Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 7 - Evidence
TORONTO, Thursday, February 17, 2005
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 9 a.m. to examine issues concerning mental health and mental illness.
Senator Michael Kirby (Chairman) in the chair.
[English]
The Chairman: Senators, we have with us this morning three panels of witnesses who will be discussing service delivery. We begin with a panel that deals with the issue of how you deliver services in a culturally sensitive manner, an issue that we addressed in our Issues and Options report.
Mr. Raymond Chung is the Executive Director of the Hong Fook Mental Health Association and Ms. Martha Ocampo, the Co-director of Across Boundaries, Ethnoracial Mental Health Group. We also have with us Mr. Raymond Cheng who is also very much in this kind of service delivery.
I would ask Mr. Raymond Chung to begin. We look forward to your presentation and then we will ask you a number of questions. Thanks you for coming this morning.
Mr. Raymond Chung, Executive Director, Hong Fook Mental Health Association: Good morning. I would thank the Senate Committee for inviting me as a panel member to provide comments and recommendations. To put my comments into perspective to begin with, allow me to ask you a few questions.
First, would you be surprised if I told you that Hong Fook Mental Health Association is only one of two ethnocultural-specific, community-based mental health programs funded by the Ontario Ministry of Health and Long- Term Care in Ontario?
Second, would you be surprised if I told you that Hong Fook Mental Health Association is currently receiving $1.96 million to work with the Cambodian, Chinese from Hong Kong, Mainland China, Taiwan, Korean and Vietnamese communities? For your quick reference, the population of these six communities currently residing in the GTA is about half a million.
Thirdly, would you be surprised if I told you that there is no family physician, no psychiatrist in the Cambodian community?
Fourth, would you be surprised if I told you that, two years ago, over 150 active mental health patients from the Korean community did not receive any follow-up care when the one and only Korean-speaking psychiatrist moved to B.C.?
To give you a little bit of background about Hong Fook, as early as in 1978, difficulties accessing the mental health services by ethnocultural clients were identified with two questions to be addressed: One, underutilization of hospital psychiatric services by the Asian communities; and, two, the prolonged stay in hospital when a non-English-speaking patient was admitted.
Hong Fook was officially funded in 1992 to provide a bridge between the communities and the hospital with the consultation liaison model. I would emphasize, ``consultation liaison model.'' Today, 23 years later, we are still looking for answers to these two questions.
The fact that Hong Fook is only one of two ethnocultural mental health organizations speaks volumes. Over half of the population in Toronto was born outside of Canada and speaks over 180 languages.
Hong Fook Mental Health Association is a member of the United Way and, as such, is funded to do community outreach health promotion work to six communities. Our health promotion strategies are based on community and capacity-building principles. I emphasize, community capacity building.
In the 23 years since Hong Fook was first funded, we have demonstrated that there are effective and efficient models to address the mental health and mental illness needs of the communities. Our current continuum of services covers a broad range of services and initiatives.
Hong Fook has shifted its approach of service delivery. Initially, our main mode of service was in the form of case management, that is what we were funded for, but we realize its limitation, as people are part of a larger system. Therefore, when looking at a more comprehensive, holistic health approach, it makes sense to provide a continuum of services which supports the consumer on his or her path to recovery as well as a consumer's family and their community.
I would draw to your attention the information pamphlets and written submission to the package for more detail. My verbal presentation will highlight some of the items that I would like you to note.
Allow me to comment on certain sections of your report, On Mental Health, Mental Illness and Addiction: Issues and Options for Canada, and provide you with some recommendations. In my written submission, I cover a few more areas, but I chose the following to be the more significant sections.
First, we welcome the report and we are in full support of the rationale of exploring issues and options relating to mental health, mental illness and addiction. I would emphasize that Hong Fook has no expertise in the area of addiction. This document is being discussed at a most opportune time since Ontario is undergoing a health care system transformation.
Chapter 1 deals with the delivery of services and supports: The Committee makes reference to a system with two key characteristics that is patient-centred and is focused on recovery in a culturally appropriate manner. It is also a seamless system in which services and supports are accessible, of high quality, and are well coordinated and integrated.
One must bear in mind and take into serious consideration that a crucial component of receiving services is accessibility. This is a major barrier for individuals and families who do not speak either of the official languages and require immediate attention. Otherwise, for example, here in Toronto, we negate over 55 per cent of the population who are from immigrant populations.
When we refer to a seamless system, one in which services and support are accessible, one need only look at our health care history. Services that are built around a medical model with the hospital being the hub will never effectively be patient-centered. It is in families and communities that we find our support networks.
When we talk about culturally appropriate delivery of services and supports, Chapter 1, item 1.2, it is important to recognize that cultural understanding and language competency are two of the many factors in the delivery of services. With over 55 per cent of Toronto's population born outside of Canada, attempts to develop services to meets all the demands of the various cultural and language groups is next to impossible.
Our recommendation is that there be emphasis on cultural competency for service providers so as to heighten their level of proficiency. This would include ongoing staff development strategies such as effective use of cultural consultation, which is an approach in the field that we use, to fine tune their practice skills and to heighten their self- awareness of how the culture in the homes of their patients would affect treatment.
As a recommendation, we would say that another achievable strategy would be funding for mobile culture and language interpretive teams. Such teams would consist of trained mental health interpreters who would be available on an on-call basis. This was one of the recommendations made by the Toronto Peel Mental Health Implementation Task Force in 2002.
We would also recommend that there be established a federal policy with mandatory guidelines on the funding, training and services delivery model of trained mental health interpreters to be made available to anyone who requires such assistance.
On item 1.4, ``Early Detection and Intervention,'' I would say that this should cover a broader spectrum which includes health promotion strategies. According to the WHO, the World Health Organization, social determinants of health, migration and mental health are major factors in living a healthy lifestyle.
As a recommendation, we would encourage a federal policy that provides a perspective of mental health which is holistic. The current interpretation of mental health is too closely attached to illness and, as such, is a deterrent to early identification. We believe that being well informed is a first step towards the reduction of stigmatization and discrimination.
We would also recommend some form of stable funding for community-based programs to support patients with culturally-appropriate services, and to provide a continuum of services with an emphasis on holistic health promotion as an early detection and intervention strategy. Unless there is such a provision, we will continually face the underutilization of services by newcomers which, in the long run, is costly to the health care system. It is only through ethnocultural, language-specific mental health prevention and promotion strategies that we can achieve the goal of early identification and early intervention. In turn, you will help to reduce the financial and human costs in our society and, in the long run, for treating more serious mental illnesses.
Findings of the Mental Health Supplement to the Ontario Health Survey indicate that, in this society, one person in five has mental health problems. With no mental health prevention and promotion through education and early intervention, the social cost will be tremendous.
A growing body of literature indicates that, as the duration of untreated psychoses increase, the duration of hospital stays increase, remissions are fewer and take longer to achieve, responsiveness to early psychotic medications is reduced, individuals' insight and social supports begin to fade, and individuals' life trajectories are severely altered.
In talking about enhancing access, item 1.2, we must be cognizant of the fact that people do not even begin to utilize mental health services if they or those closest to them do not recognize the early signs of mental illness.
If we truly are invested in the guarantee of a patient's rights to service, we would recommend that health promotion strategies be funded to help newcomer communities, particularly those who do not speak either of the official languages. The promotion of mental health and the prevention of mental illness for these individuals and their family members are important to ensure patients' rights to service. As a result of educating the newcomer communities, those affected and their family members will be more able to detect and intervene in the early stages of the illness. More importantly, family members will be one of the major partners to the continuous care of the patients.
We would recommend that federal policy include guidelines on funding for health promotion and services to family members.
Chapter 2 deals with specific population groups. My only comment regarding this will be posed as a question. Given that immigrant groups account for over 55 per cent of Toronto's population, should newcomers without the official languages competency be listed as a specific population?
Chapter 4, section 4.1, is entitled ``Combating Stigma and Discrimination.'' We strongly support the report's statement that to reduce the stigmatization of and discrimination against individuals who have mental illness requires a sustained effort with stable funding, and we are in agreement that government and media public awareness campaign strategies, combined with local education, information workshops, and other health promotion strategies are tactics that have proven to be effective means to deal with these issues.
Our recommendation in that regard is that now it is time to provide stable funding to combat the prevailing and damaging stigma and discrimination surrounding mental illness.
The Chairman: May I ask you not to deal with each item because of time constraints?
Mr. Chung: I have only one more page. As I said, this is a summary. Our written submission is much longer.
Hong Fook is one of the very few community-based, multicultural, multilingual organizations in Ontario devoting resources to promote mental well-being. Our philosophy in working with newcomer communities is to increase their resources through empowerment and community capacity building.
To work with the communities to stay as mentally healthy as possible, we provide programs to promote community awareness and understanding of mental health and mental illness; community involvement and participation in mental health issues; community understanding and acceptance of people with mental illness. Programs include workshops and seminars, health fairs, conferences, mass media promotions, community advisory committees, volunteer training and opportunities to volunteer for patients, groups to explore strategies to maintain mental well-being, and integrated social and recreational activities.
With regard to Chapter 5, section 5.4, ``Supporting Caregivers,'' we would make the following comment: We acknowledge that family members do require support. We also recognize that, with encouragement and assistance, family members are typically the best support to patients. As a result, their involvement would reduce the demand for services from the service providers.
We would recommend that guidelines be set to include support services for family members as part of the continuum of services.
Lastly, I will deal with Chapter 7, ``The Role of the Federal Government.'' We would recommend that, as the nation's policy-maker, the most important role for the federal government is to set the direction in transforming the health care system by heightening the profile of mental health, mental illness and addiction within the system.
The federal government can take on the leadership role in strengthening the health promotion strategies by setting funding guidelines. Prevention is better than treatment, and early intervention would reduce long-term treatment resources.
The federal government can set policy guidelines to ensure equitable access to mental health programs and services for individuals who do not speak either of the official languages. Legislation for rights to cultural/language interpreters for mental health services could be considered.
Ms. Martha Ocampo, Co-director, Across Boundaries, Ethnoracial Mental Health Centre: I have a written presentation as well as the thin, orange-coloured report, ``Across Boundaries,'' which outlines our holistic model of care. The last page of my submission deals with the definitions of racialized and racialization. I will be using those words a lot.
In previous reports or studies, just to name a few, ``After the Door Has Been Opened,'' in 1988; ``Improving Mental Health Supports for Diverse Ethno/Racial Communities in Metro Toronto,'' 1992; ``The Healing Journey,'' 2001; and ``Integration Opportunity: Access to Integrated Health Care for Racialized and Marginalized Communitie,'' January 2005, racism is identified as a common and unique experience faced by racialized and marginalised communities. You will note that these studies date back from the 1980s to the present and, yet, the mental health system has paid little attention to this issue. Racism in all its forms and at all levels has a direct impact on the health and mental health of the population and affects about 43 per cent of the Canadian population.
Based on the report ``Improving Mental Health Supports For Diverse Ethno/Racial Communities in Toronto,'' which identified that racism is the main barrier to accessing appropriate services, the Ontario Ministry of Health provided a small amount of funding for a centre to be developed. In 1995, Across Boundaries opened its doors as a mental health centre located in the west end of Toronto to provide a range of supports and services to people from racialized communities who are experiencing severe mental health problems and/or serious mental illness. The centre was established to provide appropriate services to address the needs of the targeted communities by developing a holistic model of mental health care within an anti-racism framework. In Ontario, no other mental health agencies and programs provide mental health and addiction services that operate within an anti-racism/anti-oppression framework.
