Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 9 - Evidence, May 13, 2004
OTTAWA, Thursday, May 13, 2004
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 11:05 a.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.
[English]
Mr. Daniel Charbonneau, Clerk of the Committee: Honourable senators, it is my duty to inform you of the unavoidable absence of the Chair and Deputy Chair. Therefore, pursuant to the rules of the Senate, I am prepared to take nominations for an acting chair.
Senator Cordy: I would like to nominate Senator Morin to act as chair for today's meetings.
Mr. Charbonneau: It is moved by Senator Cordy to appoint Senator Morin as acting chair for today's meeting. Is it your pleasure, honourable senators to adopt the motion?
Hon. Senators: Agreed.
Senator Yves Morin (Acting Chairman) in the Chair.
The Acting Chairman: This morning we are pursuing our study on mental health. It is an important issue.
I thank you very much for appearing before us. I think that you have agreed on the order of your presentations. We would like to have from you a short presentation, and then we will have time for questions afterwards.
We will begin with Dr. Kirmayer from the Department of Psychiatry at McGill. He will be followed by Ms. Restoule and Dr. Wieman.
Dr. Laurence Kirmayer, Director, Division of Social and Transcultural Psychiatry, Department of Psychiatry, McGill University: Honourable senators, I will try to keep my presentation brief. I sent along some slides and I will skip over some of them to stay within the time allotted.
I will give you some background information on what we know or do not know about the level of mental health problems in the Aboriginal population in Canada. I will raise some conceptual issues that are important for the design and delivery of health services and health promotion. We will be able to come back to a variety of issues as we move through the presentation.
I direct a program in cultural psychiatry that is mainly centred on raising questions about the relevance of mental health concepts and services cross culturally. That applies to the multicultural population of Canada, including Aboriginal peoples, immigrants and refugees, as well as to international work. I will be talking specifically about my own and other people's work relating to Aboriginal peoples. Some of the conceptual issues and the implementation of services are very similar across these different domains.
I will touch briefly on what is covered in talking about mental health and mental illness as an important continuum or set of contrasts for Aboriginal peoples and the gaps in knowledge that exist. As you will hear in a moment, we do not know a great many things that we need to know to plan services that will be effective.
I will talk briefly about suicide as an index of problems. That is one thing that we know a fair bit about. I think the other witnesses will speak to unique issues of mental health for Aboriginals. There are common issues for all Canadians, but there are specific issues for Aboriginal communities and populations. I will briefly touch on gaps in services because I know that this will be a focus the other presentations. I will also cover what is known generally about culturally appropriate models of intervention. One size does not fit all. There must be some serious consideration of people's backgrounds, language and so on to provide effective services.
I will skip over the information on the demography of Aboriginal peoples; the main point is simply that there is a significant amount of diversity. The Aboriginal population suffers from substantially poorer physical and mental health than the average Canadian. I will not belabour the statistics on this slide. I think they are very important figures, but I assume the committee has access to much information on this subject.
There is a significant amount of missing information in respect of the range of mental health problems. There have been no studies to date that have really used up-to-date psychiatric epidemiological methods to estimate the range of psychiatric disorders in Aboriginal communities. Instead, we have health surveys that ask some general questions about people's understanding of their problems, their experience and their sense of what the dominant problems are.
One major innovation that has occurred in contemporary psychiatry is the development of structured diagnostic methods and needs assessments, so that one can get a better sense of the specific needs of a population. This is important for Aboriginal peoples because there is a broad range of issues and concerns that people have, which, at one end, include severe major psychiatric disorders such as chronic illnesses, schizophrenia, bipolar disorder and major depressive disorder. At the other end, they shade into common problems, such as family problems and marital problems, domestic violence and other kinds of social and everyday problems that may be quite prevalent and usually fall within the purview of mental health care systems. When people use the terms ``mental health'' and ``mental illness,'' they should think not only of the smaller area of very severe disorders, but also the much larger area of milder conditions, many of which are perhaps not medical conditions. They need to be understood in other frameworks such as social work, community development and others.
That highlights the broad territory that is covered when one talks of mental health. In developing a mental health plan, the Assembly of First Nations and the Inuit Tapirisat talk about ``mental wellness'' in a broader sense because it goes beyond affliction to include positive aspirations for health. In psychiatry, we are predominantly concerned with the more severe end of the spectrum but the techniques and approaches can span the gamut.
There is no really good psychiatric epidemiology that provides definitive figures. There are many studies that look at clinical samples when people are doing consultation work or there is a demographic actually seeking help. Those show a broad range of problems and probably higher prevalence rates, but you cannot be certain about community prevalence rates from clinical samples.
We do have good evidence in the area of suicide where it is clear that some, though not all, First Nations and Inuit communities have elevated rates of suicide behaviour, people dying by suicide and suicide attempts. I will not belabour this because a significant amount of literature is available. This has been a significant concern in many communities.
There is wide variation across communities, which is important because it points to the possibility that there are characteristics of certain communities that are protective. This is not something that has affected every community the same way.
The next slides show that the overall rate of suicide, based on data from Health Canada on status Indians, is higher than in the general population and has been consistently higher for several decades. In a number of communities — notably among the Inuit in Nunavut, Nunavik, and in Anishnawbe communities the rates have continued to rise in recent years. This is a matter of concern because there has been some provision of services and interventions but many communities have not been able to get a handle on this problem.
The Chairman: May I interject here? Your slide shows the number of suicides and it is a real catastrophe. Is it a real curve? Is it because we now report more, or is there, in fact, such an increase?
Dr. Kirmayer: There definitely is such an increase. In small communities, very little escapes attention. There are issues on what is labelled a suicide. There may be variations in identification that would cause some inflation. Even when one corrects for both that and for population growth that is quite rapid in many of these communities, there is a real increase in suicide rates in Inuit territory and in some First Nations communities.
There are some communities with a hint of stabilization, if not an actual decrease based on data from B.C. bands. This variation is important. We can say overall that there is this very alarming problem that has existed for decades. The suicide rate is increasing, even while increased attention has begun to be brought to the problem. However, there is variation and we have the potential to learn a lot from that. Something can be learned about community wellness and particular historical circumstances that have led some communities to do better. There may be very important clues.
This raises a general issue: Mental health perspectives tend to be focused on the individual and on individual vulnerability and affliction. This kind of data really points to the working of social forces — things that are affecting entire generations of people and we need to conceptualize it in that way. Within this pattern there is individual vulnerability; not everyone is affected the same way by the same adversity. However, the overall high rate suggests that many people are being affected and that there are things that lie outside of the individual that are at play. We have the challenge to characterize social forces and to think about ways of helping people to take that in hand.
Suicide is primarily a problem among young people, age 15 to 24. It is primarily a problem of males. Women are also affected. An excess of women in First Nations and Inuit are affected, but it is strikingly high among young males. Here you can see the gender differences where you have higher than average rates among females, but a very dramatic impact on males.
The effect of the variations in proportion of the Aboriginal population in different provinces shows some regional differences. There are other reasons for regional variation as well. Quebec, for example, has tended to have a higher rate of suicide, probably for other social reasons. This slide shows data from Nunavut and the variations across communities. There is a tendency to generalize and say that the Inuit have a high suicide rate. That is true overall, but it is important to see that there is tremendous variation across communities. This, again, raises the possibility that we can learn something about the cause of these differences. There are fluctuations. Communities that have a lower rate at one time will have a higher rate at a later time.
This slide has data from the work of Michael Chandler and Christopher Lalonde's work in British Columbia showing similar variation across tribal councils in B.C. They have used this data to look at social factors that may correlate with these differences. This next slide shows a grouping by language group and shows that there is much variation across different linguistic or cultural groups of Aboriginal peoples in British Columbia.
They used some indicators that were readily available to them about the characteristics of communities to try to understand what might correlate with these suicide rates. Specifically, they looked at the following variables: whether people had some measure of self-government; whether they were involved in land claims; whether they controlled their own local education and health services; had cultural facilities; and controlled their police and fire services. They gave people one point for each of these things in an index of what they called ``cultural continuity.'' However, if you look at these variables, they might be better called ``local control'' or ``empowerment.'' They found that the suicide rate varied dramatically with variation in these indicators. The more of these indicators the communities had, the lower the suicide rate. This is dramatic data showing a relationship between community level variables and suicide rates.
