaviours that have addictive liability are regulated by the state, which actually derives considerable tax revenue from them. This includes tobacco, alcohol and, more recently, gambling. It has been estimated that more than one-half the revenues from alcohol and gambling come from the 10 per cent of people that spend the most money on these activities. This 10 per cent of the population group is at the highest risk for addiction to these behaviours. There is strong reason for government to challenge itself to develop proactive strategies towards prevention, treatment and research of addictive behaviours and their mental health co-morbidities. However, beyond that, there is strong evidence that social spending to prevent and treat addiction mental health problems provides an excellent return on investment. It is not unreasonable to expect that more of the tax revenues resulting from behaviours with addictive potential be invested in helping people who are harmed by these behaviours.
The Chairman: Ms. Bois, please proceed with your comments.
Ms. Christine Bois, Provincial Priority Manager for Concurrent Disorders, Centre for Addiction and Mental Health Centre: Dr. Patrick Smith was to be here today, but he is ill and unable to attend. I will make a few comments and some recommendations in his stead.
You have certainly heard about the prevalence and needs. My colleagues have talked about the barriers and some of the serious underfunding. I will speak to what will support concurrent disorders and what is needed to address these issues.
We actually need an approach that is bottom-up and top-down, both from the provincial and federal governments. Across Canada there are a number of bottom-up initiatives. Some jurisdictions are engaged in coordination and planning activities and have been creative in their efforts. I will leave a report with you that documents two communities in Ontario where mental health and addiction systems came together to look at what they could do cooperatively to enhance their ability to provide service.
Many training initiatives are happening. People truly want to enhance their competencies to provide better service. We are working on projects that will address stigma and that will allow people to address their attitudes and values concerning concurrent disorders. We are looking at developing models to provide supports to families. We are looking at conducting research and disseminating that research information around appropriate screening and assessment tools.
There has been support in principle from the top down for coordinating and enhancing capacity in some jurisdictions. However, we need — and we do not have — a policy framework that speaks to concurrent disorders. In that sense, we could have more top-down support. For example, any mental health strategies need to be tied into a national drug strategy. We need support for demonstration projects and for ongoing training and skill-building initiatives. We need the development of resources and training content to support those initiatives.
In summary, we recommend the development of a national clearinghouse. This would function for the 10 provinces and three territories. This function could collect, organize and disseminate the information and resources on concurrent disorders to enable other planning, coordination and training initiatives. This function could be provided within a national health strategy.
It is fundamental that addictions and mental health be tied together and not put in siloed as they are now.
The Chairman: I should like to make two points to the panel. One is directed to Mr. Kelly. I do not dispute any of the data that you gave because I happen to have a sister who manages a community home. However, I have a problem when someone's brief focuses entirely on the need for more money and does not speak to the changes to be made to the system. That is not to dispute the need for more money but there was not a word about how we would do anything different. Your presentation was based entirely on, ``send more money and we will be fine.'' Let me put both issues on the table. I suspect that may warrant a response from you.
The second point is directed to the group from CAMH. When we studied mental health, it seemed obvious to us that mental illness and addiction inevitably would co-exist in many people. Thus, we naturally put them together. Yet, when I read the briefs and listen to the comments, for the life of me I do not understand why getting people to work together is deemed so suddenly enlightening. I do not understand how we came to that. I believe that it was in Mr. Skinner's comment, ``there is a growing readiness among practitioners...'' I do not know why it was not there from the beginning.
Could someone enlighten the committee on how we came to be in this situation of silos? We thought there were many silos in the acute care system. However, this committee has discovered that the numbers of silos in the mental health system is triple or quadruple the number of silos in the acute care system. I am surprised that mental health and addiction grew up side-by-side and not coordinated. None of you have explained why that happened. Are we dealing with the classic professional jealousy issue — a not-on-my-turf issue?
I am curious about how we came to be where we are on this issue and about how public policy could force change? I do not think you can pull silos together too easily. It must be in everyone's best interest to do so — even if it requires a strategy of making them an offer they cannot refuse.
Could you provide the committee with a bit of history and, more importantly, what the solutions would be? I will turn to Mr. Kelly first.
Mr. Kelly: I have great concern coming here to speak only to the need for additional funding for community mental health and addiction programs. However, we have to get down to the basic facts. The fact is that those programs have been starved for 12 years and have seen major declines.