The report ``Ethno-Racial Inequality in the City of Toronto: An Analysis of the 1996 Census,'' by Michael Ornstein, released in May 2000, and largely ignored by city officials, shows how Toronto's racialized majority faces disproportionately high unemployment and poverty rates. According to the report, while 14 per cent of European families live below the low income cut-off, the percentage is much higher for non-Europeans: 35 per cent South Asians, 45 per cent for Africans, Blacks and people of Caribbean descent, and 45 per cent for Arabs and West Asians. Despite their educational qualifications, unemployment rates for Africans, Blacks and South Asians have skyrocketed. Among Ghanaians, for example, there is 45 per cent unemployment rate. Ornstein has concluded, ``These inequalities are almost all tied to race.''
Racism has created an environment within which quality health care is a commodity that has become socially, economically and politically unattainable by particular members of our society and a right for others. One factor that has been at the forefront of this impact is the current inadequacy of the system to provide mental health care and addiction services that are culturally appropriate, anti-racist and inclusive of all members of Canadian society, regardless of race, gender, socio-economic situations, immigration status, religion and sexual orientation.
The reality of the health care system in which racialized communities seek care in Canada is one in which a significant portion of the members are faced with barriers, hindering their accessibility to mental health services. Many of these communities do not conform to the North American systems of health care delivery that is primarily based on a biomedical, mono-cultural and Eurocentric model. Due to this fact, racialized communities are utilizing health care services less and receiving critical diagnoses and treatment significantly later than other populations. Often, the people we serve at Across Boundaries are those who are experiencing severe mental health problems.
Consumer-survivors and their families would identify racism as a constant problem they have to deal with, whether they are going for treatment, looking for appropriate housing, or simply looking for a safe place to stay when they feel depressed or isolated.
From time to time, we hear from the media, which reports are confirmed in various studies, about how racism is being explicitly linked to the high suicide rate among First Nations. Since September 11, our centre had to deal with the impact of racial profiling which caused severe mental health problems to members of particular communities, specifically the Muslim communities.
In the context of violence and abuse, racism is a form of systemic and overt violence towards communities of colour, which can cause severe depression, despondency, stress and anxiety, paranoia, social isolation, suicidal ideation, drug and alcohol addiction, problem gambling and many physical problems. These problems need to be looked at holistically with an anti-racist approach; otherwise, the cycle continues.
In the context of shrinking resources in the mental health system, racism is an economic issue. For example, the emphasis on the biomedical Western approach to treatment and its reliance on the pharmaceutical industry has taken our health system to a state of crisis. It could also be that the very people who deliver mental health and addiction services have been trained to believe that the Western medical approach is the best and only way to provide care and see other approaches as inferior or just an add-on.
In Ontario, OHIP will only cover medical services, not alternative therapies such as traditional Chinese medicine, Ayurveda, homeopathy, and so forth. It is ironic that most ethnoracial communities continue to practice the use of old remedies for both prevention and treatment of mental health problems, but such practices continue to be ignored by the system despite its professed value of the individual's right to choice of care.
The issue here is discrimination through racism. Thus, racism is the constant enduring fact we have to consider all the time when talking about the appropriate health care of the individual in the ever-changing demographics in Canada and its cultural and racial diversity.
The mental health of members from racialized communities cannot be understood in isolation from the social conditions of their lives. These conditions are characterized by social inequities which influence the type of mental health problems people from these communities develop and impact on how these problems are understood and treated by health professionals and the mental health system. For example, the mental health needs of new immigrants and refugees will have to take into account their experiences of trauma and how this impacts their health. The mental health system recognizes the need to address post-traumatic syndrome, but fails to recognize that, until racism is addressed, which is the trauma refugees and new immigrants experience on a daily basis, such an approach will be ineffective.
What should future directions be in the field of mental health, given the multicultural nature of our Canadian society?
First, there has to be a shift in the mental health policy framework from a biomedical to an understanding that mental health is, in part, socially determined and, therefore, a more integrative model of care which addresses the body, mind and soul needs to be developed.
Second, a mental health anti-racism strategy at all levels of government has to be in place which will address systemic and structural changes including governance, policies, training, education, community-based research, and service delivery. The strategy must be guided by an anti-racism, anti-oppression and cultural competence analysis and principles.
In 1995, the Ontario Government had developed ``Strengthening Voices: Ministry of Health Anti-Racism Strategy,'' which, unfortunately, ended up in a shelf collecting dust. Ethnoracial communities were consulted in the development of this document. Perhaps if there had been an implementation strategy, the policy might have moved forward.
Third, there should be inclusion of non-dominant groups in the decision-making process and in the development of policies. They must be provided the opportunity to participate fully and be given equal access to resources and the necessary supports to enable them to contribute their knowledge and skills in the whole continuum of mental health care.
Fourth, we must ensure that all community consultations, needs assessments, research studies, evaluations and other planning initiatives are conducted in accessible ways, including data, information gathering in multiple languages and diverse formats and locations to increase participation.
Fifth, we should require all funded organizations to integrate planning and program delivery for racialized communities in direct and identifiable ways such as having clear benchmarks on what needs to be achieved in order to be funded.
Sixth, we must recognize, create and implement community-specific mental health and addiction services that are responsive to the needs of different racialized and immigrant communities.
Mr. Raymond Cheng, as an individual: Good morning. It is a privilege to address you today. I am speaking to you as an ethnoracial individual who identifies with other fellow consumer/survivors and I am grateful for their earlier heartfelt words shared over the last two days with you.
I should explain that I work, advocate, volunteer, socialize and have even performed stand-up comedy on behalf of the mental health system. I should also mention I have a physical disability, significant hearing loss, that requires wearing two hearing aids.
You may want to know about how I got to where I am now as a result of the mental health system.
I want to share three points with you. First, how I ended up using the mental health system; why, what I feel works in a recovery-oriented mental health system currently; and what needs to happen in the future for more ethnoracial as well as mainstream consumers to succeed.
In using the mental health system, from an ethnoracial viewpoint, consumer/survivors, as we call ourselves, do not talk about having a crisis, necessarily. We talk about going through hard times, and for me, I define that as when you do not have the answers to what life is delivering to you and you feel that no one really understands your point of view. When even your friends and family cannot help you out, it is natural to seek professional intervention.
From an ethnoracial perspective, this is what has happened to me.
The best outcome of care has to be from staff who are genuinely interested in listening, communicating and showing empathy. This is especially important, not only to the client, but to the family members who want to understand what is going on.
Language and cultural barriers can lead to misinterpretation, a mutual lack of understanding, and possibly misdiagnosis. This is especially critical at the point of admission to a hospital.
Medications that have been tested and guidelines set up for one target population may work differently for another group. One widespread medication that has been used for many years, and I have used it, caused me severe side effects. Only recently has research established that the working dosage on people of Asian decent is considerably lower than that for the mainstream population.
Outside in the community, as my co-panelists have shared with you, there is a real lack of culturally-competent service providers to help those in need continue to get better.
I will now deal with Innovative approaches and recovery currently available in the mental health system — in other words, what I see are things that work well now. As someone who has been able to assess a wide range of community- based supports and services, I would emphasize the importance of peer support. What is peer support? Peer support is when a group of individuals who have experienced the mental health system come together regularly in a safe and comfortable environment to share each other's stories, be empathetic, and take the time to understand people.
This is very much like preventative maintenance, for after all, social isolation is the leading factor in why people return to hospital. The community-based agencies that have worked best for me emphasized the importance of peer support, and here in Ontario, we have more than 50 of these organizations run by consumers for consumers providing this very necessary, distinctive and unique form of self-help.
I am currently working for a provincial support team called the Ontario Peer Development Initiative and I personally believe that we should have many more of these types of agencies.
Furthermore, peer support works across all boundaries, and groups can find common ground by respecting their own cultures and their language of preference.
The other factor I would stress about recovery is this: Mental health is integrated with one's physical, social, spiritual and economic well-being. Hope for a future is truly realized if there are genuine expectations that inequities within society will be addressed. My friends on Tuesday and Wednesday have already eloquently spoken about what it feels like to have a job, a place to call your own, and a social network of friends. I hope you heed our collective call that individual recovery from mental health is impossible when struggling with the consequences of poverty alongside stigma and discrimination.
I will now speak to future recommendations and action steps, and I have only two.
Most of my fellow ethnoracial consumer/survivors want to work. They may not all be able to work full-time, but they want a chance to work part-time. This can be hard to do within their communities. A report that I co-wrote in 1993 for Hong Fook Mental Health Association confirmed that employers then were hesitant to give consumers a chance. A job means a lot to them. A national employment strategy that includes those with mental health issues is needed.
Should there be a funding envelope for employment supports in a mental health system? Yes, I believe so. The payoff is that, ultimately, those who work will use less health care and will pay more taxes. What is there for any politician not to like?
The range of supports that currently exist for those who are deemed unable to work includes a monthly pension with subsidized medications, subsidized housing for the fortunate, and a support network of health professionals and programs for free.
I would suggest that many individuals are trapped and left unmotivated to plan and execute an exit strategy from this cycle of learned helplessness. The spirit of recovery cannot emerge from the ambiguous expectations of people simply cycling through a set of periodically visited mental health services and supports. With ethnoracial populations, they are further marginalized if they are not fortunate to find a program that can meet their express needs and offer a better path.
Why should the life choices for those who want to get well and achieve full citizenship be constricted by systemic assumptions built into programs that have lasted too many generations without an objective review?
In conclusion, consumer/survivors and their family members are entitled to fully realize lives with achievable ambitions set within a caring and just society. I am old enough to remember who said that.
I would commend the committee for listening to me, and I look forward to your recommendations. Thank you.
The Chairman: I would thank all three of our presenters. Mr. Cheng, could you provide us with a copy of your brief?
Mr. Cheng: Yes, I have copies.
The Chairman: I have one broad question of the panel. It strikes me that here we are in a city where 55 per cent of the population are not native-born Canadians and, in fact, speak other languages, and yet both Raymonds told me when I was talking to them earlier, that there are only two ethnoracial organizations and those two are represented by you both being here, so we have a complete sample.
There is, obviously, a systemic problem. What needs to change at the governmental level to, in fact, substantially increase the number of centres, services and community-based organizations which would be capable of dealing in other languages and other cultures? There are only two such organizations, and there has only been the odd pilot project and nothing has fundamentally changed. You quote reports going back a decade. What do you see as the root cause of the problem and what can we do to change it?
Martha, would you care to comment?
Ms. Ocampo: I think the systemic problem is funding, at whatever level.
This is not to promote Across Boundaries, because our goal, just like Hong Fook, is to disappear at a certain point. All health agencies, mental health agencies, addiction agencies have to find a way to serve the people around them, the people who are coming to their centres. What is happening now is that all the mainstream agencies get a chunk of funds, and yet, a token kind of service is provided to this population. It makes no sense, because 53 per cent of the population is from these communities, and there is nothing in place to ensure that these agencies are serving the population.