They did a replication using a longer time period of data and other indicators that they established about these communities. They confirmed the previous variables and added some additional variables including, women accounting for more than 50 per cent of elected officials and the band having local child protective services. This work, which needs to be replicated in other places across Canada, has potential for identifying social and community level processes where some support intervention and a political process could be helpful in mental health promotion.
I would caution that these studies are open to alternative interpretations. This is a unique data set and people have put a lot of weight on it at this time. It is important to recognize that cause and effect have not been shown. There are many other possible interpretations, which would have somewhat different implications for social interventions. I have listed some plausible ones here that could have an impact on youth suicide.
Finally, I want to address culturally appropriate mental health services. This is an area in which we have been very involved with Aboriginal peoples and more generally with multicultural urban communities in Canada. There is a great deal of evidence that matching the type of care provided and the context in which it is provided with the needs and the cultural background of the individual improves the quality of services.
This has been approached in different ways in different countries. In the United States, there has been a tendency to try to do a kind of direct ethnic matching. The idea is that if a practitioner or clinician is from the same background as the person to whom they are providing service, things will go more smoothly. That certainly makes sense with respect to language. This is, in fact, an issue in some Aboriginal communities, where there are linguistic barriers that are not acknowledged adequately within the health care system. If the clinician and patient speak the same language, then the quality of service is better. There is clear data from Australia and other places to show this as well.
There are other levels of trying to meet peoples' needs that centre more on cultural issues. In particular, for many Aboriginal peoples, cultural identity involves living in rural and remote communities, retaining some aspects of traditional lifestyles or aspiring to maintain and to continue to learn some of their family and community traditions is very important. There is what could be called a different sense of self and a different sense of personhood.
In the dominant Canadian society, the sense of self is very individualistic — what psychologists have called ``egocentric.'' It is bounded by the skin of the individual. All of our legal and most of our mental health thinking is framed in this way: It is about the rights of the individual; it is about the agency of the individual; it is about what goes on inside the head or psyche of the individual.
There is recognition of that in Aboriginal communities. However, there is also a much stronger sense, in some communities, of interdependence between people. Thus, one's identity is very much tied to family, social network, kin and community. Beyond that, there is a sense of what has been called by the geographer George Wenzel at McGill, an ``ecocentric'' sense of self — a sense of self that involves ongoing transactions with the land, with animals, with the world around one. This, obviously, varies tremendously across communities, generations and so on, but it remains a significant factor for many people. Certainly, in the Inuit communities where I have worked, it remains a significant reality for people.
This has implications for conventional mental health care theory and practice. We understand things in terms of inner psychological workings that are based on a schema of the self — a representation of the self — that is very individualistic. Our theories of depression and psychotherapy are very much supported by this kind of model. There is reason to think that needs to be rethought and worked through in systematic ways to take advantage of the different resources, strengths and value systems of Aboriginal people.
The implications of what I have been saying in terms of the ecocentric self is that for many Aboriginal peoples, threat or injury to the environment is tantamount to a threat or injury to self. We have seen this in terms of controversies that have developed around land claim issues, hydroelectric development in Quebec and so on, where the arguments brought forward are based on very strong community and moral arguments and, on a certain level, psychological arguments about the impact that certain types of development will have on individuals. We need theories — which, I think, are available within psychiatry and psychology in the form of family therapy, family systems theory, network theory, community psychology — that pay attention to the larger webs of relatedness that people have.
Finally, I will just anticipate what some of the other people, I am sure, will harp on. There is a tremendous need for a comprehensive mental health strategy for Aboriginal people, as for Canadians in general. There is a need to find ways to make mechanisms of funding work according to assessed need. In general, for Aboriginal communities right now, funding is either absent or a response to crises, rather than to ongoing needs. There is a need, in general, to improve the quality and variability of services that are largely lacking. I will leave it to the other speakers to demonstrate that more.
These are some Web addresses, in particular for the National Network for Aboriginal Mental Health Research, which I co-direct with Gail Valaskakis of the Aboriginal Healing Foundation. If you want to track down some of the other reports and documents that we have, I will be happy to provide them for the committee.
Ms. Brenda M. Restoule, Psychologist and Ontario Board Representative, Native Mental Health Association of Canada: Honourable senators, I would like to thank you for inviting the Native Mental Health Association of Canada, and for the opportunity to share our views and experiences on Aboriginal mental health in Canada.
Aside from my position as an Ontario board member with the Native Mental Health Association of Canada, I am also a psychologist providing psychological services in three First Nations communities in Northern Ontario, around the Sudbury area. I have also provided some counselling service to Aboriginal women in the federal prison system. I will utilize those experiences, as well as my own personal experiences of growing up in a First Nation community, to share some of my thoughts on Aboriginal mental health.
Honourable senators, during the work you conducted on acute health care in Canada, I am sure you heard testimony that First Nations people suffer from overall poorer health status than the general population. As with physical health status, the mental health of First Nations people is also generally poorer than the Canadian population.
Based on the limited research in this area, along with my professional and personal experience, I have noted that First Nations people often experience significantly higher prevalence rates of all types of mental illness and mental health issues. As Dr. Kirmayer has indicated, there is very little data. What I tend to see in my practice is that many First Nations people appear to be diagnosed at disproportionately higher rates with mood disorders such as depression and anxiety, and especially post-traumatic stress disorder.
First Nations children and youth are often labelled in the school system as difficult or having behavioural concerns. In many of these cases, these children and youth are often quickly labelled as ``oppositional defiant disorder'' or ``attention deficit disorder.'' As part of my practice, I often spend time with individuals to assess their background and their family, personal and community history. They report being exposed to a multitude of issues and stressors that have led to the development of some of these disorders or — in my opinion, more commonly — they exacerbate their negative moods.
It is quite common for First Nations people to report higher incident rates of anger and aggression, domestic and family violence, parenting issues, relationship problems — whether marital, between children, parents, or among family members — high rates of suicide, grief and loss issues, unhealthy family relationships, childhood abuse and neglect, involvement of child welfare agencies and abandonment or family breakdown. Complicating this multitude of issues is the high prevalence of addictions to alcohol, solvents, substances, and gambling experienced by Aboriginal people. It would suggest that First Nations people also experience higher prevalence rates of concurrent or dual disorders.
The concept of dual disorders is relatively new and, in my experience, this concept has yet to be embraced in First Nations communities. It leaves many of our people at a disadvantage, since community workers do not adequately recognize their issues and, therefore, the treatment they are offered often does not meet their needs. This can result in poor treatment outcomes or failure in the treatment process, often leaving these people in a position where they have few or limited coping skills to deal with the complexity of their issues. In many cases, these individuals are termed as ``difficult to treat,'' and they often choose not to engage in the mental health system since they feel marginalized within the system.
To exacerbate the issue of dual diagnosis, the workers in the community may not be aware of the concept of dual disorders, rendering it difficult to recognize the unique needs of this population. Other issues, such as the training of our community workers, also impact on the service providers' ability to work effectively with this population.
Other forms of serious mental illness, such as schizophrenia, bipolar disorder, and psychotic disorder, also occur for First Nations people. As Dr. Kirmayer has shared with you, there are really no clear statistics to indicate if the prevalence is higher among First Nations people. I have found that those who have been diagnosed with this mental illness often fall into two categories. There are those who are protected by their family in the community and their bizarre behaviours are not really seen as a way to describe the person, but that sometimes these behaviours are present on certain days and on other days they remit. On the days when they are present, families may seek out the help of the medical professions outside of the community or the health care workers in the community. They just cope to the best of their abilities until those behaviours remit. In other cases, when these persons exhibit the bizarre behaviours and they are often accompanied by alcohol or substance abuse, they may be seen by community members as frightening or threatening to others, and they quickly become marginalized from the community. They eventually leave the community and take up residence in an urban centre where they continue to be marginalized.
Many Aboriginal people report exposure to harsh, violent and abusive circumstances, often linked in some way to the residential school experience. Children exposed this experience experienced such things as physical abuse, mental and emotional abuse, neglect and spiritual abuse, of which I am sure honourable senators are aware. The removal of children from their families and community has caused a breakdown in family traditions and culture, which I would say has been transmitted across the generations. Research has shown that cultural identity is a significant contributing factor in a person's physical and mental health status. John Barry, of Queen's University, has done much work that would suggest this. It is my opinion that the significant cultural loss of Aboriginal people, which may be linked to the residential school experience, has been a contributing factor to the poor mental health status of Aboriginal people, which seems to be widespread in our communities across this country.