Before we can begin to move forward and build a progressive, integrated system that locks into our acute system and diverts people from courts, court services and the jail system, and that gets people out of emergencies, we have to stabilize the system because we can no longer respond.
Within the mental health and addiction sector there are numerous examples of excellent work that is improving access to services. For example, there are 21 supportive housing providers in the City of Toronto who have come together to create a program that provides one-stop access for supportive housing for all mental health and addiction clients in the community. The problem is that the program has been in place for two years and they have gone as far as they can. They cannot move it any further. They are waiting for approximately $80,000 per year to fund the program.
The Chairman: We have heard about the 12-year freeze in Ontario before. Has that only happened in Ontario or have the programs been starved everywhere as best as you know?
Mr. Kelly: It is varies in different parts of the country. Generally, across the country, we there has been a very intense focus on acute care services over the course of 10 or 12 years. Housing and case-management programs were devalued during that time period. We have created a vicious cycle because we have more requirements for acute care when people would be better served by community-based services. It is hit and miss across the province, but it has been a general trend.
I will go back to my other comment on examples of excellent coordination that exist across the province. In Thunder Bay they have tables where not only mental health and addiction service providers but also long-term care, community-based providers are trying to coordinate services. The problem and the reality is that most of that is done on the goodwill of volunteers and the donation of resources of these community-based organizations. There is no policy support coming out to address those issues.
I understand that you do not want to hear about the funding because that becomes a drone. However, until those those sectors are stabilized, we cannot go forward as a system.
You noted that it is interesting that suddenly talk about working together. We have to look at how policies from health ministries across the country have affected how service delivery has developed. We also have to look at funding mechanisms that go to community-based services — how they are funded as compared to hospitals, doctors or other parts of the health care system. That is one part of the problem.
The Chairman: You mean because they are funded as silos?
Mr. Kelly: In Ontario — correct me, you would have a better history, I think — we had addictions and mental health together, then we had addictions broken off into the Ontario Substance Abuse Bureau, then they moved back and then they moved out again. The ministry has been creating those silos.
The Chairman: The fact that people have responded to the particular funding structure is hugely positive from our point of view. It says that if we can get the right incentives into the funding system, the silos will break down in a hurry because they will chase the money. That is very encouraging. That is partly what I meant by making them an offer they cannot refuse.
Does CAMH want to comment on that?
Mr. Skinner: There are positive aspects in the history; it is not all a negative story. However, it is the story of two traditions that have gone along parallel tracks. There is now a more consensual awareness that those tracks need to converge.
I could give reasons for why the systems are not working. I would not put it at the level of people who are doing the work actually. I would suggest that the fundamental problems are ideological and structural. Ideologically, addiction has a long history that does not involve a medical model. It involves many people in recovery and a number of other things. That is a strong tradition. You then have the mental health tradition that has been preoccupied with the severely mentally ill. In those traditions, large populations have been ignored.
As we turn our attention more to those populations of people with moderate substance abuse problems rather than people who are severely addicted, for example, we have had to change our views on this. At the practical level, many people are working ad hoc trying to bind together responses to help particular clients. At the level of the systems, we have two structural worlds that have been set up along different traditions. We have to bring those together.
Our experience at the Centre for Addiction and Mental Health, which was a bit of an implosion of four services — two for addiction and two for mental health — has been that that is possible. However, we need to see it as an ongoing bit of work as well. We still have much work to do, and we do not have bragging rights to be so excellent at this.
The Chairman: I have one question for clarification. You comment on the two models. Senator LeBreton and I have spoken separately to a number of groups about some of the things we learned at the committee. One point we make is that people in this area seem to approach the issue from the medical model and others approach it from the social model — never the twain shall meet. I am using language that is different from yours, but that is essentially what you mean when you said that there are two models. Correct?
Mr. Skinner: Yes. A bio-psycho-social model of both of these sets of problems is emerging and most people subscribe to it, at least rhetorically. There is an increasing willingness to work together. Rather than contesting which is the more important problem, people are realizing that we must see both as primary issues and that we need to work aggressively on both issues if we are to get good outcomes for people. Programs that are doing that are building the evidence base of successes.
The Chairman: Is your sense that some may agree on a joint model, for example, as long as a psychiatrist is in charge?