Many years ago in Ontario, agencies were asked to send in proposals respecting an anti-racism, cultural competence strategy. The highly resourced agencies were best able to do that. Therefore, the big agencies or mainstream agencies got most of the money. Struggling agencies such as ours continue to struggle. However, when they are delivering the services, it is not somehow trickling down to the population that they are serving.
I think there has to be systemic change. They have to be accountable to the population that they are serving. That is not there.
Mr. Chung: I want to make two comments. One is that funders should make the service providers accountable. When they claim that will use the funding to serve a certain population, can they prove that they are capable of doing that? Currently, many mainstream agencies, service providers are claiming that they can serve the Chinese, for example, because a member of their staff has the Chinese language, but if you look into it, the Chinese language- speaking person might be an administrative assistant and may not be a front-line worker.
My second comment relates to the approach, as Martha mentioned, to the Western concept of treatment. How comfortable would new Canadians, new immigrants feel walking into a certain office? Would they feel welcomed?
As the U.S. Surgeon General's report indicated training interpreters is key. A couple of states have legislation under which service providers must guarantee that they have trained interpreters to communicate with patients who walk into their clinics or centres.
As I mentioned earlier, I think it is unrealistic to think that more organizations such as Hong Fook or Across Boundaries will be set up. Hong Fook set up 23 years ago and Across Boundaries set up 10 years ago to bridge a gap. We know that, culturally, we have the knowledge and the expertise. We also know what treatment models, health promotion and other strategies work, because we have the knowledge and the expertise, but nobody is consulting us.
The Chairman: You say that the majority of the money is going to the well-off organizations. Does that mean that the vast majority of the money for mental health at the community level is, in fact, being used to serve people who largely speak English simply because those organizations are not capable of providing services in other languages?
Ms. Ocampo: I think that they might be serving these communities, but they are inappropriate. Many of our clients might have gone to these other agencies, but they have not felt any better because either they were being served inappropriately, or there was no real service. They are turned away because no one speaks the language. They are turned away because of certain interpretations of the medical profession which indicate that a person does not need that kind of care. They are given some medication and turned away because the person who is there to help them does not know where the consumer is coming from.
When we see them, they have already gone round the revolving door many times. They keep going back to doctors for medication. They have been given medication of all sorts, but yet they do not feel better. When they speak to someone who understands their language and their culture, a lot of time and money can be saved, as well as a lot of the pain that these people have gone through.
The medical approach tends look primarily at treatment. It may not recognize that perhaps the most important thing for a person is housing, perhaps education or perhaps employment. There is no holistic approach. If a person cannot sleep, you give him a sleeping pill.
That is key in terms of the determinants of health. It is important to recognize how these things play out in mental health and addiction.
Mr. Chung: As my friend Raymond mentioned, the social space is important. With the medical model, you come in as a sick person who is treated and then you leave. The more culturally appropriate approach relates to the social space. A person should feel comfortable walking in and not necessarily seeing a doctor or social worker, but being able to see other patients so that they can break their isolation and can have peer support. That is all important. That is what my friend Raymond has been emphasizing.
Mr. Cheng: I would like to follow up with what Martha is saying about appropriate services. It is important to realize the people who do not communicate well. Some find it hard to express themselves. They have a language barrier, and, of course, service delivery in the mental health system is based on symptoms. If someone is unable to communicate well, or appears not to be co-operative, you know, is speaking in a way that people cannot understand, you tend to attach a diagnosis, and when that happens medication follows. At this point, you may not fully comprehend the situation of that individual. Once you start down the road of medicating and the person is unresponsive, you add medication, you add more intensive treatment, and you reach a stage where the person can never come back to a stage of clarity where he or she can say, ``This was what I wanted to talk to you about.'' Even consumer/survivors who speak English as their first language, when they are in crisis, find it hard enough to communicate, but if you are in crisis and English is not your first language, then that is really bad.
In my personal experience, English is my first language, but people look at me and make certain assumptions, and that is even worse. When you are 23 years old and you have this uppity tone of voice that I am using before you esteemed gentlemen, and then you are talking to a psychiatric resident who thinks he is the smartest guy on earth, you are bound to have a personality conflict.
I am lucky. I scraped my way out. I speak on behalf of a whole bunch of folks who have not been as fortunate. I consider myself very lucky to be able to make that plea on behalf of many people I know who have not been able to make it the whole way back.
Senator Trenholme Counsell: I want to thank our wonderful presenters this morning.
I have been listening and thinking that I have heard the same stories and requests in my province of New Brunswick where we have so few immigrants. I wish we had many more. If you can encourage some people to move to New Brunswick, please do.
I believe that throughout this there is a common thread, and that is the need for interpretation. However, perhaps interpretation is too narrow a concept. It seems to me that a broader concept is community support provided by someone like Raymond Cheng who can speak anybody's language it seems to me. We need someone within the community to be there for X number of families during the stage when people are beginning to deal with their illness.
Largely, it is a first generation problem, is it not? Once the children of new immigrants have gone through school, they can communicate in at least one of the official languages. It is those people who have just arrived in Canada who need the support.
The same problems would arise at a mental health clinic, at a prenatal clinic, at a doctor's office, at a housing agency or even at an office where you would go to fill our application forms for a pension, and so on and so forth. The need to communicate arises everywhere, albeit there are very specific issues to be dealt with when it comes to mental health and addiction. As a multicultural society, are all of us doing enough to ensure that, in those initial years, there is community support? I mean support in one of the many dozens of language and cultural groups who live in a city like this. We do have a scattering in the less densely populated provinces. Are we doing enough?
Mr. Chung: Communication is only one aspect of it. Let me give you a couple of examples.
In the Korean community, what we call the 1.5 Generation, meaning those who were born outside of Canada, but grew up here, they can speak fluent Korean, but they would prefer to come and make connections with Hong Fook because we recognize their cultural identity. Other service organizations cannot provide that.
Recently, a group of 1.5 Cambodian young people approached me and said ``We know that our parents are stressed. We cannot communicate with our parents in our own language because we speak English and they speak Cambodian.'' In response to that they rolled out the screen and produced their own DVD as a way of expressing the stress they feel as a 1.5 Generation, especially if one of their parents is suffering from mental illness. The DVD will be launched this Sunday in the Cambodian community. That was done strictly by the 1.5 Generation. They wanted to do it. The DVD is produced in mixed language, Cambodian and English.
They are fluent in English, but not in Cambodian. They recognize the importance of communication, and in language and in the cultural environment, that is key. Language is only one of many factors. The cultural comfort level is what we are talking about.
Ms. Ocampo: I want to emphasize community connectedness. We have a lot of referrals from particular communities because we make sure that we have service providers who are well connected in the communities. Probably 60 to 70 per cent of our referrals come from the communities, not from hospitals or from other health agencies.
Many new immigrants in Canada are health professionals. They are driving taxis and doing all kinds of domestic work because of our current system. When we hire people, we make sure that they have solid experience in mental health from their home country.
That puts us in a difficult position because, as a rule, the recognized qualifications would more likely be a college diploma or a university degree from a Canadian institution. That is a big gap. There are very skilled people from the communities who are not being well utilized.
Connection is an important aspect of mental health. A mainstream agency will tell you that connectedness is a hallmark of recovery — that consumers are connected with somebody and more so if they are connected with the natural supports that they would have, which would be their community.
Mr. Cheng: The traditional model that services are provided and received on a nine-to-five basis is a model that does not quite ring true now in the 21st century.
First, people want to be able to give support as well as to receive services. Ideally, as their health status improves, they would like to receive fewer services and less support as they become more independent.
The other issue deals with how you deliver health services where, at the same time, you have expectations of recovery. Can someone work nine to five or ten to six and say, ``Excuse me, I have to visit some place. I ca not tell you where, but I have got to go every week between 2 and 4 o'clock.'' How can someone realistically work in those circumstances?
There must be flexibility in service delivery. The term ``services'' may not be appropriate. We are using that word to very politely cover up, frankly, a lot of inequities in the traditional system. The needs of the clients, the patients, the consumers, the consumer/survivors are changing because we have different expectations. We expect to get better, we expect to be well, and yet, at the same time, we find that the services and supports that are being offered to us are still in a timeline that is reflective of the industrial age, and we think that is inappropriate.
Senator Keon: I would congratulate all three of you on a truly precise and intelligent presentation.
I am just trying to appreciate your predicament. As I see and appreciate it, and please correct me if I am wrong, the Asian community of Toronto is within one of Canada's 20 largest cities. That community itself could constitute one of our largest cities in Canada. The difficulty you confront is the tremendous number of languages and dialects that you have to deal with. As you pointed out, you must also deal with the tremendous problem of the 1.5 phenomenon, which I have never heard of before.
The resources that you need seem to be available, although maybe not all of them inside Canada. There must be a way of bringing in the occasional person that you need to fit in the system and get the job done. The problem is compounded by the non-reconciliation of traditional or holistic medicine and Western scientific medicine.
The good news is that you have a huge number of students at the University of Toronto, and they are among the brightest and the best students at that university. Is there some way of tapping this enormous resource and get these people into the kind of system that you want?
In defence of this young arrogant psychiatrist that Raymond talked about, I would say that it is tough to get into medical school in Canada. The medical students whom I have taught think they are all geniuses. That is a problem in itself. Perhaps we should be using criteria other than I.Q. to select these students.
Is there some way that you can tap the educational system now? You have tremendously clever young people in the system, and perhaps they could be educated in such a way as to fit into the kind of community service work that you need, with the broad dimensions that you envision. That could be very helpful. The problem is that they might qualify as doctors, lawyers, social workers and physiotherapists, but in the traditional mould of those professions. However, your organizations could interface with the deans and the other educators at the university and tell them that you need people with somewhat different qualifications. Perhaps you could work with those people to achieve that goal.
Mr. Chung: You touch upon a key point of training professionals. The assumption is probably that a lot of Asian students can get into medical school. There is also the question of whether the X Generation or whether 1.5 or second generation, can speak their mother tongue when they graduate.
I would go back to the example of the Korean community. Recently we were able to get an intern who is doing psychiatry, but he does not speak a word of Korean. Thanks to his good heart, he is going back to U of T to learn the Korean language. He is the one and only so-called ``Korean decent'' psychiatrist. Within the profession of psychiatry, not many are willing to work in community psychiatry. They would prefer to work in hospitals and do research.
There are different systematic issues. Recruitment is an issue I touched on in my submission. Not too many non- white students are being registered, being recruited, for social work in the U. of T. That applies to recruitment strategies all across the board. What kind of criteria do they use to recruit students? Do they actively go out there and recruit students on the basis of language and culture? My daughter grew up here. She does not often speak her Chinese language. However, culturally, different families will continue to promote that because we have to combine culture and language.
Allow me also to respond to what Raymond said about employment. There are two aspects. There is the systematic kind of barrier. Many people want to be involved, but the percentage of consumers and survivors who can go back to gainful full-time employment is not high. Somehow the system expects them, in order that they can claim to be recovered, to be employed. Of course, the Ontario Disability Support Program, ODSP, does not encourage that. They were punished, and many of them do not want to work because if they make over a certain amount, then ODSP will cut them off. There are ups and downs.
Employers do not understand that, say, Raymond Chung can work for three weeks and on the fourth week would have to take two days off because my mental health would drift down a little bit. Full-time employment is not a common, but supportive employment is possible. Part-time employment is possible, but the system does not encourage. Yet, the system expects patients, on their recovery, to work. If they do not, then they have not recovered. We are sending a double message.