Social conditions in First Nation communities complicate our mental health status. Statistics identify that First Nation people often live below the poverty line. The economic depravity in First Nation communities is highlighted by the high unemployment rates, low-income levels, and significant financial hardships experienced by many individuals and families. Poor housing conditions are also evident. Aboriginal people report overcrowding, substandard housing, poor sewage, and lack of running water as common complaints of the daily stressors they must face. First Nation people often do not adequately access the health care system, possibly because of the tendency for health care providers to over-prescribe medications or because of the lack of cultural awareness and sensitivity displayed within the health care system. The result is generally poor health status of First Nations people.
Throughout our country, Aboriginal people continue to experience racism and discrimination that can negatively influence their desire to seek higher education, to live in an urban centre where there are more opportunities for employment or to seek employment outside First Nation communities. In some cases, the racism is systemic. I have worked with individuals involved with the Children's Aid Society. The expectations placed on the families are often unrealistic and, in some cases, are almost impossible to achieve. The role of child welfare agencies does little to recognize the unique stressors that First Nation people face. They hold First Nations people to the same level of expectations as the general population. I am not suggesting that First Nations people should not be held up to an equitable standard of child safety but it has been my experience that the Children's Aid Society makes a higher number of referrals for services for First Nation families; becomes involved much earlier in a child welfare case; remains involved in the case much longer; and is much quicker to remove the children from the home. Some districts of the Children's Aid Society do make attempts to recognize such issues as customary care agreements and the importance of culture and tradition, but their assessment guide often discriminates against the needs and abilities of First Nation families.
Other kinds of systemic discrimination and abuse occur in the legal system, as Dr. Kirmayer pointed out. We find that Aboriginal people are over-represented in the federal and provincial prison systems, sometimes comprising 70 per cent of the overall prison population. This is especially true in Western Canada.
There are larger systemic issues that impact on the mental health status of First Nation peoples. Funding for mental health programs is extremely limited and, in many cases, it is a piecemeal process. The majority of First Nation communities utilize such funding as Brighter Futures and Building Healthy Communities to implement their mental health programs. Other communities also use monies from the Aboriginal Healing Foundation, Head Start funding and, here in Ontario, the Aboriginal Healing and Wellness Strategy and Early Years Challenge. The requirements for each of these funding sources are different, including who can be serviced with the monies they received. The funding is often time-limited and can vary significantly.
Most recently, there was a threat to the Brighter Futures funding because of the large deficit of the First Nations and Inuit Health Branch. As I mentioned, most communities utilize these dollars to implement mental health programs so there was much concern by our leadership about the implications should such funding cuts occur. After a strong letter-writing campaign, the decision was reversed but communities were reminded that funding cuts would occur in the First Nations communities to bring down the deficit. There is a concern that if it is not done within mental health care, it will be done somewhere else, which will continue to impact on mental health.
Current funding is already inadequate, at best, and does not meet the needs of the community and its members. Since the funding formula is based on population size, many communities receive a small amount of funding, making it difficult or, in many cases, impossible, to deliver mental health counselling and intervention services. Most communities must use their funding to establish mental health promotion and mental illness prevention programs. Although these types of programs are needed, the funding does not allow for a continuum of care that is desperately needed for First Nation communities.
For those communities able to implement an intervention program, additional challenges arise. The funding is so low for the salary of mental health workers that professionals such as social workers, psychologists and psychiatrists often do not find it desirable to work in First Nation communities. This often results in the position being filled by an untrained or unskilled worker who is expected to meet the high demands of the community. There is little recognition by the First Nation and Inuit Health Branch, Aboriginal leadership or administration about the need for the development and delivery of high quality, effective mental health services in First Nation communities. This results in limited or no resources being allocated to supervision, management, policy and procedure development and professional development.
Other kinds of mental health funding, such as fee-for-services or crisis management are often very restrictive regarding when and how the funding is accessed and who can access it. I also understand that this funding continues to be more and more restricted with the future possibility that the fee-for-services, which is mental health counselling, will eventually become be obsolete.
The Chairman: Could I interrupt for a moment? Is the funding to which you refer from the provincial government or from Health Canada's First Nations and Inuit Health Branch?
Ms. Restoule: It comes from both are both.
The Acting Chairman: The funding has two sources. When you say ``provincial'' you mean Ontario. Would you extend that to other provinces?
Ms. Restoule: I believe they have other forms of funding. I am not sure what they are called. In Ontario, it is the Aboriginal Healing and Wellness Strategy.
The Acting Chairman: You referred to cuts in mental health. We know what you are talking about. We know that in Ontario they are addressing financial problems. Are you referring to cuts at the provincial level or at the federal level?
Ms. Restoule: They are at the federal level
The Acting Chairman: Could you clarify this? I was not aware that there were cuts from Health Canada's funding to the First Nations and Inuit Health Branch. There have been cuts at the federal level to the mental health program. Is that what you are saying?
Ms. Restoule: I am referring to the fact that the minister wrote to the communities suggesting that they would be cutting the mental health dollars and there would be funding available for the first three months of this fiscal year, after which it would be cut completely. The political leadership in the communities and representatives of the mental health programs created a strong letter campaign in response to the minister requesting that this not be done because of the large number of mental health issues in our communities and the decision was reversed.
The Acting Chairman: Therefore, there is no cut at the federal level in respect of mental health.
Ms. Restoule: At the moment, no, but the letter that returned from the minister suggested that there will be cuts.
The Acting Chairman: This has been reversed. I am trying to understand for information for the committee's report. Am I right in saying that cuts at the provincial level, at least in Ontario, have occurred but at the federal level, there are no cuts in the mental health program right now?
Ms. Restoule: That is correct. There are no cuts at this time.
The Acting Chairman: We do not have to address that issue right now, and you are satisfied that this will carry on. We are working at the federal level so it is important to know what Health Canada is doing.
Ms. Restoule: My understanding is that Health Canada plans to make some cuts somewhere to the First Nations health care system. However, that cut to mental health was stayed for now. Where it will come from, I am not sure.
The Acting Chairman: Thank you for the clarification. Would you proceed with a summary of your presentation?
Ms. Restoule: I will move to our recommendations.
We have found that many First Nation communities are beginning to integrate what I would call ``western-based services,'' such as counselling services and using the medical model of diagnosis, in conjunction with more traditional activities and ceremonies.
There is really no data to suggest this has improved mental health status. However, I have heard from many of my clients and from communities that implement such a system, that people report improved health much quicker, that they recognize or feel they have a better quality of life and they just feel that things are more holistic for them. Aboriginal people tend to be concerned about holism — the concept that we find in the medicine wheel where there is interconnectedness between the mental, emotional, physical and spiritual domains. This requires that we look at relationships — be they between social conditions, economic conditions, cultural conditions, and health conditions, to relationships between people and within the community and within programs. As Dr. Kirmayer suggested, Aboriginal people feel challenged when there is no connectedness and no teamwork between programs so people's needs are not being addressed in a holistic fashion. It is very individualistic and in one area or another.
Some of the recommendations that the Native Mental Health Association of Canada would like to offer is the elimination of operations of programs for services in what we call silos. Instead of funding for mental health, funding for social services and funding for other issues in the community, we favour more team approaches based on partnerships, so that what is available to a community is integrated and made available and accessible to our clients in a holistic way from the top to bottom — from policy-makers and planners to local governance.
We recommend all the health determinants that I have talked about be seriously considered and employed to determine whole health priorities so that the underpinnings previously mentioned achieve elimination of sexual and other forms of abuse and of violence including lateral violence. They would also take care of grieving and healing needs so the family and community members are able to enjoy self-care, mutual aid, self-determination, genuine friendships, community togetherness and quality family life.
We recommend that resources to implement all priorities and strategies tailored to address all health determinants be made available on a continuing basis so that genuine change takes place and is sustained.
We recommend that resources are provided to recruit, educate and train competent frontline workers with culturally strong ways to promote healing, personal growth and other measures that actively support capacity building and to prepare and equip knowledgeable and skilful leadership that can effectively manage policy-making, strategic planning and the related work.
We recommend that priority be given to Aboriginal people so that they are able to identify and undertake large- scale research that will provide evidence that supports concrete actions leading to desirable change.
Finally, as I had shared back with the senators in October at the town hall meeting, we recommend the development of a national strategy on Aboriginal people mental health as well. Thank you.