Mr. Skinner: No, I would say not. The psychiatrist is an important member of the team. They have certain skills and certain responsibilities that are singular. However, I would say that most people in mental health adhere to multidisciplinary teams. That is heartening important people on the addiction side who probably came to these joint relationships with a bit of paranoia.
The Chairman: Correct. That is why I asked the question.
Ms. Bois: I wish to add one further comment. You mentioned the psychiatrist being the head of the team. Alternate funding plans for physicians and, in particular, psychiatrists, would be useful to allow psychiatrists to be involved in the training and planning activities that would be important to bringing these two fields together. That is one of the barriers that we had not mentioned.
The Chairman: If it is structured properly, presumably there is an incentive for them to move in that direction.
Ms. Bois: Yes.
Senator Morin: It is a barrier in Ontario. The other provinces have other systems.
I would like to address my comments to Dr. Rush on the issue of de-institutionalization. Psychiatric institutions in the 1950s were 100 per cent federally supported. This was terminated in the 1960s and the provinces had to support the institutions. This was partly why patients were moved away from dedicated psychiatric institutions and sent into the communities, mainly large urban communities.
At the same time, there was an increase — as you pointed out — of substance abuse. That is not surprising because 50 per cent of those who are substance abusers are mentally ill. There was a sudden rush. We were told last week that hopelessness coincided with this phenomenon. We were also told that the increased prevalence of mental illness in correctional institutions occurred at the same time.
Is it better for you to be in a psychiatric hospital or to be in jail? Is it better for you to spend the night in a psychiatric institution or on the sidewalk on Yonge Street? Much of that was rationalized. It was financial, but it is easy to rationalize. In some countries — Italy for example — institutions were completely closed down for financial reasons.
You know this better than I do. Many patients do not want to be discharged. They want to remain. I realize that it is undue, but for various reasons, there is a proportion of patients who are sent out onto the street. We are talking dollars and cents here. I do not think this is the main issue. However, as we were talking about saving money, I wonder if we are, in fact, saving all that much by putting people into the street. We are sending them to jail. As the co-morbidity increases, we see an increase of AIDS. It costs $20,000 a year to treat a patient with AIDS. There is also increased violence and so forth.
Perhaps we should consider institutionalization for those who accept it. You have repeatedly said that we do not have the resources in the community. Mr. Kelly has been saying that we do not have the resources. The patients are in jail, and this and that happens. Perhaps we should consider institutionalization and come back to that system.
Mr. Rush: I have spent most of my career working in the addiction field. I do not consider myself to be a world expert on the deinstitutionalization movement in mental health. However, I would offer my perspective that a bit too much has been made historically about the financial incentives for the deinstitutionalization movement.
Most of the hospitals still exist — they are partly empty — and there is still a huge financial drain, and the money that was saved has not been reinvested. Rather, it has been scooped by other parts of government. It has not been invested sufficiently in the kinds of supports that are needed to keep people in the community.
The main reasons for providing services to people in the community relate to humanitarianism and respect and dignity — the same rationalization that has been given for providing community supports for people with developmental disabilities. Almost all those institutions have been closed, and people are being quite well supported in the community with supported employment, supported education, and housing — all the supports they need. The mental health field could learn a lot from the developmental disability field and the kind of investment it might take to support people in the community, which would still save money in addition to providing people with dignity, respect and a choice to live in the community and not in psychiatric institutions.
I would not see turning the clock back to re-institutionalization. It may have gone too far in the sense of providing not enough accommodation or residential support. Hospitals did provide shelter and did provide a safe place for people to live, by and large.
Senator Morin: They were a safe place for people who felt they could not cope outside. They knew that they would commit crimes and become addicts and be violent. They may have preferred being in an institution instead of being in jail.
Mr. Rush: I understand the concern. I invite you to think in terms of levels of care. Institutionalization in the hospital is the most intensive, highest support form of care. In the other extreme there is living in the community with case management and minimal supports. In the middle — and what we do not have in Ontario, mostly because of policy and funding decisions— are the residential services that can provide a middle level of support for people. They are not institutions; they are community residences where people can still live and be protected, yet have the dignity of living out their lives in a home instead of a hospital bed.
England has invested heavily in these services and found just changing the environment of some of these services to a more home-like atmosphere has decreased the use of medication and improved the quality of life. People felt good about themselves living there. We have been unable to fund those services. There is the argument in Ontario that the Ministry of Health does not fund houses. We do not fund bricks and mortar anymore. We fund outpatients and ambulatory services.