Ms. Ocampo: We have placement students from all the universities and colleges. That is our contribution. We show our model to these future service providers. However, it is very difficult for us to have one session with the Department of Psychiatry at the U of T. It is very difficult for us to go to any university and talk about how we implement this holistic and anti-racism framework that we operate.
They put up all kinds of barriers. They point to their existing curriculum. When we are able to have discussions with universities and colleges, it puts a great strain on us because we do not have many resources. We want to tell people what we do that is effective in our communities, but we do not have the resources.
My attendance here today takes away a resource from my office. We are a struggling agency. It is important for us to do this if we want to demonstrate our model which is effective. If we had lots of people who could devote their time to training, that would be wonderful.
Mr. Cheng: If there is any kind of an innovative approach, it will take a long time to come to the surface.
For example, the idea of services, supports, run by consumers for consumers has only been around for 13 years here in Ontario, and we are at the same level of funding we were at in 1997, 1998. We have conducted empirical studies. We have CMHC studies which are funded by the Ontario Ministry of Health. They show that consumer/survivor initiatives work, they are effective, and we know that this model works hand in hand with the kind of peer support that is ongoing within ethnoracial organizations, yet we cannot seem to squeeze the bucks out from the powers that be. We want to say, ``You know it works. Why are you still funding Groundhog Day?''
It makes no sense to me that you have a health care system and a mental health sector that is not driven by what people want, but rather, what people seem to feel you deserve.
At the end of the day, I think that is the story of ethnoracial services. It is not what you want. It is what your people feel you deserve, and we are speaking to an audience that has, by and large, as large a hearing loss as I do.
Senator Callbeck: I certainly can identify with you. I have been involved with the Vietnamese family that immigrated to my province of Prince Edward Island, so a lot of what you said I have experienced through them.
Martha, in your recommendations, you refer to wanting to be more involved in the decision-making process and policy planning. You mention a strategy that the Ontario Government did in 1995, which got shelved, so, obviously, you do not know what recommendations were in that strategy.
Ms. Ocampo: I actually have a copy here. I can leave this with you. I believe that there was no implementation strategy. You must remember that, when we are talking about mental health and addiction services, it is a highly political subject. It depends on how the current government views that issue. I think this strategy was developed during the term of the NDP government, which was followed by the Harris government which had a totally different direction.
I want to share, though, the importance of what is said when communities are asked to participate. You might use the same words I use, but it is very important for me to own what I say, that it is not said by others. I think that is part of empowerment. People really feel that, ``This is what I said and this is important to me.''
When people are given an opportunity to participate, you must remember that new immigrants or refugees are trying to settle and will need certain accommodations in order for them to participate fully. If the issue is child care or transportation expenses, there are many things that you have to consider. I think of our position in society. If certain things are not available, the communities will not participate. For example, where would you the consultation? Would it be in a place where they would be comfortable?
For example, today, I have to be very honest and tell you that I feel very intimidated by this group — and I am one of the well-spoken people. However, I do not see me represented in this panel. This is an example of how important it is and the stress that is created. The mental health issues that come out of this are key. If you do not see yourself, you are a token person. Do you see yourself fully participating at the best of your capacity?
Mr. Chung: The implementation is key. Martha, Raymond and myself are token presenters to many task forces at many stages of their many reports. Over the last 23 years, I do not know how many presentations I have made. The latest report was the one prepared by the Toronto-Peel Mental Health Implementation Task Force. Where is it now? Mr. Michael Wilson spent three years doing the work, and the task force report is sitting somewhere. The three of us made the same presentation, maybe from different angles, but the fact that only three of us were involved again speaks volumes because we are also the only people who are being identified as representing the ethnocultural, the multicultural mental health system. That is not right. There are more than the three of us.
Senator Cochrane: Do you have a link, either through your cultural individuals or groups, with the Ontario health system? I know, Madam, you said that it was hard to get a hearing in the system, but do you have like a particular group or individuals that are — I used the word ``gung-ho'' at getting in and being heard?
Ms. Ocampo: We are well linked with the mental health system in Ontario. For example, we are part of the Federation of Mental Health and Addiction. We are linked with all the neighbourhood agencies. We are well linked, and they like us to be a part of them. All these other agencies must take responsibility to ensure that the population they serve, all the people in their area, are served appropriately.
We hear from a lot of the communities that they are not served appropriately. They might have been going to a doctor, they might have been going to a hospital, but they are not being served appropriately, so they end up in the revolving door until they might hear from the community about Hong Fook or Across Boundaries, or there is a peer support group that is mainly Southeast Asian. If they do not have that, how is information passed along? If they do not speak the language and if there are no pamphlets are available, the information does not get to the communities.
We are always available, and at our expense. We have to attend all these meetings. We do not want to miss any meetings because we want to make sure that our voices are heard, but how many meetings can we go to?
Mr. Chung: We have networking with the other mental health agencies and hospitals. Again, they invited us as a token. When they are approached they say, ``We have Raymond and Martha. What more do you want?''
There is also the question of service delivery. When they get referrals who cannot speak the language, they automatically send them to us. They are not fulfilling their responsibility. Excuse me for saying it, but we have been the dumping ground.
Mr. Cheng: There are times in the lives of patients when they need care and when they get care. I do not dispute that. They will even say that they are grateful for it. What happens to them, though, when they are past that stage and they understand the situation? They want to tell people what they want and they want to express their goals, but there is no one to understand them. There is no one to hear them.
Everybody just assumes that, after a patient has had the services that are available, they will be able to go back to the community. They are left looking for somebody that really understands where they are coming from, and that is where the community health system breaks down because at the end of the day, it is us, the three amigos, that they turn to. If you are not of the certain ethnoracial community and you are not lucky to find somebody in a helping field that is maybe not the mental health system, maybe is a settlement house, or maybe is a community mental health centre or some other kind of informal supports, well, gosh darn it, how are you going to improve your health status? It is as simple as that.
Senator Cochrane: Why are some ethnic groups funded and your groups are not?
Ms. Ocampo: There are no other ethnic groups in mental health or addiction.
Senator Cochrane: I do not know if it is of any consolation, but we have heard from people within the groups that have appeared before us, that full-time employment is very difficult because of the medication, because of health, going to see doctors and so on, so these people find mostly part-time work.
Tell me about your own system. Are you any better off in Canada, in regards to mental health, than you were back home? Is that an awful question to ask? If you do not want to answer that, fine.
Mr. Chung: I cannot answer that because I have been a Canadian for the last 35 years, so I do not know what is happening back home.
Ms. Ocampo: I do not know which ``back home'' you are talking about because, for example, at Across Boundaries, we serve many people from the African continent. There is so much diversity among Southern Africans. We want to emphasize that the practices that are used by these communities are practices that have been used for many years, generations, for example, acupuncture. Yet, because of the biomedical model that we use, the Western approach, we are critical of that approach. There has to be an integration of these practices, but the way these practices should be recognized is in such a way that they are on an equal footing with the Western approach because they have their own merits.
All of you know that acupuncture has been used for centuries. Ayurveda is a very old form of medicine that still today is being practised by many people, but is not recognized by our system. As a result, when people want to access an Ayurvedic doctor or an acupuncturist, they have to pay for it out of their own pockets, and the people that we are seeing are all mostly on social assistance or in difficult financial situations, so most likely, they will not be able to access those things. Then they are forced to see a Western medical service where very often, there is some kind of labelling, wrong diagnosis, because certain assumptions are made.
After September 11, certain assumptions were made that most of us were part of that whole September 11 terrorist attack. We receive people who are severely psychotic and are running away from the RCMP. They think that somebody is after them. Now, you are not sure whether it is true or not.
They are being labelled psychotic and they are given medications galore. Sometimes you just have to sit down with them and find out exactly why they are thinking that way. They have been watching TV, the media, they open the newspaper, it is all about them, and so it adds all adds up.
Where does that person turn? The people who try to help them may not be familiar with medical terminology or with pharmaceuticals. I think training is very important. Now we are training people in the Western medical approach, continuously.
Senator Cochrane: We are learning about acupuncture, herbal remedies and so on from our Asian population. I think the healing power of some of these substances is wonderful. I spread the word about things that have helped me.
Senator Pépin: I would say to Raymond that I do understand you when you say that ill people have a hard time finding medical staff to speak to them in their own language. I have not experienced that problem because I am from Montreal, but if I were to fall ill in another province, I would want be able to express myself in my own language.
You started to speak about alternative forms of medicine. Perhaps you could elaborate. Which group offers those services? Can an individual go to your clinic and receive alternative forms of treatment?
If I understood correctly, those services are not covered by OHIP. If there were, do you think that they would be used more often?
Ms. Ocampo: I was talking about a holistic approach. When we say ``holistic approach,'' we would use different approaches that would be effective for an individual. For example, when we use acupuncture, that is not the only treatment involved. We could offer many programs that would complement another treatment. Even acupuncturists will not just administer acupuncture alone. They will provide lifestyle counselling. They will work with the client and say, for example, ``If you want to stop smoking, we cannot just give you acupuncture; you have to change your lifestyle.'' Examples of that are yoga, meditation, and we use a community kitchen to be able to address both nutrition as well as financial aspects. People come to the centre because they will be able to have one good, full meal. That addresses both the financial as well as the nutritional sides.
We look at current events, which is news, but we know that the news is often biased. The people who are disempowered or marginalized need to have a voice. They need to be able to express an opinion. You may ask: What has this to do with mental health? It has a lot to do with mental health because, if I have a voice, I will feel confident that there is something that I am saying that is worthwhile. Those things do not come into play when you are talking about a biomedical model.
I think you need a combination of all of this. You cannot just use herbal medicine and you cannot just use medication. You must address all the issues that people are facing. If the main issue is housing, then that may be the first issue to address because they may be facing eviction.
Mr. Chung: There are different forms of traditional medicine methods. Cambodian women, for example, have gone through war, and they suffer from post-traumatic stress and whatnot. They tell us that they do not want therapy. They say they do not need. They say, ``Just give me the chance to, once a month, come in and dance.'' Dance is the treatment. They will get together and dance for two hours and then they go home and have another good month.
Our Chinese men and Chinese seniors have a group whereby they just come in and talk. Sometimes they might do some line dance, or Tai Chi and whatnot, but there is mutual support. The isolation is broken. They are able to be with others. Those are the important, non-medical models that Martha and I have been talking about. It need not be an acupuncture needle or herbs. It could be simple dancing. Just give them some music. We do not need to do anything. That is the kind of simple support that we are able to provide.
Mr. Cheng: To follow up on what Raymond has said, what people need sometimes is a safe and comfortable place, open at hours they want, accessible to their needs, and having a feeling of community and sharing food, talking to one another, laughing together, and helping one another. Unfortunately, here in Ontario, that does not constitute billable hours, so we do not get the kind of financial support that we need, but it is just as valid and just as helpful.
Senator Cook: Thank you very much for coming, and I, too, would seek your wisdom in helping me to understand this. The first shock of the morning, and Mr. Chair, you will agree with this, was the recognition that I come from a province with the same population as the population that you serve in this Greater Toronto area, so it is difficult for me to understand the situation.