Dr. Cornelia Wieman, Psychiatrist, Six Nations Mental Health Services: Good morning, honourable senators. I wish to thank the chairperson and members of this committee for the opportunity to share my perspectives with you in the area of Aboriginal mental health.
I am originally from Little Grand Rapids First Nation, which is part of the Ojibway nation. In 1998, I became the first Aboriginal woman in Canada to train as a psychiatrist. I am currently an Assistant Clinical Professor in the Department of Psychiatry and Behavioural Neurosciences at McMaster University in Hamilton. For the past four years, I have worked as Director of Native Students Health Sciences Program in the Faculty of Health Sciences, also at McMaster University.
For the past seven years, I have worked as a psychiatrist on the front lines at a community-based mental health clinic located on the Six Nations of the Grand River Territory, a reserve community located near Hamilton and Brantford in Ontario. It is my experience working in the Six Nations community that forms the basis of my presentation to you today. Over the next few minutes, I would like to take you to work with me and ask you to imagine what it is like for me working in this community.
I work two and a half days a week, seeing patients in my psychiatric practice. I provide direct clinical services, which includes psychiatric assessments, consultations, and short- and long-term follow-up for patients with serious mental illness including depression, anxiety disorders, schizophrenia et cetera. Other services that I provide include indirect consultations, which is a discussion with a family doctor, for example, about a patient without the patient being present; case conferencing; teaching mental health issues to other service providers in the community; and participating in many different community awareness events dealing with mental health issues, partly in order to address the issue of stigma about mental illness and psychiatry.
I see fewer patients per day than do many of my psychiatric colleagues. I see approximately six to nine patients per day. Each new patient is seen for a one-hour consultation, at a minimum. Each follow-up patient is seen for between one-half to one hour, depending on specific needs. While the majority of patients are diagnosed with illnesses such as depression — the same as in the mainstream population — and are treated according to the same standards of practice, my experience has been that First Nations people living on reserve present with an extensive list of psychosocial stressors that also need to be addressed and a management plan formulated in order to improve their mental health.
I believe both Dr. Kirmayer and Ms. Restoule have reviewed many of these in detail already, but they do include things like education, employment, finances, housing, transportation, et cetera. As Ms. Restoule mentioned, there is an inextricable link back to the historical experiences of Aboriginal people in this country that include colonization, residential schools and racism.
Many of my patients do not have a method of transportation and we are a large rural community spread over a vast area. Significant numbers of my patients live with many extended family members in inadequate housing. Some homes still have dirt floors, no indoor plumbing, or no source of heating in the winter other than a wood stove. I often provide home visits to my patients if they cannot make it to our clinic because of a lack of transportation, mobility problems — for example we seem to have a significant number of people who are paraplegic or quadriplegic — or because of emotional or psychiatric issues, meaning they are very reluctant to come forward to our clinic and seek services. For example, I have seen an older man now for several years who suffers from paranoid schizophrenia that had been untreated for decades. It took us almost six months to develop a relationship with him just standing in his doorway. He would only hold the door open a few inches until he felt comfortable enough to allow us into his home to speak with him.
Many of my patients present as being either acutely or chronically suicidal, and many of them have ready access to means to seriously harm themselves, including firearms. Many of my patients are also involved with other health and social service programs including substance abuse treatment programs, child protective agencies such as the Children's Aid Society, CAS, and involvement with the legal system.
Because our clinic offers mental health services to all Six Nations band members living on reserve, we do not have any exclusion criteria that some mainstream or tertiary care psychiatric services may have. By that, I mean we see everybody. I have seen individuals who have previously been declared as dangerous offenders. Currently, I see an individual who has completed serving a sentence for murder.
While Six Nations band members do have access to family physicians, we have a medical clinic in the community that is staffed by a variety of family physicians who each work one to two half-day shifts per week. This works out to the equivalent of having one family physician in the community working four and a half days per week. Six Nations has approximately 22,000 band members. About half of those live on reserve so that works out by straight numbers to be one family physician for 11,000 people so people have to seek primary care elsewhere.
Not every patient at my clinic has a family doctor, although we try to find one. At times, we have found ourselves trying to manage or triage acute medical crises such as people arriving at our clinic with severe exacerbations of diabetes or in hypertensive crises. Finally, our clinic offers crisis response services that may include going into the community on an on-call basis to deal with acute psychiatric emergencies. Most commonly, we are called when someone is acutely suicidal. I will just make mention that we do not actually have a traditional healer on staff, but we do have access to traditional healers in our community.
It took a number of years of work in this community to establish relationships with the traditional healers so that we could be assured that the people would see healers who were reputable in the community. When they come to our clinic, people have the choice of seeing me, one of my psychiatric nurses or a traditional healer or a combination. We try to be very flexible, offering access to both western and traditional ways of healing. Our ultimate goal is to empower the community members to take responsibility for and to be able to make decisions about their own mental health care.
I would like to review a few issues related to the delivery of mental health services.
There is a lack of information about the epidemiology of mental illnesses amongst Aboriginal peoples. As a result, we are not well informed about what types of mental health services are most effective. Although there are very few models that exist other than our own for delivering mental health services in such a broad way in a community, we need the opportunities to share these experiences with other First Nations communities across the country.
Another issue involves trends that I have noticed in psychiatry. As a practising psychiatrist, I keep up-to-date on the standards of practice in my chosen area of medical specialty. I am somewhat concerned by what I perceive to be a very limited ``consultation only'' model of providing psychiatric services that is advocated by some medical profession associations. I do not believe that I would be as effective in my role as psychiatrist in my First Nations community if I did not deliver services in a way that is similar to those provided by a primary care physician.
As well, I am concerned by the increasing focus on biological models of mental illness. While I recognize that our knowledge of the biological basis of mental illness is important, this knowledge factor is much lower on my list of priorities in treating my patients. For example, I have a patient who last year lost a son to suicide while he was in police custody. That same year, she was diagnosed with kidney cancer and underwent removal of her kidney by surgery. Her youngest daughter, age 14, has coped with her brother's suicide by engaging in extremely risky behaviour including engaging in substance abuse, unprotected sexual activity and staying away from the home for days at a time. This woman has been on medical leave from work, which has caused a great deal of financial stress. She also has several extended family members living in her home. She is widow with few social supports.
Using this patient as an example, it would be unrealistic of me to simply prescribe her an anti-depressant medication and reassure her that over time she will feel better. However, by prescribing an anti-depressant as well as activating a number of psychosocial supports, including counselling, and after working with her quite intensively over the period of a year at our clinic, she is finally feeling better. She returned to full-time employment this month.
In respect of working collaboratively with other community services, Dr. Kirmayer and Ms. Restoule have described to you how different mental health services in First Nations communities are very separate, or ``siloed.'' I work as a fee-for-service physician in my community. I am only paid for direct patient contact. I do not get paid for the time I spend case-conferencing with other service providers about the clients that we share. It is very difficult to learn and to teach how to work collaboratively with other health and social service providers.
One of the recommendations that came out of the Advisory Group on Suicide Prevention — of which both Dr. Kirmayer and I were members — was that mental health, holistic health, and social service workers be trained in case management, case-conferencing and other models that support integrated client services and collaborative interdisciplinary teamwork.
Additionally, it would be my opinion that these community service providers need increased support to improve their attitudes, knowledge, and skills in working with clients with mental health problems. I suggest attitude training because I see many people being fearful of people with mental illness, which has much to do with stigma. If we can work on some of these things, the service providers in the community can hopefully deliver better mental health care.
Presently, my patients can access individual counselling through the Non-Insured Health Benefits Program, NIHB. Ms. Restoule spoke about the federal funding that comes through First Nations and Inuit Health Branch for this program. However, in Ontario, the limit is 15 sessions with the possibility of renewing for a further 12. A total of 27 sessions for many people is not sufficient to help them adequately address their mental health concerns. The mandate of the NIHB program is to provide support for clients in crisis or who cannot access counselling by other means. That counselling could be from an outpatient psychiatric clinic or health service that is funded by the provincial health care system. They could also pay for private counselling.
The vast majority of my patients live on a limited income and would not be able to pay for private counselling. As a result of transportation and access issues, many are also not able to access counselling services in smaller communities nearby or in larger urban settings such as Brantford or Hamilton. You can tell that these people do fall through the cracks in the system.