Again, I would not see a need to turn the clock back to institutions, but there may be forms of residential support that are needed. We certainly need to take the money we are saving from closing hospital beds and reinvest it seriously in community supports, including addiction.
Senator Cook: I am from Newfoundland, which has a much smaller client population. As I have listened throughout these committee hearings, I feel that we are doing well for the client population that we represent.
I hear you loud and clear about deinstitutionalizing that client population. In my province, they did go out without the appropriate support to be able to achieve some kind of semi-independent living. However, as I look back, the community responded. Perhaps we are a bit ahead of the game. We have evolved.
NGOs in my province play a large role in assisting this client population. You have all said it in some form or another; it is ad hoc. There is no standard except for the level of care and the standard that we give.
Out of that evolved a social centre of which I am proud to continue to belong today. It is close to 30 years old. Initially, it was a place to come in out of the cold, and nothing more. It evolved through Rotary, and through governments cutting our funding from $70,000 down to $20,000. However, we are still there and providing a service. Participation at the centre is voluntary. The consumers set certain standards. It is a good news story.
Senator Fairbairn is aware that we have a hockey team — a farm team — the Maple Leafs. They gave us a grant of $17,000 for a literacy program. This was a voluntary program, but once you signed on, you were there. It is amazing what this has done for those individuals who chose it, because one gap was in knowing when and how to take their meds. They came out of the hospital environment, which had a very structured lifestyle, into a boarding house where they would be alone in a room. That entire network was gone. Someone did a disservice to this client population. Is there any data showing we have learned something as a result of what the system did?
I heard you talk about stigma, the lack of appropriate screening, integrated treatment of services and human resources. I heard you talk about a national training agenda, a national home care program. Ms. Bois referred to a national health strategy. Is there any model out there that we can consider and that would lead us to components of these elements that we could put together?
I did not hear you talk about the justice system and the impact that the justice system has on consumers of mental health, not to say the families who cope with this. There are mental health acts all across the country, except in two provinces, if I recall correctly. If we are going to have a national anything, surely we must have one national piece of legislation — that is, if legislation is indeed necessary.
At home, if a cop on the beat picks you up for whatever reason, he takes you to the emergency and, depending on how busy they are, you are seen sooner or later. You could have been drunk or overdosed or whatever, but the policeman has to sit with you for however many hours you sit there. There is quite a drain in the justice system. You might be put in a cell with no support system. If we are looking at a national anything, it must include components of the justice system. That is my observation.
I always look for solutions when I have problems or challenges in front of me. We talk about integration. Is there a place for this in the new public health agency that we saw the creation of in the Speech from the Throne?
Ms. Bois: You are absolutely right. We have perhaps included in our comments — although it was not said as well today — the importance of people who are in the criminal justice system, in fact are dealing with concurrent disorders and are not receiving the service they need. That is very important.
In respect of a national strategy, we would hope that concurrent disorders, the coming together of mental health and addiction, would occur in this national health policy agency.
Senator Cook: That is struggling to be born with a number of components. If we can move in there and move with the integration into the community, we will have captured something.
Ms. Bois: A number of countries such as Australia and the United States have been working on this. Several years age the U.S. they released a major report on co-occurring disorder to their Congress. Britain is doing work and there are models there, including some of the advice in this Canadian document, which could contribute to a strategy within the national health agency.
The Chairman: Would anyone else like to comment?
Mr. Kelly: Also included in there is what the federation views as to what is needed for a basket of services for a national home care program.
Senator Cook: It scared me. There is never a way I could achieve that in my province. The services that are there are in an ideal world; they are not out there in the community.
Mr. Kelly: Among the problems faced by mental health and addiction services is that we end up picking and choosing so we never look at the complete person. The client groups are so vulnerable that you should offer a complete basket of services — and we can debate which ones are necessary — and look at the person holistically. That person needs a place to live, a friend, a job. They want to be a productive part of society. We have to look at the whole person and offer a range of services that they need to go forward and to remain functioning in the community.
Senator Cook: When we talk about gaps in the service, we are talking about gaps in the training of nurses, doctors and other allied health professionals. We see a lack of this kind of caring being given or offered to the people who go out to take care of other people.
Mr. Kelly: There are huge gaps in training right across the sector. I am sure you can comment more on that. There are giant gaps out into the community.