I would be interested in knowing in that community of a half million people the size of your client population. We are trying to understand the subject for which we are attempting to create a model. You can call it holistic or you can call it integrated. We talk about seamless delivery, and I do not know how in the name of common sense we will ever get to the seamless delivery of a complex service or be able to focus on the well-being of the individual.
You talk about early intervention, and we have about all those elements from many different panels and groups. What I have heard from you this morning is an added element which I think will help me personally, and I hope the committee, and that is a strong sense of community.
As long as the immigration policy, in Canada, is open doors, we will be always coping with language. When people are second, third and fourth generations from immigrants, the language issue will fade. However, your service will always involve a revolving door when it comes to language. I think you will always have that need.
You talk about self-help, promotion, family initiatives, as do most of the witnesses who have appeared before us.
I heard a new word this morning. I am referring to the stigma attached to the word ``newcomer.'' I had not heard that before. I have heard of the stigma attached to language and culture; and I have heard of racism.
I smiled when Raymond referred to his problems as ``going through a hard time.'' I come from Newfoundland, and often as not, we are always going through a hard time, one way or another.
You talk about appropriate caregivers, appropriate meditation and appropriate peer support. The word ``appropriate'' takes on a whole new meaning depending on who I listen to. You say you want to work. The goal of all of us is to build a better place in Canada. We all feel it is a pretty good country.
However, through all of that I hear you saying that the system is giving to this client population what it ``believes'' it needs, rather than consumers, the clients getting from the system that which they need.
With the permission of my colleagues, I would say to you, Martha, that we are ordinary people undertaking a very extraordinary task, and we need the help of all of you. We need your understanding and, as for me, I need your patience.
I would like Raymond to comment on the medical model which, I think is multi-faceted. Somewhere along the continuum, with all the care that your agency provides, there may be a need for medical intervention. Would you comment on that?
Mr. Chung: Because we are not funded to administer treatment does not mean that we are not using a medical model. As a continuum, it is working alongside. We know that a good number of patients require medication and they will see the doctor or psychiatrist. However, there are complementary kinds of activities that I am trying to promote. All along, we have been talking about the medical model alone, and in many of our communities, that will not work. The community support has to be built in.
If you are sick, you get the service, you get the medical treatment. The community and the family members are not getting support. Then, without family or community support, the patient is isolated. The patient can only get the medicine or the top therapy. The other supports have to be built in. Building the communities is important because, if the communities can provide support to the families and to the individual patients, they do not need to go to service organizations as much. They are kind of mutually complementary to each other.
In the Asian culture, family is still the most important support, but the stigma attached to mental illness crosses cultures. Is it higher in Asian culture? I am not sure. They are not well informed. I can guarantee that there are patients who are not getting any form of assessment and treatment because the family does not feel comfortable exposing the fact that the family member is sick.
Mr. Cheng: In response to what you say, I will reply with a general statement. As someone who emigrated to Canada at age six, just in time for Pierre Elliott Trudeau to become Prime Minister, my perception of what it means to be in a community of Canadians as a visible minority is considerably different from the people that I have worked with, that is, those who arrived in Canada later, who do not have the same familiarity with mainstream culture and our two officials languages.
That being said, I believe that the health care system, not just the mental health care system, needs to practice what it preaches which is being patient-centered. I speak, I think, on behalf of all of us when I say that we want patient- expressed needs to be served and understood. That is pretty much a universal message that we all can understand. I am not a genius. I do not know how we get there. That is for you folks to decide.
The Chairman: I thank all of you for coming. The committee appreciates you taking the time to be with us this morning.
Senators, I would welcome our next panel of service providers. We have with us Mr. Steve Lurie, the Executive Director of the Canadian Mental Health Association in Toronto. I have already spent an evening picking his brain on a few issues. We also have Dr. Paul Links, a professor of psychiatry at the University of Toronto, but who is really here on behalf of the Canadian Association for Suicide Prevention; and Gordon Milak, who is with the VON in Middlesex- Elgin. Thank you all for being here. I think you know the format. I will ask Steve to begin.
Mr. Steve Lurie, Executive Director, Canadian Mental Health Association (Toronto Branch): Thank you, Senator Kirby and members of the Senate committee.
The first thing I want to thank you for is allowing Pat Capponi to wear a hat the other day. You would not have heard her stories had she had to take it off. Much of what she and her colleagues had to say is the message that I think all of us, whether we are service providers or community representatives, want you to take away.
I also want to say that the first three volumes of your report are just magnificent. I think you have got it. The challenge going forward, and it is probably the biggest challenge, is to create a report that the whole country will move on because just writing a good report is not good enough. We have to generate the political and bureaucratic will that has been lacking.
I would start by providing some historical reflection, because I think that helps you with your argument. In 1963, the Canadian Mental Health Association said the following about mental health services in its report More for the Mind:
In no other field except perhaps leprosy has there been as much confusion, misdirection and discrimination against the patient, as in mental illness... Mental illness even today is all too often considered a crime to be punished, a sin to be expiated, a possessing demon to be exorcised, a disgrace to be hushed up, a personality weakness to be deplored, or a welfare problem to be handled as cheaply as possible.
Written over 40 years ago, these words support the need for an anti-stigma campaign and a legislative guarantee of access to mental health treatment and support services in federal and provincial legislation.
Twenty years ago, I was asked to do a review of More for the Mind, and the following observations were made after reviewing the evidence that was available at that time from Statistics Canada, which used to compile mental health statistics nationwide. They do not do that much any more. The observations included the fact that Canadians are making more use of mental health services than ever before, the bulk of these services are hospital-based, and the transfer of resources that was to accompany deinstitutionalization has not occurred. That was in 1984.
Since all that was written, all provinces have embarked on mental health reform with what we would have to acknowledge are mixed results, and the observations of 20 and 40 years ago are still relevant today.
I understand that Senator Kirby met Bev Leiber, who talked about the Graham report, which was probably the first beginning of a provincial mental health strategy. I found what I think is the only one in Ontario. I have made a copy of it for you.
Reflecting on the Graham report, because I had the privilege of helping Bob Graham write it in 1988, the glass was half full then and, despite some promising developments, it is still half full. We have not got there yet.
If you refer to the second report on the Health Care of Canadians: Toward a Healthy Future, they identified that, just 10 years ago, Canadians spent 15 million days in psychiatric facilities — more than heart disease and cancer combined — and that was despite the availability of knowledge and service technology that could reduce hospitalization by 80 to 90 per cent.
As you have probably heard from other witnesses, the problem of access to care is still a huge one. Anywhere from 50 to 75 per cent of the population suffering from mental illness do not get care, either in a timely way or they do not get it at all, and that creates a huge problem. It is one reason why we have to generate that political and bureaucratic will to move the mile posts as places like New Zealand have and Canada has not.
This was the first report to set out planning objectives. It is a model for a mental health plan that you would want each province to produce; but where it falls short is that the subsequent governments that continued the bipartisan agreement to do something about mental health care were never able to specify specific spending objectives, service targets and support targets, and so the will declined.
For example, here in Ontario today, we are fortunate that between federal and provincial funding over the next five years, $185 million will be added to community mental health funding. That is impressive, but it represents only about 12 per cent of the estimated price tag which was put together by the Provincial Mental Health Task Forces chaired by Michael Wilson and colleagues in the last couple of years.
What do we need? We need a mental health reform strategy with the following elements: Each province and territory should develop mental health plans with a 10-year horizon, specific performance objectives, committed funding, in other words, new money coming in every year, and ring fencing of existing mental health resources, and as you have heard from the previous speakers, this has to provide both access to treatment and access to the supports that people need to get a home, a job, a friend and opportunities to participate in the community.
I would estimate, taking the provincial figure of $1 billion that was developed by the provincial task forces here, that probably across the country we need a commitment of at least $3 billion, so the good news is that it is less than daycare, but the bad news is, not many of us expect we will ever see it in our lifetime.
Just to give you an example of that, it has taken 20 years in Toronto to develop 2,000 supportive housing units, even though we know today we need another 3,200. Does that mean we are going to have to wait 30 years for those to come on stream? There really does need to be definitive plans by each province and a coordinated plan on the part of the federal government.
The federal government itself should develop a plan that includes funding for supportive housing, employment, and mental health services to immigrants and refugees that would be available to community groups, provinces and territories. The reason I state it in that way is that I think when people need service, they do not care where the funding comes from. This is where I think the communities come in. I think of the Healthy Communities movement, the City of Toronto urban alliance which has said, ``Fund communities to move forward. Yes, create pooled fundings, but do not get hung up in provincial jurisdictions.''
For example, ``After the Door Has Been Opened,'' which was a landmark report on the mental health of immigrants and refugees, called for action by all levels of government, and I think to be fair, what we ended up doing is closing the door rather than opening it.
The federal government does not provide sufficient resources to meet the mental health needs of immigrants and refugees and, if you refer to the recent report on the health of immigrant women, the paradox is, the longer that immigrant women are in the country, the worse their health becomes. While this report did not zero in on mental health, one could assume that significant problems in that area emerge over time. Yet, the way the federal government funds settlement services, no money is allocated to work in the area of immigrant and refugee mental health.
We have a report in this community which centred around the needs of French-speaking people with mental health problems. It is a wonderful report, published by the Toronto District Health Council which is going out of existence on March 31. Hopefully, you will still be able to get the report, which was called I Only Have the Words In French. There are stories from consumers who talked about the barriers that people face when they cannot express their mental health issues in their own language. The problems are huge. We have to do a lot more in that area.
The third point would be that federal, provincial and territorial governments need to collaborate to improve services to people experiencing mental illness who are involved with the criminal justice system. I understand that some members of the committee may be interested in that. I chair the Toronto Mental Health and Justice Coordination Committee, so while I will not belabour my opening remarks with points on that, I am certainly prepared to answer questions.
The fourth point would be provincial, federal and territorial governments should collaborate to increase funding for mental health services evaluation — and you have identified this in your report — and work with community mental health services and universities to develop research partnerships.
A good model for this is the Community Mental Health Evaluation Initiative that was developed here in Ontario. I think we would not even have to change the acronym, CMHEI. It could be called the Canadian Mental Health Evaluation Initiative. I urge you to seriously consider that.
The fifth point is that funding should be directed at improving access to treatment and community mental health services and focus on improving connections at the front line, rather than organizational restructuring. I am certainly happy to address that at length. I have shared with the committee a number of papers I have written on the subject, but you get a seamless system by making it easy for people to connect, and as people in the Somali community would tell you, if you talked to them, in Scarborough where we provide services, it is not necessarily a direct link.
Our experience is that, if somebody is having mental health difficulties, he or she will call our worker to access the care, and our worker might be the first point of entry, the person who will hook the consumer up with a physician, who will hook him or her up with a psychiatrist as well as the alternative types of supports the worker identifies that the consumer needs.
A triage system that is hospital-based will not work for some communities. Therefore, you need both elements. You need a better organized system at the front line, but you need flexibility in connecting to communities and organizations such as Across Boundaries, Hong Fook and others, and even mainstream organizations like ours that are moving into this area.
The sixth point is that a mental health commission similar to that in New Zealand should be established to work with all levels of government to develop consumer and family leadership and report on and monitor progress across the country. This is critical. The pressure needs to be on all governments. It is best to have consumer and family leaders pointing out where you are falling short. ``Here is what you need to do. Here is where the traditional approach is not working.'' That has been a strong contribution that the New Zealand Mental Health Commission has been able to make.