Dr. Kirmayer alluded to training an increased number of Aboriginal health professionals. One of the important ways in which access to health services and health outcomes, including mental health, can be improved is by training an increased number of Aboriginal health professionals. Barriers to seeking various mental health services could be overcome and providing more culturally relevant care could be accomplished. The Royal Commission on Aboriginal Peoples in 1996 recommended that 10,000 Aboriginal peoples be trained as health professionals in the next 10 years. We are now only two years away from 2006, and I do not believe that we are anywhere near that goal. Estimates state that there are approximately 150 Aboriginal physicians in this country, most of whom have trained to be family physicians. Off the top of my head, I would estimate the number of Aboriginal specialists at probably less than 25. I am only aware of two other Aboriginal psychiatrists in this country, with a fourth individual graduating from the residency program in Manitoba this June.
Training more Aboriginal health professionals, including those who would work in the area of mental health, must be a priority in a health care system that is inclusive of Aboriginal peoples. I have been part of group at Six Nations to develop a plan summarized in the document entitled ``2020 Vision: Training Aboriginal Physicians in Ontario.'' The goal of this strategy is to graduate 60 Aboriginal physicians in Ontario by the year 2020. The strategy is based on partnerships and commitments among key stakeholders including Aboriginal peoples in Ontario, academic and health institutions, federal government departments, ministries of the provincial government, and the private sector. We are positive that we can achieve our stated goal with a total investment of $35 million from all partners over the next 15 years. I have brought a copy of that document. We only completed draft number 10 yesterday, which is the reason that I did not submit it earlier.
There is a common saying that no one is irreplaceable. I ask you today, after seven years of working in the Six Nations community and providing psychiatric services to more than 400 patients with over 600 episodes of care, who is there to replace me?
The following are my recommendations to contribute to improving mental health services and outcome for Aboriginal peoples. There needs to be optimized and more integrated mental health services for Aboriginal peoples. This has already been stated by Ms. Restoule and Dr. Kirmayer.
As stated in the Speech from the Throne this February, there needs to be improved federal-provincial-territorial relationships in the delivery of health care, specifically in this instance, for delivering mental health services to Aboriginal peoples.
We desperately need to train more Aboriginal health professionals including physicians, nurses, psychologists and physiotherapists and occupational therapists. The list goes on.
We need to device ways of providing comprehensive psychiatric and mental health services that pay attention to the general determinants of health such as housing, education and poverty. I would add that it also should be respectful and inclusive of indigenous knowledge and ways of traditional healing.
We need increased funding for mental health services specifically, more federal funding through the NIHB program for mental health counselling. I will not share the numbers with you in my particular presentation, but I have the numbers if you want to talk about that later.
Thank you for your attention and consideration of this matter.
The Acting Chairman: Thank you for the reference list. Will the document to which you referred be made available to us?
Dr. Wieman: Yes, it is here.
The Acting Chairman: Could we have it so that it could be circulated? That is a very important document for us.
Senator Cook: I hardly know where to begin, but thank you for a very thought-provoking overview of where you are in your challenge.
I am a member of the United Church of Canada, which has worked a fair bit with First Nations people. I remember the stories of the residential schools and the healing that accompanied it. Have you ever seen the video The Taming of Elizabeth Shaw? Elizabeth Shaw was a teacher in British Columbia in one of the residential schools. That piece left the greatest impact on me.
I am listening to where you are and the challenges that you face with a growing population. I am looking back, because I cannot decide if we were well intentioned. I would like your comment on that. Did we understand? Do we understand now?
Within the conference of my church, there is an all-circle native conference. We have come together, admittedly in small part, in attempting to understand. We all live in communities, as you do live in communities. I am hearing that the communities may be far away. I just cannot get it through my head that someone so close to the heartland of Ontario would live in a house with no floor. If you told me Inuvik, Iqaluit, the Far North or some faraway place, I would be just as distressed but I could understand it better. We have a million people and they are part of this land called Canada. How do we live together?
You live on a reserve that is very structured, and you also live in urban centres or near urban centres where from an economic perspective, the jobs are accessible. If you live in the North, the economics are vastly different.
I also sit on the Standing Senate Committee on Fisheries and Oceans. We just did a study of the northern fisheries of Nunavut and Nunavik. We heard from the people that they want to grow their communities. They want to live in their communities, and make them sustainable. One piece of that economic puzzle is access to licences to fish, access to infrastructure and so on. I am wondering how important is that in the scheme of things?
I know that your area of expertise is in the well-being and the mental health of your population, but somehow or another, I believe it is all interconnected. I am from Newfoundland. We went through two resettlement programs in my lifetime. It was difficult. Will we take a hard look at things and say, ``You cannot live there.'' Is that what we will do to people?
The North is harsh — trying to build infrastructure, trying to live in a sustainable community, trying to have a sense of well-being of who you are in your spirituality. I wonder at what point we will look at that piece. I would like your opinion on that.
Dr. Wieman: Senator Cook, I think you have covered pretty much all of Canada's history in that one question. What I got from your comments, in some ways, were two different types of questions that I will try to address. The first, as I interpret it, has to do with how we live together as people in this country. I am sure, because of the diversity of Aboriginal peoples, you would get 100 different answers if you had 100 Aboriginal people sitting around this table. I can only give you my own perspective.
Culture is part of our identity and our wellness. That is who we are as people. On a personal note, I was one of what is called the ``60s scoop'' kids. We talked about the residential schools experience; we have not talked too much about 60s scoop. The 60s scoop followed the residential schools experience, once those closed started to close. Many of the child protective agencies — Manitoba was probably the worst affected — in the 1960s started to take Aboriginal kids out of their homes and away from their communities in large numbers. That is the community where I am from, in Manitoba.
I was a Crown ward. I lived in about six different foster homes and I was adopted and raised by a non-native family. I spent many years, of course, going to school and getting my training as a physician. I can tell you that I did not feel that I was a whole person again until I returned to a community. I chose not to go back to my original community and practice because I felt I could make the most impact working at Six Nations, which is the largest reserve community in the country, and because there were so few psychiatrists. That was the basis for my reasoning. I can tell you that I did not feel that I was a complete person until I once again worked in what I call my community now.
As Dr. Kirmayer said, there is an interconnectedness; there is a sense of belonging that is hard to articulate but is nonetheless there. In my opinion, Aboriginal people do not want to go back and blame the past. They want to acknowledge what happened in the past. Even this morning, getting ready to come here, I was listening to CBC Radio and they were talking about the two founding nations of this country: the English and the French. I was thinking, ``Hmmm, we are the first peoples; we are the indigenous peoples of this country.''
Much of that history has been lost. Many young people in this country do not know about the original Aboriginal people in this country. That needs to be rectified. One way we can live together is by each acknowledging our own contributions and how we live together as people while we retain our sense of cultural identity.
I do not think people want to live in isolation. People in my community want to go out into urban settings and get training that is necessary; but a lot of people want to return to the communities and do the best that they can. Having the experience of working both at an academic institution like McMaster University, and also being based in an Aboriginal community — sort of being a bridge between those two worlds — is not an easy place to be. It is one of the biggest challenges in my career. Nonetheless, it is valuable.
Even my life experience has been a valuable thing that I can offer to people. My patients appreciate that I have also suffered. As Dr. Kirmayer said earlier, Aboriginal people respond — my clients respond to me because even though they may not know my life story, they recognize some sort of commonality.
The second question had to do with access to mental health services. I see this as one of the major issues that we tackle in delivering mental health services, and that you as a committee will likely have to tackle in terms of making recommendations or statements around mental health services for Aboriginal people.
There are many different reasons why access is difficult, from purely physical reasons of not being able to get to a certain place to non-physical or psychological reasons. We know, for example, that psychiatric patients or people experiencing emotional difficulties find it hard to be organized enough to get to appointments. In other words, there is a very high no-show rate for appointments. For example, in my clinic at any one time we have a 10 per cent to 33 per cent no-show rate. I will give you an example from the mainstream.
If you attend appointments at the office of a highly specialized psychiatrist in Hamilton and you miss one or two appointments, you simply will not be seen by that psychiatrist again. However, at our clinic, if an individual misses an appointment, we cannot exclude him or her from our services. We have to retain the person as a patient. I know many of my patients quite well, so sometimes I get in my car and find them because I have that hour booked to see them.
We have tried to access services in Hamilton that are more specialized, that we do not offer. Those might include treatment for anxiety disorders or cognitive behavioural treatment for depression. We do not have the resources in our clinic to do that.