With deinstitutionalization, the main thing that did not happen was a launch of community services. They closed the hospitals and people left them and went into the community without any support. That was our greatest failure and tragedy in the mental health and addiction services. Until we address those and fill in the gaps with supportive housing, health promotion, training, case management, we will be in a vicious cycle.
Senator Cook: We have two populations out there. We have those who were deinstitutionalized and those who need core group services and who were never institutionalized. Here we are trying to care for the total client population. We must meet the needs of both. How do we achieve that goal?
Mr. Kelly: Both of those groups have similar needs. We must build a system flexible enough to offer a range of services to meet individual needs.
Mr. Skinner: You are raising substantial issues. My vision is of a comprehensive community health care system that can deal with mental health issues as well as general health.
Senator Cook: Would that be through the public health system?
Mr. Skinner: Yes, in the broadest sense, available in every community. As we work with concurrent disorders, we have found some of the best examples of collaboration in the smaller communities — for very reasons that you illustrated in your story. It is a finite enough world that if you can get people making the same assessment of the situation and being willing to work together, they can turn things around quickly.
In larger communities such as Toronto where there are so many pieces you are trying to play with it is harder to make changes happen. We should go to some of these communities. We are doing work in some communities in Ontario to support them in this way.
Broadly, imagine a community care capacity that includes mental health and addictions. That system has a right for support from specialized resources. That is where a place like the Centre for Addiction and Mental Health should be deployed in Ontario. Because of the nature of our environment, we have a lot of expertise. Our challenge should not be whether we can see everybody in Toronto but how to help the community caregivers in Ontario, in the broadest sense, work with their complicated cases. Can we give them the training to make them good primary care workers? Can we support that effort? When they have trouble with the people with whom they are working, because of complexity, can we help them by providing more specialized assessment?
Maybe we have the residential services they need to come in to for a while to be stabilized and re-evaluated. We in the specialized service world should have a dynamic relationship with the community care services. First, however, we need a vision that starts with a really adequate community care response system. It is not about making everyone multi-tasked and multi-skilled, but it is about people having good case management skills and then having resources they can access as they have specialized need. Most people who have these problems can be very well helped by a good responsive community care system.
Senator Cook: I do not see a stigma in my community. We have been able to integrate the needs of the consumer into the community because we are a small population. The NGOs make a great contribution both in money and in services to the well-being of that individual.
One is called the Stella Burry Corporation, which is funded by the United Church and run by a community board. It offers shelter housing where the board takes the risk and pays the rent to the landlord — it is now in the process of purchasing. The consumers run the facility. It currently houses about 65 people and it offers a homeless shelter. The NGOs are the lead people in the community.
Is there a role in this national scheme of things if we are to integrate all other aspects of care? We have to look at the social aspect to give the best possible piece of living to the person for whom we care.
Mr. Kelly: A sense of community is the main philosophy behind federation membership. They are all operated by volunteer boards. They do a large amount of fundraising and have led the way in developing some of the unique services in the province in respect of supportive or sheltered housing. Those are the projects that are successful. These groups can document clearly their outcomes.
The problem is that it is a disjointed system because of funding silos, policy decisions, lack of funding, lack of coordination, and lack of integration with some acute services. Sometimes people do need a hospital.
I think the real role here is to help break down some of those silos and encourage the development of community- based services.
Senator Cook: Is there a model out there we might look at for the delivery of the health care for this client population?
Mr. Rush: For this particular group of addictions and mental health, one excellent model would be in the state of Arizona, which has a particularly progressive approach.
Mr. Rush: New York State is another one that might work better for you. Arizona has a requirement, grounded in legislation, that all addiction and mental health services must be capable of serving both populations or they will not receive funding. That is one area.
I would like to comment briefly on a couple of things that you said. I was in Prince Edward Island consulting with the mental health and addiction service providers. They all fit in a room of this size. It was a highly dynamic workshop. I suggested that this idea of integrating mental health and addiction would put them one step ahead because they all know one another. They said that no, it was worse than that — they were related to all the clients. They said that it should work because they knew all the clients.
There is another concrete idea that you might help in respect of a public health agency, which has arisen largely out of the SARS crisis and public health from the perspective of infectious disease. There is a risk in this country that the predominance of infectious disease in the context of public health will overshadow issues such as addictions and mental health, which have a much larger impact on public health. With respect to that one agency, which we do need, there should be a place for addictions and mental health, even if it is just from a prevention point of view.