Finally, federal, provincial and territorial governments should collaborate to develop anti-stigma campaigns that use both media and community education techniques.
I would end by quoting the late Dr. Clarence Hincks, who himself had a mental health problem. He gave the rationale for moving forward to us just before he died in 1964. He said:
All we need is leadership by people who recognize the fact that we are in the ox cart stage of development... In Amsterdam they haven't built a mental hospital in years because their mental health workers are working in the community, where they should be working.
The Chairman: Thank you, Steve.
Dr. Links, please proceed.
Dr. Paul Links, President, Canadian Association for Suicide Prevention, Professor of Psychiatry, University of Toronto : Thank you for this opportunity to speak with you today.
As Senator Kirby said, I am primarily wearing my hat as the President of the Canadian Association for Suicide Prevention and that is because I wanted to share with you the document, the blueprint, which you have in front of you.
The Canadian Association for Suicide Prevention is a group of professionals that was incorporated in 1985. Its primary purpose is to work to reduce the rate of suicide and minimize the harmful consequences of suicidal behaviour. Our organization works by facilitating, advocating and supporting the efforts of suicide prevention, intervention, bereavement and postvention initiatives across Canada.
Let me remind you of the magnitude of the problem, although I must say I was most impressed on reading the reports. I echo Steve's comments and I am encouraged that we are on the right direction. However, about 4,000 Canadians die by suicide each year in Canada. More than 10 Canadians will die each day in the coming year, and about 400,000 Canadians self-harm each year in Canada. Suicide is the leading cause of death for Canadian males from ages 10 to 49, more than cancer, more than motor vehicle accidents, more than HIV/AIDS.
What is important is that we have a proposed solution. Unlike Australia, Finland, France, the Netherlands, New Zealand, Norway, Sweden, United Kingdom, Scotland and the United States, Canada does not have a national suicide prevention strategy. As you outlined, Canada needs a comprehensive action plan on mental health, mental illness and addiction, and a national suicide prevention strategy must be a central component of that action plan.
The Canadian Association for Suicide Prevention presents to you today the blueprint of a Canadian National Suicide Prevention strategy. It outlines the goals and objectives to begin to formulate a national strategy. As you will note, the blueprint was released in October 2004 at our annual general meeting. I hope everybody has a copy to refer to and review.
We have a solution. We need a national suicide prevention strategy. Like other nations that have been successful, it needs federal leadership. The federal government must set out policy related to adopting a national strategy and, of course, lead collaboration with federal, provincial and territorial governments to develop a national suicide prevention strategy that can be brought to all levels of community throughout the country.
There must be funding for this effort to coordinate and implement this activity. A good analogy to this initiative would be the Canadian Patient Safety Institute, CPSI, in terms of its mandate and resource allocation. The institute was recently established to provide leadership with respect to patient safety issues in the context of improving health quality. The CPSI promotes the best practices, raises awareness, and provides advice on effective strategies to improve patient safety. The Government of Canada announced funding of $10 million annually to support the initiative of patient safety throughout Canada.
Today I thought I would focus specifically on your third report, Issues and Options for Canada, and specifically on section 4.2, suicide prevention, addressing the questions on page 28. I will try to answer the very important questions that you have raised.
You ask: Who among the federal, provincial, territorial governments and non-governmental organizations should be involved in the development of a national suicide prevention strategy?
All levels of government, various community agencies and organizations, survivors and clients need to be involved, but it is clear that we must have federal leadership to set out policies, provide resources and set outcome targets, including actual reduction in suicide rates.
Your reports are clear about why the federal government has to take leadership in this, and I just highlight a few of the important rules that relate to the national strategy. Obviously, the federal government has importance in terms of surveillance. We do a very good job of that now, but we have to move to the issue of surveillance of suicidal behaviour. The federal government has the role of leadership and research and, in 2003, the Canadian Institutes of Health Research set out the priority areas for research in suicide-related studies.
Of course, you have priority for direct service for a number of high-risk groups who are at risk for suicide. The federal government has asked for increased accountability related to health care spending, and obviously a reduction in the suicide rate and suicidal behaviour has to be part of that outcome.
Of course you have leadership in health promotion where we need initiatives in targeting stigma. That would be in the federal domain.
In this area, we need federal leadership. As was done for the Canadian Patient Safety Initiative, we need leadership in bringing all stakeholders together and working together on the basis of something similar to the blueprint and in order to move forward with a national strategy.
The next question you raise is: What should be its specific goals and objectives? I hope you will view the blueprint as a beginning. We anticipate that, as you travel across Canada, you will meet other board members from CASP. I hope that, as you have an opportunity to read the document, you will address specific questions to my colleagues who will appear before you, so that you will have an opportunity to become more familiar with the blueprint.
You then ask: What programs or activities should be part of a national suicide prevention strategy? Again, I think the blueprint provides a beginning in the task of outlining those activities.
You ask: How much would it cost and how could it be funded? Again, I think that the funding for a coordinating and implementing body can use the analogy of the Canadian Safety Patient Institute, which has in the range of $10 million annually, to set up this implementing and coordinating body. Obviously, monies are needed for surveillance, research and evaluation, programming related to health promotion and, of course, direct programming for the high- risk populations that the federal government serves. There will be a need for provincial and territorial monies, and I think we can move ahead to involve corporate initiatives in the area of suicide prevention.
Your last question is: Should there be a single national strategy, or should each level of government establish its own? I believe that in this area the answer is clear: National strategies require federal leadership. The goals and objectives of national strategies are well-established. They have been adopted in almost all nations that have undertaken this, and I think they are included in our blueprint. The objectives are broad. They allow for us to move down to the local level, and they are comprehensive. They should include and encompass all initiatives and all communities in Canada. I will stop there.
The Chairman: Thank you, Dr. Links.
We will now hear from Mr. Gordon Milak from VON Middlesex-Elgin.
Mr. Gordon Milak, Victorian Order of Nurses, Middlesex-Elgin: Mr. Chair and honourable senators, thank you for the opportunity to speak to you this morning.
VON recognizes the progress made on mental health with its inclusion in the first ministers' accord, the recent Canada Health Council recommendations, and of course, the study by this committee. VON appears before this committee with a slightly different perspective from that of the illustrious individuals and groups that have appeared in the past. VON is about community care for all vulnerable groups including, but not specifically targeting, mental health. As such, we encounter mental health issues every day in many environments. There is a recurring theme that I have noticed this morning — it is about community, and that is what I will be speaking to directly.
The Victorian Order of Nurses is a national not-for-profit organization and federally registered charity that has been caring for Canadians in their homes in the local communities for 108 years. VON delivers more than 50 home nursing, health promotion, support programs and other services to a million Canadians every year. Our more than 7,000 health care providers and 13,000 volunteers know that community responses need to be tailored to the specific community. We know that community responses are different, and we know that the consumers are the best guide to establishing worthwhile, effective programs. Consumers' best opportunities to be heard are at the local level.
VON branches are lead by local volunteer boards of directors who act as champions and advocates for their communities. Their role is to identify unmet needs in the community and mobilize the resources to address those needs, whether VON delivers that service or not. Volunteer visiting, adult day programs and Meals on Wheels are just some of the programs that you will find VON delivering across Canada.
Common to all VON programs is our focus to support vulnerable populations wherever they live. Although mental health issues are factors we deal with in all services, groups and populations, it is our experience with the homeless that I shall make reference to this morning.
In London, Ontario, the Salvation Army has been assisting the disadvantaged for over a century by providing hot meals and a warm place to sleep. Those unfortunate enough to find themselves living on the street or in a shelter seldom have family physicians, regular checkups or visits to the dentist. If health care of any type is accessed, it is often in crisis at an overcrowded emergency room and, many times, while accompanied by a police officer. The homeless, like society at large, is an aging sector and with age comes an increase in chronic disease, often undiagnosed and certainly untreated. Even more serious is the rising incidence in hepatitis C and drug resistant strains of tuberculosis to which the homeless are particularly vulnerable.
In 1995, VON Middlesex-Elgin began to provide charitable nursing clinics to several agencies and shelters working with the homeless. By 1999, VON had formed a partnership with the Salvation Army to establish a medical clinic within the shelter to meet the needs of the growing number of homeless. Consistent access to primary care provided detection, treatment and health promotion. While the physical needs provided by the Salvation Army combined with the medical needs provided by VON improved the quality of life for the homeless, and lightened the load on overburdened emergency departments, it did not affect the fundamental issues that led to homelessness in the first place, such as, poverty, drug and alcohol addiction and of course mental illness.
In 2000, VON provided funding for research at the University of Western Ontario under Dr. Evelyn Vingilis to determine the prevalence of mental illness in southwestern Ontario. The study determined that among the male, homeless population, 61 per cent suffered with two or more disorders, 46 per cent had substance-related disorders, and 31 per cent suffered from both.
In 2004, VON Middlesex-Elgin was successful in a grant proposal under the Primary Health Care Transition Fund for a Mental Health Demonstration Project. The grant provides two years' funding for enhanced physician access for the clinic and the addition of social work to specifically address crisis and supportive counselling, rehabilitation, addiction support, access to housing, and income supports.
Hostel clients can now access an interdisciplinary team providing on-site primary health and mental health care, nursing, social services, as well as a referral process to psychiatry, addiction programs, specialized medical and social services. A service strategy is available to each resident via coordination with hospitals, regional mental health, detox, CMHA, London Housing, and many more who represent the main systems. Through meetings with key stakeholders, the project model has been linked to the entire existing network of health services in London-Middlesex.
In addition, we continue to link with the University of Western Ontario schools of medicine, dentistry, nursing, facilitating student placements, and King's College, mentoring third year social work students. The VON/Salvation Army clinic is also a partner agency in an application submitted from the University of Western Ontario entitled, ``Creating Interpersonal Collaboration Teams for Comprehensive Mental Health Services.'' The application was from the faculties of medicine, dentistry and health sciences.
The short-term objective of this project is to increase the number of health care professionals trained for collaborative, client-centred practice before and after entry into practice.
If funding is secured, the Salvation Army Centre of Hope clinic will be just one of the practice sites. This month, VON and Salvation Army have submitted the clinic project for consideration as a family health team under the Ontario Ministry of Health primary care reform initiative. Family physicians are increasingly and understandably unwilling to take on complex mental health clients who need ongoing support and case management. It is our intent to establish the clinic and demonstration project as permanent resources for the homeless in London, providing the homeless a family practice of their own.
Our shelter and clinic represent a failure of the current system to meet the needs of the mentally ill. Primary prevention programs have not been effective in addressing the roots of the problem. The fact that we have resources in place to link clients does not ensure that those services are even available. A bottleneck continues to exist, while wait lists for service grow and the availability of particularly affordable housing remains far below the actual need.
The Issues and Options report correctly identifies underfunding. The work I have just shared with you is an excellent case in point: The medical clinic is currently funded through the volunteer board of VON Middlesex-Elgin and the Salvation Army through fundraised dollars, literally bingos and bake sales. The mental health demonstration project has less than 16 months funding remaining. The success and size of this project has grown beyond the means of both charities to sustain through fundraised dollars.