I do not know what the factors are, but we have a very difficult time accessing these services. I would be reluctant to put a name on it, but I would suggest that people simply do not want to deal with our people sometimes. I am not sure why that is, but I have my suspicions.
The community where I work is divided right down the middle in terms of catchment areas. There is Haldimand- Norfolk region, Brantford region and Hamilton region. In some ways, you become a little paranoid in thinking that this is done on purpose, because no one knows where to go. If you show up in Brantford you may be told that you are not their problem but Hamilton's problem. If you go to Hamilton, they may say that you are Brantford's problem. I referred to that with the provincial-federal problem as well — in other words, no one wants to take responsibility in whole or in part and say, ``Yes, you are our problem.''
Senator Cook: In my province, Goose Bay is the closest area for the seven or eight communities along the Labrador Coast, and the services are limited. I do not need to speak to the crisis of Davis Inlet, because everyone is familiar with that story.
In the 1970s and 1980s, the United Church, in partnership with social services, ran a number of programs for the youth in Goose Bay. It did not go very well because we were getting the same young offenders. Life was different from the perspective of the 8- to 16-year-olds. The downside was that the parenting skills were lost in the communities. That did not work.
How do you deliver services? How do you maintain a people's culture and the economics of living in such far-flung worlds? You did not speak to the justice system, the sensitivity or the insensitivity. The only person seen in the communities is the RCMP. All of those pieces contribute to mental health and well-being of people who choose to live in more remote communities — which is their right. They have a right to live wherever they want to live.
Ms. Restoule: My thoughts go to something Dr. Kirmayer referred to earlier about a sense of empowerment and ability to plan one's future. It makes a big difference if communities have the ability to develop education and health care systems that meet the unique needs of the families, that create economic opportunities, that have culturally based child welfare services and that are sensitive to health services. That is why some of our communities do better than other communities. With strong leadership and strong ideas, they are able to enforce, plan and implement in the communities. That tends to make a difference, because suddenly people feel that there is sustainability, that they have responsibility and that they are empowered. Suddenly their well-being tends to improve because they can make plans and see growth and sharing. Community programs are interconnected. That makes a big difference.
I was speaking with some of the board members of the Native Mental Health Association of Canada to ask their opinions. The board member from Eastern Canada said this to me: ``If I could leave you with one thing, it is that, on the East Coast, suicide rates were quite high prior to the Oka crisis.'' They found that immediately following the crisis there was a significant decrease in suicide rates. It seems that suddenly there was a sense of hope among the youth in Eastern Canada, that Aboriginal people had a voice and could make a stand about what was important to them and that they would be recognized and heard. That struck me as interesting. I would not have thought that, but I think empowerment plays a very big part in our well-being.
Senator Cook: The people of Labrador became Canadians just over 50 years ago. There were no indigenous people, according to the terms of union. Dr. Wilfred Grenfell, an English medical missionary, serviced the coast. That is now done by teachers from Labrador, and by social workers and nurses. Would it help if their curricula included training with respect to the particular population?
The Acting Chairman: I would like to hear from Dr. Kirmayer on this issue.
Dr. Kirmayer: I would be pleased to respond. Some extremely important issues are being raised that go right to the heart of things. I am glad to have things situated historically. The processes of the last 200 years are ongoing. I want to show one slide, which I skipped over earlier, that acknowledges that we had in Canada, as in New Zealand and in Australia, an explicit policy of forced assimilation — that Indians, First Nations people, were less civilized and that it was a kindness to them to bring them up to speed and to force on them a kind of Euro-Canadian culture. Many policies, such as residential schools and other kinds of interventions, stem from that attitude. That attitude is not dead, unfortunately, although some things have changed. There seems to be a growing awareness of the intrinsic value of Aboriginal traditions and the right for people to maintain their traditions and the value of diversity.
There is a strong tendency to hold people to one model of how to live life that infiltrates all of our design of services. That speaks toward the educational goal. Unless the issue of cultural difference, diversity and tradition is made explicit and is grounded in models of mental health, rather than in models of community development for people, then well- intentioned people will attempt, inadvertently, to impose an ethnocentric model. Many nations are looking to Canada's experiments in allowing and fostering a kind of diversity and a kind of pluralism. Certainly, relations with Aboriginal people are a big part of that. In medical education and in the health professions, there is little training on issues of culture.
On this slide, I wish to draw senators' attention to one thing. Most of the points are quite explicit, but one line says ``essentializing identity.'' That is a particularly interesting notion because it speaks to the idea that we impose a cookie- cutter notion of identity on people.
We say, ``Okay, this is a First Nation individual, so he or she should be living like this.'' In fact, young people have available to them a tremendous diversity of opportunities. People in the most remote communities in Canada are connected to the Internet, satellite TV and mass media. They have an awareness of self and local worlds in relationship to larger global phenomenon.
Aboriginal identity is a moving target. People are developing it in individual ways. If they are given opportunities and resources, and if practices of exclusion do not continue, a range of communities and types of identity will flow forward.
In the past, and as recently as last year in an op-ed piece in the Globe and Mail, all the problems were blamed on people hanging on to the past, that they should assimilate into mainstream society and communities should dissolve. That thinking is no different than what existed in the late 1800s and what contributed directly to the magnitude of the mental health problems that the communities are experiencing now.
Senator Cook: The federal government is paying a terrible price economically for what you just referred to. The people of Davis Inlet were not asked what kind of housing they wanted. They were not asked how they would like to live in their new community of Sango Bay. Once again, people are paying the price; the government is paying the economic price, dollars that could be better used. That is my rant, thank you.
Senator Keon: I, too, do not know where to begin. I see two huge problems that perhaps could be addressed. One is the suicides, particularly in young males, and the other is the criminalization, particularly, of young males.
Both these phenomena are catastrophes. I should like to do whatever little bit I can through this committee and through the Senate to help you to focus on these two areas to see what can be done to correct them.
The suicide phenomenon is frequently associated with criminalization. I know of a recently publicized incident of a young male who looked like he had a very bright future. He was arrested for drunken driving, and suddenly he is a criminal. He has no future. He cannot leave the country. He cannot go to university. He cannot do anything. He shot himself.
If there were some way of decriminalizing these people, or at least lifting the burden of criminalization from them, they could attend university, work for the federal, provincial or local government, travel and be a normal person.
I do not know how we could help you, but I would like to see you focus on those two areas and see what we can do to help you. I should like to have your comments.
Dr. Kirmayer: I wish to speak to that just for a moment. Along with Dr. Wieman and many other people, I have been involved in some initiatives to look at the problem of suicide. This issue has been ongoing for years, and there have been many efforts.
I am concerned with putting exclusive focus on that, for a couple of reasons. I really see the problem of suicide as an index of broader problems that affect many more people. The exclusive focus on suicide does not lead one immediately to the roots of the problem.
Certainly, the fact that young males are more directly affected than other segments in the community says something important about the opportunities, the vision of the future and the sense of self that young males have in some Aboriginal communities. Arguably, there are ways in which males have experienced the rapidity of culture change and the impact of forced assimilation somewhat differently. They have been harder hit in a way. There has been more discontinuity in their roles and in their options as important members of the community. In many Aboriginal communities, men were very involved with subsistence activities and maintaining the economic welfare of the community.
As the communities have shifted toward being service-based with human resources and human relations jobs available, women have been more represented proportionately. Men may have fewer options in some communities. That may have a indirect impact on youth.
All that to say that I think that a broader focus is important. The suicide statistics are very alarming. It involves deaths that are deaths of the youngest people with the most potential for the future. It is just agonizing for everyone.
The danger of focusing on that exclusively is that we might miss the broader social issues, the fabric of the community and the sense of self-direction in the community. The point was made earlier that those communities that have a sense of local power and of making a difference probably have a lower rate of suicide because young people think they can make a difference. They can imagine growing up with a voice and an impact on government and the future.
That is one of the best antidotes to the personal and individual despair and suffering that drives people to suicide. Even if one takes the problem of suicide extremely seriously and puts it right at the centre, one is led naturally to being concerned about issues of community development and empowerment for young people rather than focusing on suicidality.
In regard to criminalization, your point is well taken about the need to deal with issues of racism within the system. Decisions are not always made in an unbiased and equitable way. We must also look at alternative forms of conflict resolution, of maintaining ties of connectedness and not creating the feeling of being cut-off, which is a catastrophe for everyone, not only for Aboriginal young people.