Senator Fairbairn: Of all the hearings I have attended on this issue I have not felt more frustration and anger than I have listening to what you have said today. The system is clearly a problem. It is common sense that mental health and addictions go together. Is our difficulty in coming together on this as a country as result of the structure of our federal- provincial systems? Is that one of the reasons?
For several years, my husband worked at the Royal Ottawa Hospital, which was initially for psychiatric care but then it became much more than that. It also had a program for young children, and teens with mental problems and/or addictions. It seemed to me that it was building a service, the main purpose of which was to get people back into the community. Of course, the law was such that anyone could leave when they chose to leave. That was when your problem began because there was nothing built before that law to accept the group coming out.
Therefore, I wonder how we get beyond this. More importantly, how do we get beyond this across this country? Provinces choose to install video lottery terminals, VLTs, and gambling programs for revenue purposes. In every small community in my province of Alberta, you no longer have the huge numbers going to Alcoholics Anonymous; they are not going to Gamblers Anonymous. Sometimes they bring them together but not often.
I would like your perspective on my cry of anxiety. I am trying to understand how we can bring all of it to the same table and develop a useful, productive program across this country that will enable these people to receive the help they need and eventually become self-sustaining.
Mr. Rush: I understand the frustration. As we have talked about the distance between these two systems of care and the frustration of the people manoeuvring them, perhaps we have not spoken enough to the walls of the silos that are coming down in many communities and in some provinces — in particular those areas that have gone to regional health authorities. They are bringing addictions and mental health together. B.C. is the most recent example of that. There is much is happening and we refer to it as from the ``bottom up.'' There is a great deal of enthusiasm within the programs to begin to work better together.
They need to hear — and you can tell them — that it is important and a good idea. Show them a mental health strategy for the province and show that addiction has a place in it. They need to see them together. Support them with policies and, if you have the ability, support them with funding.
These two separate systems are slowly coming together in this country, as well as in the United States, in Britain and in Australia. Those are probably our four closest models. In some other parts of the world, addictions and mental health are completely integrated, but they have no resources. We have all the resources and we allow them to operate independently. We funded all the hospitals independently. We funded thousands of mental health and addiction services in the communities to operate independently. They have been independent but they need to work more closely together.
With respect to the point about VLTs, I could not agree more with the extent to which government seeks short-term solutions to revenue problems. They found a big one in gambling, which is closely related to substance abuse and other mental health problems. The biggest source of funding for alcohol and drug treatment in most provinces has come from gambling revenue and not from designated addictions funding. Manitoba is the best example of that.
That is a matter of the policies and principles by which some things are funded. Mr. Kelly's suggestion to take a small percentage of tax revenue from alcohol sales and designate it for treatment and prevention is a good one. The same strategy is being used for gambling — although they take in billions and provide little back. The principle is important and it is a good suggestion.
Senator Fairbairn: One of the great frustrations I sense is that in our system funding is for many different purposes. Funding is shared with the provinces. However, in this case, how does the federal government rationalize a block of funding to a provincial jurisdiction where a decision has been made to carry on public policy that virtually destroys the lives of its citizens? That is the basis of my frustration and anger. It is extremely troublesome that while we wish to help, but there is a barrier there that makes it very difficult.
Mr. Kelly: I share your frustration. It is key that everyone in this room has had a family member or close friend affected by an addiction or mental health or both. One of the greatest difficulties we face as a sector is to find the champions who will come forward and say that enough is enough; and we must begin work to coordinate and address these issues. Sometimes it is referred to as stigma. Sometimes it is closer to the discrimination of people with mental illness and addictions — namely, the blame they get for their diseases.
When Senator Kirby spoke last year at our joint conference between the Centre for Addiction and Mental Health, and the Ontario Federation of Community Mental Health and Addiction, that started the signal that some of the messaging that had been coming from the community for many years is starting to go through. Each of you knows the impact that an addiction or mental health can have, and we, as sectors, and the people who are using or trying to use those services need you to come forward as champions for them.
Senator Fairbairn: God knows we try.
Senator Cordy: I am in the middle of reading a book called The Tipping Point, which is interesting when you talk about how things are happening. I am wondering when it will tip over.