I would conclude by stressing that the need is urgent to redesign community-based mental health treatment and support options. Innovative and flexible models of care delivery are needed along the continuum. People do not need all the services all the time at the highest levels of delivery. Models need to allow clients to move in and out of care options as their needs change. Training in mental health must become a core complementary for all medical personnel.
In conclusion, we believe that this is as much a social justice issue as a health care issue, and if we have a right to quality end-of-life care, or transplant programs, we also have a right to relief from the kind of suffering mental illnesses and addictions incur. As an organization, VON is responding in ways that we know and understand.
We urge you to evaluate the effectiveness of existing programs, discontinue those that do not have proven outcomes, ensure the use of the right level of staff support at the right time, and take the delivery service options to the clients where they live.
The package that I provide speaks specifically to the questions that we feel most qualified to answer.
The Chairman: Mr. Milak, could we have a copy of the study you referred to on the homeless in London? I presume that is a public document.
Mr. Milak: Yes.
The Chairman: Do you know of any other studies of the homeless that have been done elsewhere in the country, because this is the first one we have heard of. Steve is nodding yes. If someone has other references, those would be helpful to us.
To all of you, but principally to Steve who raised the question, we understand the importance of increasing funding on the ground, that is to say, improving services to the client rather than what Steve called ``another organizational restructuring.'' Either this morning or at some other time, we would like to hear your thoughts on that could be done, keeping in mind that the services are delivered on the ground, and whether the funding is federal or provincial, that is a long way up the food chain. The challenge is how to deliver the services to the people who need them without being too directive.
As well, all three of you commented on the need to evaluate the effectiveness of programs because, obviously, the solution is not simply to throw money at the problem. You want to put money where it can be most effective. Automatically, the minute you say you will do an evaluation, that forces you back up the food chain again because you must decide who is going to do the evaluation. Then you have to be sure that the evaluation is done properly. How would you know that? That is a balancing problem.
If you want to make any initial comments now, that is fine, but how we ultimately strike the balance between the need for evaluation, which is essentially value for money, and the need to deliver the services on the ground in a way that is sensitive to the consumers, is a huge problem in structural design. Any thoughts anybody has from the ground level will be most useful. Would you care to make a general comment?
Mr. Lurie: In a sense, part of the challenge is identifying what you can build on that is already in place. For example, in Ontario, probably 10 or 15 years ago, there was an out-of-country mental health expenditure problem, whereby folks with addictions problems were being sent to the States. The Ministry of Health funded the development of the Drug, Alcohol and Treatment Registry which was a way of identifying what services were available for addictions treatment. They then linked people with assessment referral centres at the community level so that people could get better and easier access to an appropriate range of services.
The good news is that a number of us pushed for the application of that system to mental health. On September 7 next, in Ontario, George Smitherman will likely be in London to announce the opening of the mental health services registry. It will be an online, telephone-based way for consumers, families, family physicians, other service providers to find out what is available? It will not be in the form of a book that has to be republished every year. It will be a live, interactive approach. I believe there is something similar in B.C. or there used to be. When I was there about 10 years ago they had a mental health information line.
This is establishing easy ways in which the public and allied services providers can find out what exists in the community, because communities are very complex.
The ministry will mandate that anyone funded by the Ministry of Health and providing community mental health services, will have to describe our services in ways that are understandable, in plain language. We will also have to regularly report to the registry, based on our service types, and advise when we have a vacancy. That opens the door in that it lets people know about the range of services that exist in any community. It also allows, in a methodical way, communities and provincial governments to look at the gaps. They will see which organizations have been utilized, that is, people need their services, and which organizations have capacity but are underutilized. That is a very important building block regarding access to services.
Another way to do this is to recognize, as have other jurisdictions, that your funding should encourage the behaviour you want. If you are looking for good referral relationships amongst providers, and networks of care to be developed, the funding criteria should specify that. Then the funder can made decisions on proposals, whether from VON or CMHA. My colleague from VON talked about a collaborative venture. You foster collaboration in units that make sense in terms of size.
For example, the Wilson Task Force here in Toronto-Peel recognized that Toronto was just too large to have one mental health group connecting everybody to services. They decided that there needed to be some division of the city into either quadrants or some other units. Then what you would do is set a process in motion where service providers in North York, for example, would be given the assistance to come together with a mental health plan for their community and have the debate on the range of services. They would discuss: ``How do we connect the inpatient beds with the case management supports? What role is the crisis provision playing in our community.'' They would come up with a plan, but it would be a bottoms up community planning approach.
The funder, in this case the provincial Ministry of Health, proposed a mental health authority similar to the one in New Brunswick, the commission that was in place for 10 years. The funder would tell the service providers that they must play the game, they cannot say that they are not interested in a collaborate effort. ``We just want to do our own thing.'' There would be some consequences for groups who were not prepared to engage in collaborative planning. That is not to say there will not be debate. We all do not agree all the time, but there is, in fact, an amazing degree of consensus.
Here in Toronto, for example, in the last three months, a group of housing providers that is characterized by different models and different approaches came up with a coordinated plan for supportive housing that will bring on 6,000 supportive housing units across the province, 3,000 in Toronto, over the next three years.
We have come up with the funding model. We have come up with the capital development model, and we have got the sign-off and agreement of the Ontario Federation of Community Mental Health and Addictions programs, the Canadian Mental Health Association, province-wide, and the Ontario Non-profit Housing Providers Organization.
Some of this is, again, a matter of fostering community planning and collaboration and holding people accountable for that.
Then you also need simple information strategies based on performance targets, as is done in New Zealand. That will tell you whether you are getting there or not. Some of that has to be driven home to the network of providers. They have to ask themselves, ``If we said we were going to serve 150 people through this enhanced case management program, did we? If we did not, why not?'' You create conditions where the providers ask those questions, because government is too far removed from that. However, government can set the conditions by which that occurs.
There is a good example of the government doing. You may be aware that, on January 12, George Smitherman announced $27 million for people who have mental health problems and who have been involved in the criminal justice system. The funding plan has basic components. There is what they call a precharged diversion component; a crisis response component; a court support component; a housing component; and a case management component. The Ministry of Health along with the people who were funded have created tables to develop implementation plans. Each agency is not doing this on its own. Everybody who is funded for precharged diversion is sitting in a room and designing a coordinated plan. The same thing is happening for the safe bed network. The same thing is happening for the supportive housing piece. Through the court support consortium, and same thing is happening for case management.
Not only that, I will chair a meeting on March 30 where all the work that those individual groups have done will be brought together, and we will talk about how we will connect the dots. How do we make sure that the safe beds are connected to the supportive housing, are connected to the crisis response? Essentially, this is a community planning activity. In this case, the Ontario Ministry of Health, Toronto Regional Office, is to be commended for setting the stage for that to occur. It is a very different model from the RFP which was, ``Let us all compete with each other to get the service. We will show we are the best.'' This is where governments are often confused. When you put out RFPs, what happens in organizations is that the friendly organization becomes your competitor and you take the attitude, ``I am not going to work collaboratively with you or tell you secrets so that I get the contract.''
You could, however, set an environment where you expect organizations to work together, to play to their strengths, and identify the areas where all organizations need to grow and learn. There are some things we cannot do but most of the things we do know how to do and have been doing them on and off for 25 or 30 years. I think that is the way to go.
The private sector literature will tell you that 80 per cent of mergers fail. However, strategic alliances is the way that most organizations, corporately, are growing. You want to set up notions of strategic alliances around the provision of mental health care in the community. That is in everybody's interest.
The Chairman: The key point you are making is that — and this is our problem, not your problem — we need to figure out what are the incentives that would encourage people to do that, and what are the consequences or the penalties they would suffer if they did not.
Mr. Lurie: We had this debate in the systems design group of the Wilson Task Force. If you say, three years from now we do not want to see 35 operating plans from all the mental health agencies in North York, we want one and we will provide some resources for you to come up with the plan, does it make sense to get the case managers working together? In fact, the Ministry of Health has taken some steps in that direction. There is a plan in North York and Scarborough combined, to improve access to individual support services. They created a committee called PASS. They funded it, and we now have a plan.
The question is: Will there be money to implement the plan? One of the problems is that people assume that collaboration comes for free, and that system work and system building is just something that we can all do with our spare time. Well, we cannot because we do not have any spare time.
A few years ago, Industry Canada did an interesting study where they looked at small and medium-size enterprises. They were trying to develop collaborative networks here in the GTA. They found that they needed to sell the notion of collaboration, but the most important finding was — and it does not cost a lot of money — that they had to provide the tools for the collaborators to, in fact, collaborate.
A good example of this is Jeffrey Dyer's work called, Competitive Advantage where he looked at the supply chain that Toyota has been able to put together. He writes about automobile production being a highly complex undertaking. I would say that the same comment applies to mental health care. If you look at Toyota in terms of quality, the data shows that they have the lowest transaction costs of any of the automakers. They have built a supplier network with what Mintzberg calls the ``one-company mindset,'' to provide training to their suppliers. They consider quality issues together. Consulting is available.
From other jurisdictions we can learn how to create a one mental health system mindset at the appropriate level. However, it cannot be too large. For example, the challenges Ontario will face in moving to the LHINs environment, which will take in central north. The LHINs that will come into place on April 1, goes from North York to Grey- Bruce. That is not a natural community. Central East will go from Scarborough to Haliburton. That, again, is not a natural community.
Within that, there will be times when the folks in Scarborough will need to also talk to the people in the Durham region that abuts Scarborough. There will be cross-border issues. However, networks already exist.
That would be my final point on this. There is a lot of networking going on. You could ask about that when you go into various communities. You could ask, ``Is there evidence in your community that providers are working together to provide services?'' I think you will be given lots of examples similar to those Gordon talked about in London.
Mr. Milak: No one is more frustrated than the clients and the front-line workers, regardless of the discipline, about identifying the gaps and where there is a need for change.
Your report, I think quite rightly, is fairly critical of the segmentation across the system. We need the specialties. However, part of the challenge is that each discipline becomes quite reliant on its own solutions, and it is almost impossible for each discipline to comprehensively understand the value of the rest of the system. We do need systemic change and to create interdisciplinary teams. I am referring to the people delivering the care, physicians, nurses, social workers or other mental health workers working in collaboration. That will bring a grass roots change in philosophy. We need direction from the federal government to the provincial government down, but it has to be simultaneously changing at the front-line-service-provider level as well.
Senator Cordy: You talk about a change in philosophy. We all know that, with de-institutionalization, resources were not transferred to communities. We also know that we still tend to look at the doctor-hospital model. We have heard evidence from many people to the effect that what they want in many cases is a sense of community, which what you were talking about this morning. They also said that they want funding for peer groups to get together and for social activities like dancing. Yet, while there may be collaboration and networking among providers, government departments still seem to be working in silos.
Does the Department of Health give you money to provide peer networking? How are government departments starting to break down?
The second question is, should we have targeted funding? One of you mentioned directed funding or funding requirements. Should we have targeted funding so that we can provide some of the services that individuals want?
Mr. Lurie: I was looking over this report, and I highlighted what we said about this issue in 1988. I will leave this with Senator Kirby. There is a need for inter-ministerial focus; and a good example of that would be the housing piece.