Dr. Wieman: You said that you did not know what to do. I can help you with that. I agree with Dr. Kirmayer that we cannot necessarily allow the primary focus to be on suicide.
I have provided honourable senators with background information on a project that was commissioned by the First Nations and Inuit Health Branch of Health Canada and the Assembly of First Nations. That report came out in October 2002. It was entitled ``Acting on What We Know: Preventing Youth Suicide in First Nations.'' We called the report that because we know about suicide, we know how often it occurs, we know who is doing it, but now we have to take action on it. The report was really a call for action.
In some of the background information that I provided to Senator Morin last fall, I included the executive summary from that report. There were some 30-odd recommendations that this group made. We worked over a period of two years to examine the problem from every angle possible. I can honestly say that the work of that group was extremely thoughtful.
Every recommendation in that report was achieved by consensus, which is important for you to know. Everyone felt strongly that each recommendation should be there. Many of the recommendations outline a role for the federal government.
The recommendations are centred around four major themes. First, we should increase what we know about suicide and what we know about suicide prevention. The second theme was about optimizing mental health services that are delivered for First Nations people. The third theme was how to go about fostering community development approaches, communities' own ideas of what would be helpful to them in terms of preventing suicide. The fourth theme was centred around fostering youth's identity, their sense of themselves and their culture.
That report was not meant to be the definitive statement on suicide. It was meant to be a living document that we could go to over time and see how many of these recommendations have been carried out. Some of them are in process. For example, Dr. Kirmayer mentioned the National Network on Aboriginal Mental Health Research. That would be one initiative that is funded through the Institute of Aboriginal People's Health, the Canadian Institutes of Health Research that brings together a group of people who are researchers with an interest in the area of Aboriginal mental health. Suicide is but one of the areas of interest.
My plea would be that you take look at the recommendations from that report, at least, and see if we can keep the momentum going in terms of addressing some of those things. A lot of work has gone into the different reports, and we would like to see things actually start happening rather than just doing report after report every decade or so.
The Acting Chairman: The clerk has that report and it will be circulated to members.
Senator Keon: Dr. Wieman, would you comment on what measures you have in place, and what measures you think you could put in place, for decriminalization of these young people who are in prison? It is not so much the fact they are in prison, or in and out of prison, but that it is the end of the road for them. It is so tragic for them. Is there any initiative?
Dr. Wieman: There is not a specific pan-Canadian initiative that I am aware of. My colleagues may know differently.
What you describe is the same type of problem that I often see in practising medicine, which is that we tend to only deal with the crises. We only tend to manage people on an emergency basis. We do not do any primary prevention, or early prevention programming, before these young people even become involved in the criminal system. I think that is perhaps what the other presenters have spoken to as well.
We need to look at families and communities, and families and communities in distress, and why young people act out in the way they do and why they exhibit behaviours the way they do. At some point, the only way we are going to achieve long-term improvement and benefits and, frankly, cost effectiveness in terms of monies that are spent on interventions is if we start looking at a primary prevention focus for things. My concern is that we will continue to throw money at something that is not all that effective or that does not have a long-lasting effect. On some level, we need to take a step back and, instead of looking at the symptom, look at the underlying actual problem and what it is related to.
Senator Keon: I was a heart surgeon in my other life, and I lived with the criticism throughout my career of blowing a lot of money on operating on people whose disease was preventable. I did everything I could to provide the very best resources and preventive programs in my institution; however, for the guy lying in front of me who had 12 hours to live but could get another 30 years by having a heart operation, the prevention program was not relevant. For the 19-year- old kid who has a criminal record, the prevention programs that you are going to institute are not relevant. That kid has had his life ruined. I think we cannot afford to wait for some of this stuff to catch up.
Dr. Wieman: To clarify, I was not suggesting that we move exclusively to primary prevention models. In the case of the 19-year-old you mentioned, I would not necessarily address his criminal behaviour exclusively; there must be underlying mental health reasons, among others, as to why he is behaving that way and making the choices he is making. That is what I was trying to address in my presentation. I deal with many people in my community who are involved with the legal system. It takes a lot of time to work with people and to get them to develop an insight into why they behave in certain ways.
That is partly the answer to your question. I am not simply suggesting that we have prevention models. However, the way that I deliver services in my community, I think, is actually very helpful for people, but it takes a long time for some people to bring about positive changes in their lives.
I have a hard time relating to some of my colleagues in the department of psychiatry, because I use about half of what I learned in my psychiatry residency. I am not saying that I am off the wall in terms of my treatment, but I have had to modify my approach and deliver services differently from how I was trained in some ways.
In terms of the 19 year old in your example, it would take intensive work to help that person and to support him in making changes in his life. I am saying that 27 counselling sessions is not the answer, nor is a six-week stint in a substance abuse treatment centre the answer. It might help, but it probably will not.
Senator Cordy: I should like to get back to the issue of human resources. When we spoke a couple of week ago, or last week, to people from New Zealand on a teleconference, they spoke about how they have encouraged more Aboriginal peoples, Maoris, to get involved in the health care services.
I look at ways to do that. Certainly, you cannot do it without funding and you cannot do it without scholarships for students who are going to go on to medical school or into psychology. However, I believe there is more than that. You cannot just have the pot of money over here that no one will access. You have to have encouragement and support and leadership from native leaders, role models such as yourselves. How do you go about doing it?
If we are going have culturally appropriate services, particularly for mental illness and mental health, but also in all areas of the health care system, it certainly is helpful if native people are providing the service. There is a shortage of medical personnel in all of Canada, but particularly so, I think, in the Aboriginal community. Could you give us some suggestions as to recommendations that we could make, aside from funding issues?
Ms. Restoule: I have some fairly strong thoughts on it. As an Aboriginal person, choosing to go into a mental health profession, one of the things that I encountered in graduate school — and this sort of relates to something Senator Cook said earlier — has to do with having education that is culturally sensitive.
What I encountered in graduate school is that there was little acknowledgement or recognition about the special needs of First Nations peoples. When we were being trained with respect to counselling services, or on issues around children and family and youth and forensics, there was little talk about the unique needs of First Nations people. One of the things I had to do on a daily basis was ask my professors does such and such applies to First Nations people. Unfortunately, I have to tell you that they often told me they did not know. They left it to me to get my own training with respect to First Nations people.
I think an education of the unique needs of First Nations people is important — so that we are acknowledged, as Dr. Wieman said earlier, as being one of the founding fathers of this country, that we have a unique history and a contribution. I think that is part of it.
Without that, Aboriginal people do not feel that their needs and abilities are acknowledged, and they do not want to be part of a profession where that is not recognized. There are, at my last count, 30 Aboriginal psychologists in all of Canada. That is an extremely low number. One of the reasons has to do with recruitment, I think, in terms of how to encourage Aboriginal people to come into these professions.
There are associations such as the Native Psychiatric Association or the Native Physicians Association. There was at one time the Native Psychology Association. I know I am getting back to funding — but there is no funding for these associations to be a voice in communities and to encourage our young people to get into these professions.
We need to support associations that have an Aboriginal component where there are role models, so that they can be in the communities and recognizable to the young people, so that they perceive that this is something worthwhile to do.
I also think it is important for our communities to support our young people to go into higher education, to even go on to university. Some of our young people are so connected to our communities, have such a sense of belonging, that when they leave their communities there is a sense of loss. That is quite difficult. There needs to be a strong base within the community and within the family to support these young people to go off and leave their communities.
In my experience, my community had less than 200 people, and I chose to go to the University of Western Ontario for my undergraduate training. When I drove through the gates of the university with my parents, I told them I thought I had made a mistake, because the university was larger than my own community. I was afraid to be there. Had it not been for the strong support of my family at that time, who called me on a very regular basis, who came to visit me, who brought me home, it would have been more difficult.
By the time I got to graduate school, within many universities native student associations had sprung up, which made a big difference. A native student was able to identify with other individuals who were in similar situations, who were far from their home, far from their families, and oftentimes removed from those traditions and cultures that made it significant for you.
Those are some of the important things to keep in mind, in terms of getting some of our young people into these professions.
The Acting Chairman: The New Zealand people told us that they put an emphasis on getting more people through high school. That is one issue. As we know, the numbers are not very good for Aboriginal people graduating from high school. Without that — health professionals are important, but you need more engineers and other professions too.