I would like to return to the topic of the deinstitutionalization movement. Indeed, it was good in the sense that it gave people dignity and respect to live within the community. When people came into the community, the communities were not ready. I am not sure they are ready now because of problems such as housing, nutrition, education and a whole gamut of things.
In dealing with those things, you are dealing with both federal and provincial jurisdictions. Then, even within provincial jurisdiction, you are dealing with many different departments — housing, community services, health and so on. You have all these little silos or departments that do not want to spend their money if they think another department will do it.
Mr. Kelly, you discussed the need to increase community services, and it should be 80 per cent for the community and 20 per cent for the hospital, which sounds like a good fit considering the policies in place. You said we are nowhere near that.
Mr. Skinner, you talked about the hidden burden and the need for family support. You also mentioned that everyone around the table knows somebody who has been affected by these issues. When we started our study on mental health, we went around the table and everyone said he or she had a relative or friend or whatever. Without committed family support, many of these patients — particularly the high percentage who are in co-morbidity — would either be dead or in jail because they would be living on the street, basically.
Dr. Rush, I think you spoke about patients who get frustrated because they have to go through two separate systems when they are trying to be cured, so they opt for early release, even though they may be a danger to themselves. However, because of the patient's rights, he or she is allowed to walk out the door, which is extremely frustrating to a family to see that happening.
How close are we getting to the 80-20 model and also family support? The families are supporting the patient, but sometimes the families also need support.
Mr. Kelly: Depending on the reporting, at this present time in Ontario it is approximately 33 per cent for the community, 65 per cent to 68.6 per cent for the institution sector. That depends on the reporting mechanisms. From the federation's perspective, we do not think we have gotten that far.
In discussing that we have to be careful because you can imagine what sort of political will it would take to make that switch. There are much better ways that we can go forward in doing that. For example, if it were by making these investments in the community, we would begin reversing or lessening the increases needed in the acute system, where you would start slowly having the shift coming. In Ontario, it is a $26-billion machine for the health care system. You cannot turn that around in a month or a year. It will be a process.
What we think is a comprehensive strategy to invest in those community services will then start diverting people from using the hospital system, and that will then shift the funding and focus to that sort of split.
Senator Cordy: Is there support for families?
Mr. Skinner: Families in different communities get mobilized to support themselves. The system under-attends to this dimension. At the same time, we speak about the need and the value in community living for people with addiction and mental health problems, but operationalizing that is not just getting the client turned around and out your door, it is also working with families and communities.
We must have notions of resiliency and health that we extend to families and to communities. Senator Cook from Newfoundland gave a good example of a very healthy community that could do that. We should identify the models that are out there and work with them.
We are now involved in a project around family support, trying to set up support groups and information materials for family members who are affected by concurrent disorders. We are hoping it is something we can provide more broadly after evaluating it.
It is one of the missing links in all this. If we want to succeed at what we are talking about, we have to go there. It is two-sided. One is to see the family as suffering in its own way but also to see the family as part of the solution because the more resilient and committed the family is, the better the effect for the individual.
In working with groups of family members who stayed loyal to somebody with a severe mental illness and addiction, I have learned that these people also felt abandoned. They talk about how they have been abandoned by other family members — not just the person who has the illness, but also their families, their neighbourhoods and communities are stigmatizing them for staying loyal to somebody who has a severe, persistent mental illness and addiction. They deserve the greatest respect. When people are willing to make that kind of commitment, we have to join with them and help them stay strong.
Senator Cordy: I would like to switch to the need for training, which you have all talked about. I think Mr. Skinner said there is a need for a national training agenda, which could possibly be an area in which the federal government could help to develop skills.
That is good if people are already in the field, but what about encouraging professional schools? Could medical schools and social workers be encouraged, because they are the front-line people? You gave examples of the patients going to the hospital, and it is the front-line doctors and nurses who see them initially who may not be diagnosing the co-morbidity.
Mr. Rush: We have made a lot of progress in the last decade in getting alcohol and drugs on the medical curriculum for the standard education of physicians and nurses in Ontario. However, that does not include the co-morbidity. That is on our list.
We have two separate systems for training social workers to work in mental health and addictions. They separate off early. One of our recommendations in the national reporting on this issue was to be supporting and encouraging the universities and community colleges in Canada to focus on training in both these areas.
Senator Cordy: Police academies could be brought into the mix also because oftentimes they would be finding people on the street.