Ms. Restoule: That is a good point. If I look at my own community, our community is fortunate. We are an hour away from our high school, and I am pleased to say that at least 85 per cent of our young people actually complete high school. The students travel one hour each way, but they do it, so there is something within the community that supports at least education as far as high school.
My concern, and something I have talked about in my community, is what we are doing to support them once they have to leave the community on a more long-term basis — but your point is a good one.
Senator Cordy: Does each university have a native student association, and is it up to Aboriginal students who are attending universities to organize those associations? In a large university, that might work, but in smaller universities Aboriginal students may feel quite isolated. Is there a support system they could access over the Internet, or is family support what you would look at?
Dr. Wieman: Because I work in the Native Students Health Sciences Program at McMaster, I know a little about what you are asking. I think each institution ought to have its own program, but not every institution does. For example, there are 16 medical schools in Canada. Not all of the 16 medical schools have a native students program like the one at McMaster.
If you want to look at support for, in this case, medical students, the gold standard program exists at the University of Alberta in Edmonton, although I think the University of Manitoba would argue with me on that. They are the institutions that graduate the highest number of Aboriginal students — partly I think because they admit what I would say is a significant number, five to six individuals per year, into the program. As Ms. Restoule was saying, they can support each other at the same time, as well as get support from the program at the university and from family back home.
I imagine that is variable, depending on the institution. Some support programs are well funded, while other programs are not well funded at all. There is not much consistency across the country.
The only other point I would add to what Ms. Restoule said earlier is that, in terms of what Senator Morin said about encouraging completion of high school, it goes back earlier than that. At our community level, we need to encourage kids to stay in elementary school. I see kids dropping out at grade six in my community, with no hope for future gainful employment unless they re-enter school. Families need to be proud of their achievers. In our communities, we need to foster that sense of achievement and accomplishment. It is okay to be smart. It is okay to stay in school. It is okay to want to achieve something. It is okay to want to be a doctor. It is okay to study mathematics and the sciences. That is one area that First Nations need to work on.
One of the things that is talked about in the Vision 2000 strategy I brought you — which is just a recommended approach in Ontario as an example for you to learn by — is that even before we start talking about recruiting people into medical school, we need to ensure that they are prepared. That would include not only being academically prepared but also being emotionally prepared to make that step to spend significant amounts of time away from home.
Dr. Kirmayer: A program at the University College of Cape Breton under the direction of Cheryl Bartlett and others from Eskasoni Micmac Reserve is trying to bring elders together with people teaching in the biological sciences. The idea is to heal the split that exists between conventional scientific education and traditional identity, traditional values, the idea that youth can learn both. That needs to happen, so that there is not an either/or in people's minds in terms of what options are available to them. Potentially, you can see that reaching back into high schools, in the activities they are developing, to meet some of the pedagogical needs that are being raised.
Senator Cordy: Thank you for speaking about the University College of Cape Breton. It is in my hometown, where I grew up. When I was an elementary school teacher in Nova Scotia, we had access to people from the university to teach teachers how to be culturally sensitive. They have been very active in this area for a long time.
Some of your comments relating to it being okay to be smart remind me of some of the difficulties with young teenage girls, who, having reached the age of 13 or 14, decide it is not okay to be smart. It is a whole social type of thing you have to work through.
Once an individual graduates from medical school and is working on fee-for-service basis, seeing, say, six to nine patients a day, he or she is not going to become wealthy. It is great to be compassionate and caring for your people, but you also have to exist financially. We have heard this from people working in the area of mental health overall, but looking specifically in the area of the Aboriginal community we should be using another model, it seems. Should we be looking at another model?
Dr. Wieman: Yes, we should look at another model in capital letters, and I will speak to that briefly. I am paid for direct patient contacts only and payment varies according to the amount of time spent with a patient and the type of service delivered. For example, I can bill a different amount for a consultation as opposed to a follow-up appointment. I am probably the lowest-paid psychiatrist in Ontario.
However, this model does not work, in my experience, because services for which you are not remunerated include discussing a patient with the nurses that provide me with support and backup at the clinic, conveying effective information to the family doctor and providing feedback with that family doctor. We are trying to encourage this continuous model of care between primary care physicians, the family doctors and specialists. Reviewing cases with family doctors takes a great deal of time.
I spend much of my time communicating with the pharmacist in my community in an effort to limit the overuse or the over-prescription of medications. I also receive some information from the pharmacist about patients. If I wrote a prescription six months ago that has not yet been filled, then I know that patient is not taking his or her medication.
We are not paid for telephone calls that we make or for faxes that we send. It is my opinion that delivering effective mental health services involves case conferencing with the family doctor, the psychiatrist, the psychologist, the community health representative, the counsellor in the community and the substance abuse counsellor. We all work in different programs, and there is no time for us to spend communicating about a person under our care to formulate an effective management plan. When that happens in my community, it is on my own time; I am not paid for that service related to my patient.
As I mentioned before, we are paid for face-to-face contact; there is a high rate of no shows. I am unlike a psychiatrist in downtown Toronto that would send an invoice for at least $100 to a patient that missed an appointment. Most of my patients live on either general welfare assistance or on long-term disability payments. An invoice for $100 amounts to one quarter to one third of their monthly income. The OMA's Physician Code of Ethics contains guidelines on when it would be unreasonable to charge someone for not showing up. In all good conscience, I could not charge patients for prescription renewals over the phone or for filling out forms, especially from insurance companies.
At one time, insurance companies paid for forms being filled out. However, most forms now contain a line that states that any fee for completion of this report is the responsibility of the patient. I cannot charge my patients $80 to fill out a form for them. I do all that work for free on my own time.
That is a long-winded way to say that the fee-for-service model does not foster good mental health service in looking after a patient and does not foster a state of well-being or reward at providing work in the community. I think communities would have a hard time recruiting people to work if they did not offer an alternative approach to remuneration for services, such as being on salary.
The Acting Chairman: This is intensely provincial. Other provinces have solved that problem, as you are probably aware. In Quebec, the great majority of psychiatrists are no longer on fee for service; they have block funding or salary. I am not sure that we should pursue this. Rather, I think this should go to provincial officials. Many provinces have solved the problem; Ontario is the only province in which psychiatrists are on a fee for service system. Your efforts should be made provincially.
Senator Léger: Dr. Kirmayer, do we know how many Aboriginal specialists there are? Dr. Wieman, you said that you are the only one, or the first one. Dr. Restoule said that there are 30 Aboriginal psychologists. Do we have data? If 85 per cent of Aboriginal students are going to high school now, we are getting there. These results should be tracked.
Dr. Kirmayer: I do not know of any figures that project how many psychologists and psychiatrists will be of Aboriginal background. Maybe Dr. Wieman or Dr. Restoule are aware of such data.
Senator Léger: I did not mean projected figures, but rather figures for today.
Dr. Kirmayer: Today's numbers were quoted and are quite low. There are associations that try to track such figures. As Dr. Wieman said, there are three, soon to be four, Aboriginal psychiatrists. There is little training within conventional psychiatry for the non-Aboriginal psychiatrist to be attuned and competent to begin to address issues should they choose to work with people from Aboriginal or any other background.
Senator Léger: If they had that information, it would augment the efforts immensely. Dr. Wieman and Dr. Restoule, do you think that eventually you would develop your own schools? Is that inevitable? Dr. Kirmayer said that our way of thinking and educating is individual, while the Aboriginal way is holistic and interdependent to the land, the people, the environment and the community. We have to count on the Aboriginals to bring that to us. Perhaps the traditional schools, bit by bit, would hear this. Am I correct in my assumption? I think it will go high rapidly.
Dr. Kirmayer: That is a wonderfully optimistic view. Obviously, many people look at Aboriginal peoples and, despite their predicaments, have a romantic view of how they may hold the key to solving our larger ecological, social and economic problems. I am not certain if that is true, but Dr. Wieman's experiences in trying to raise consciousness within one particular school have brought home how difficult it is to achieve a change in consciousness. Within the area of research, there has been some progress with a separate institute for Aboriginal people's health, headed by Aboriginal scholars, and with an explicit focus on capacity building across the country. Programs expressly designed to build capacity for research within Aboriginal communities and to support Aboriginal students may hold the keys to a bit of a boom in the availability of researchers. Parallel developments have to happen in the area of care providers and people going into health services, in particular.
The Acting Chairman: I wish thank our witnesses for taking the time to attend before the committee today.
The committee adjourned.