Mr. Kelly: A whole human resource strategy is needed for the field.
Senator Callbeck: I have a couple of questions in respect of Mr. Kelly's presentation. You talked about the history in Ontario, the services being integrated and not integrated, and I think that happened a couple of times. I believe you are now integrated with separate budgets.
When was the last time you were integrated, and why were the services separated?
Mr. Skinner: We could all speculate a little bit. My version is that the addiction system felt it was the weaker sibling in that arrangement and part of its agenda needed to be separated out and be championed on its own. There were some advances, because of that, over the late eighties and through the nineties. It is much like a dialectic, where things swing back and forth and evolve historically. I would argue that some good things have been accomplished by it.
However, we are now at this point of realizing that there is more to be had through integration and collaboration. I think the addiction system is probably a bit stronger and more cohesive and able to engage in that kind of dialogue with the mental health system than it was back then.
The two have very different world views. There are different types of personnel. People in mental health typically have professional education in a health science. Many people in addiction are there because of their own recovery. Those are not trivial differences.
As Ontario regionalizes people are realizing that in many cases both systems are working with the same people but applying different lenses to them. For particularly the more difficult-to-help clients, we are not getting the kind of good outcomes that we want. Perhaps pulling the resources together in the next stage of this historical development is an important thing to be engaging in.
Ms. Bois: That is a good overview. Historically, the mental health and addictions fields came from very different backgrounds. The addictions grew out of the self-help movement, the non-medical side; the mental health area from the medical side. They viewed each other with suspicion for those reasons.
I want to add one further comment about Arizona. Mr. Skinner and I took an opportunity to visit with them. When I first spoke to them on the phone, I asked why they came together. The person to whom I was speaking said, ``I was responsible for mental health; the person responsible for addictions at the state was just down the hall for me. We got together and agreed that we had to work together.'' Ultimately, the size of the bureaucracy and the cooperation and collaboration assisted that. When you get into larger bureaucracies, it allows people to be more separate.
Mr. Rush: Regarding the comment about the mental health system and the addiction system having their own respective evolutions, they were once together back when we first developed the big psychiatric institutions. Most alcohol and drug services were in places like the Homewood Sanatorium and the big insane asylums in the late 1800s and the early 1900s.
With the power of the AA movement, the self-help movement and some addiction services advocating for a broader health perspective on addictions, this system began to distance itself from the medical community while the mental health system kept much closer ties.
The opposite then began to happen. There began to develop the professionalization of addictions treatment. We now have a real mix of personnel and a mix of programs. Multiple perspectives evolved as the addictions system became more ``professionalized'' — I use that word carefully. The mental health system, which was so closely linked to psychiatry and hospitals, has gradually moved towards a powerful consumer movement and a very powerful family movement and towards a tradition of self-help. They are gradually coming together. These things are breaking down, but it is taking time.
Senator Callbeck: I have a question on this proposal for generating new revenue. What has been the reaction of the Ontario government to that?
Mr. Kelly: There has not been any official reaction from the Ontario government. I think they have looked at this as a potential to address some of the chronic issues in the addictions sector in times of deficit restraint. We know there is a precedent with problem gambling dollars. This proposal has been presented on budget submissions and it has been sent to every MPP within the province and right across the senior civil service, but there has been no official response.
Senator Morin: They are opposed to dedicated taxes. They never liked that.
Mr. Kelly: That is right. That is probably part of it right there.
The Chairman: I know we kept you longer than we intended. I thank you for coming.
May I say, Mr. Rush, as you gave a summary of the history, you have detected among my colleagues a huge degree of frustration — I think ``anger'' was the word Senator Cook used — in the sense that if you are looking at this system from the outside you conclude that, first, it is not the system. The second conclusion is that you say, ``How can rational people not operate a system that is somewhat more rational than this one?'' Please take our frustration as frustration of policy people trying to deal with a problem.
On that note, let me leave a question that I would like you to think about as individuals — not as part of Mr. Kelly's official position or your position at CAMH. If we were ultimately to end up recommending two, three, four or five things, could you think about it for a while and, sometime in the next few months, send us a note as to what they would be?
Mr. Rush: We would be pleased to do that.
The Chairman: I am not interested in having it filtered by your organizations because then I get the lowest common denominator. I am interested in your positions as individuals working in the field.
Thank you for coming here.
The committee adjourned.