The federal government, people would argue, does have an involvement in the provision of housing. As well, there is an Ontario, Canada affordable housing strategy where they are still debating the terms. However, this will mean the establishment of 20,000 affordable housing units here in Toronto. Perhaps we could get that commitment from both levels of government. Perhaps there could be a flexible approach where the federal government would say, ``Ontario, if you have a deficit and you cannot fund your affordable housing initiative for the first three years, we will kick in some money now to get things built.'' The Ministry of Health, through the health accord money, has some provision to fund the support services.
It is a matter of, at the governmental level, looking at what is needed. What are the housing targets? How do we, as they have done in the U.K. and other jurisdictions, pool funding to do that? Then there should be flexibility around recognizing the ability to pay. That is also important.
For example, you might have the federal government saying that it is not going to fund Ontario because this government is unwilling to match funds. I would just say that the average citizen does not care who funds it. The issue may be: ``You could have more if your provincial government would match, but we are going to make sure you at least have something.''
Then there are areas where the federal government has jurisdiction. You heard about the range of services necessary for immigrants and refugees. There is no funding stream from the federal government for the mental health needs of immigrants and refugees. They say that that is a provincial responsibility. The province tells us that they cannot even fund community mental health here, and they want to know how they can fund more Hong Fook, more Across Boundaries, and those are very small.
There must be some agreement on what needs to be in place at a provincial level. That has to be driven by a bottoms-up planning process where, in North York for example, people come together and ask, ``Are there enough peer support programs on the ground in North York?'' and, if there are not, ``How do we change that?''
Some of this involves identifying essential functions. That is what the Graham report did. You need agreement in both a national action plan and a provincial action plan, that there has to be access to treatment. There has to be crisis. There has to be case management. There have to be consumer and family supports. There has to be a menu. Then the federal government can say to the provinces, ``Together we need to make sure that money hits the streets for certain services, but you decide locally what mix is appropriate.''
If we have a mental health commission, that will be watching. It will be conducting hearings across the country to assess whether, say, Ontario got it right or not.
It is a multifaceted approach. I draw your attention to both Australia and New Zealand where they said that they would ensure that 3 per cent of their population who have mental illness would have access to care at any point in time. Seven years after the New Zealand mental health plan, the average across that country is about 2.5 percent. They have made real progress on meeting that service objective. Those kinds of things must be specified, whether it is in a provincial mental health plan or otherwise.
In 1992, Ontario set for itself the New Zealand funding targets. We wanted to have 60 per cent of the money in the community by 2003. It is now 2005. We have achieved about 40 per cent, up from 20 per cent. How long will it take to go the rest of the way?
I think that, for example, on the ground, the federal government does a good job, although it is an annual process, in that they do have responsibility for and fund employment programs. The Ministry of Health here does not have money to put into employment programs. Our agency, for example, has been able to access about $750,000 a year for employment programs that are targeted at people with mental health issues who are having trouble entering or staying in the work force.
You have to recognize that, even if you have various jurisdictions, you must make sure that the employment money is on the table at the same time that the Ministry of Health is funding case management. It is a menu approach, that is, identifying what needs to be in place in a community and determining what role each level of government can play in that.
The other interesting thing is, on the employment side, we not only leverage federal government money but we use the ODSP for that purpose. That is an example of a multi-ministry approach. However, the consumer does not know that the federal government is funding the worker or that ODSP is funding the worker who is helping him or her get a job. The consumer just knows that the worker is out there to help them get the job. I think that is a good model.
Senator Cordy: Paul, I want to turn to suicide prevention and programming. How do you go about letting people know how to identify people who are at risk? Are there programs, say, in schools where you target a specific group? You talked about the incidence of suicide amongst men. How do you go about targeting a group?
I remember when sex education first started in the school system. The hew and cry from the community was that, if we taught kids about birth control, they would all go out and have sex. Do you find a similar attitude when you approach suicide prevention and suicide programming in schools?
Dr. Links: That is a very important point that is actually part of the goals and objectives of the national strategy. You have to do some gatekeeper education. People at the front lines need to be informed about who is at risk and then know what to do.
As an example, we are currently working with the Toronto Transit Commission to try to educate staff about identifying people who may be stressed and at risk, with the ultimate goal of increasing what they call ``apprehensions,'' that is, taking people to hospital or to a care centre with the ultimate goal of reducing the risk of suicide on the subway.
All of this has to be carefully done because by just giving people the facts without telling them what to do and who to go to, will not necessarily have an impact. Certainly, gatekeeper education is part of an effective suicide prevention program.
Senator Cordy: Did you say the transit system?
Dr. Links: The Toronto Transit Commission. They have a problem with suicides on the transit system. The goal is to increase the education of all staff about what they can do to prevent it. It is a good example of how you can run gatekeeper education programs.
Perhaps I could echo what Steve is saying. In the area of suicide prevention, what we do know is what we should do, what the goals should be, and where we should take the lead. One thing that is missing that is in your report is leadership. I think federal leadership will have an impact in suicide prevention in that you can set targets, as other countries have done, in seeking a reduction in rates as one of the parameters to determine if your dollar is being spent well.
Senator Trenholme Counsell: This morning I have two questions. This is an excellent blueprint. I sometimes sit here and wonder if we are reinventing the wheel. However, your final comment that federal leadership will make a difference is what this committee is all about. You give us some hope that we are not duplicating too much.
First, what response have you had from the federal government, since we are representing the federal government, on this particularly excellent blueprint?
Second, I wear the shoes of an old, family doctor and I have the strong feeling that, if we are ever going to get this right, and if we could redesign things all over again, whether the community health centre is the ideal thing.
For instance, in the city of St. John the kind of centre that is being developed brings together many different aspects of health care, rather than having mental health clinics and so on. I do recognize that mental health requires a great deal of special attention. I wonder whether we could bring so much together community by community, region by region by working with all of the health providers, the federal government providing leadership and, serve our people so much better than we are now.
One of the most challenging groups to bring into this concept is the family doctors, the physicians themselves. In an ideal world, would this make a huge difference if we could have that concept well-embedded community by community, region by region across this land?
Dr. Links: I will speak to the first point first. The blueprint has only been out since October, so we are still getting the message out. Where we have had response is from a number of communities who have gone through the document and say that they are working on this.
For example, a group that is related to CASP is working to set up a national crisis phone line so that there would be a 300 number throughout Canada. One of the objectives is to have something that would be easily accessible in all communities. We have heard about other initiatives.
In our province, the Association of General Hospitals with Psychiatric Services has recently started an initiative to look at preventing suicide within a general hospital setting where there are, of course, many people at high risk.
When we put the blueprint out, the groundwork was already done. The community in the suicide prevention field has a long tradition of working together. That is the message I want to convey. If we have leadership now, lots can happen.
Mr. Milak: On the topic of community health centres, VON's opinion would be, a resounding yes. We do believe that is a model that has great merit. That is not restricted to the community health centre, we also see a role for home care. Ontario has one of the highest levels of home care in the country but still, nursing has been rationed. A result of that is loss of early detection, particularly as it relates to the aged. The loss of school nurses means that the young are also not necessarily benefiting from the same level of early detection that we had traditionally.
Mr. Lurie: As Gordon just said, I do not think one size fits all. Community health centres have done a good job. In Ottawa there are one or more community health centres that have assertive community treatment teams. I know Carrie Hayward spoke to you about that the other day. It is a partnership within one organization. It is a specialized mental health service for people with serious mental illness as well as improved primary care.
There are many examples. The CMHA Windsor branch has been able to hire a nurse practitioner for their clients who have serious mental illness, and in one year, they have picked up 800 people. When I heard about that, I thought that we would like to do it in Toronto. However, we could not do it here because Windsor is identified by the Ministry of Health as an underserviced area, and Toronto is not. If we had said to the Ministry of Health, ``Isn't mental health an underserviced area?'' then we might have been able to qualify, but we could not.
There are also the shared care models that Nick Kates and colleagues have developed. I am hopeful that they will either make written or oral presentations to your committee. Twenty years of work has been done in t the area of how to provide support to family physicians. Paul Links and I were at a meeting last spring where a network of GP psychotherapists working with psychiatrists around mental health issues has been formed.
There are lots of models. The conceptual frameworks I would leave you with are, to some degree, New Zealand and the U.K. They have got it right in terms of a planning framework.
From a population perspective, if you say that one in five Canadians or 20 per cent will have mental illness, but 17 per cent will have mild to moderate forms of mental illness, and since family physicians are the gatekeepers to mental health care in at least 50 per cent of the time, you could determine that the main access point will be through family physicians, community health centres, but you may want to have a shared care framework. You may want to have technical assistance provided to GPs as a formal program.
Helen Lester is a psychiatrist in Birmingham. She did an interesting review of access to care through GPs for people with mental disorder. She found was that the good news was, if you went to your GP, you could get rapid access to care. It was easily accessible. However, she also found that, for example, amongst GPs, because they had not had a lot of training in mental health, they had huge problems with stigma. Consumers reported that they would tell their GPs that they wanted to go to work and the GP would say, ``You have got schizophrenia. You cannot work.''
A lot of work needs to be done. We can use the primary health care reform initiative to knit the parts together in a more substantial way.
Senator Keon: Thank you for your truly thought-provoking presentations and the tremendous amount of information you have given to us that we, no doubt, will use.
As you know, this is the first province we are visiting. We will visit all the provinces and territories, and then hopefully by December we will have a report out that will, in fact, be some sort of strategic plan for mental health. We are the only G8 country without such a plan. It will be a structural framework for tying together all of the services to which you have referred, Steve. It will be the ``menu'' that will make this possible.
To date we have heard that the missing link is the combination of community services, primary care, home care and emergency care at the community level. We are groping for a way to tie that together.
I am fairly familiar with the Ontario model because I have worked in the Ontario system as a practitioner and as a health administrator for 35 years. When you look at that model and at the organization chart of the Ministry of Health and so forth, it is truly a nightmare.
The LHINs are coming out and, in mental health, we have nine proposed areas. Those have not been implemented so far, but they are in the planning department, and those do not correspond to the LHINs. All the Ministry of Health silos are funding this, that and the other thing. The chances of getting resources in the way of personnel and cash flow and so forth down through the system to fill the holes and to complement what is there in the way of good resources at this point in time are not great.
Should mental health services be planned within the existing health system of Ontario? Much of it was outside, although it is gradually coming in. How can this network with social services and community services? I do not believe in this, but is there still a case for planning a mental health system that would network with the health system and with the social services system? I would like to hear from all three of you on that.
Mr. Lurie: I will start with a historic view. When we developed asylums in this country, we had a separation. Then the general hospital sector came on. In the 1960s and 1970s we saw the development of general hospital psychiatric units. Then, in the 1980s and 1990s, we saw the development of community mental health. Since then, we have been trying to figure out how you bring the system together.
The task forces to which you referred came up with different models but, interestingly enough, with the exception of the southwest, which went for a pure network model, the other the task forces said that we need something like a mental health authority such as the New Brunswick Mental Health Commission, which was very successful.
I think you will always need to knit mental health into the health care system. The discussion we have had about access to primary care for people with serious mental illness is a good example of that. It is also important to be able to organize the mental health system and the addictions system because they are not organized. As I said earlier, that can come from a community planning effort where specific objectives are set.
I want to give you a concrete example, because you could go either way on this. In Auckland — and I will have a chance to observe this first-hand in a few weeks — they have, as you know, a mental health plan that specifies what needs to be in place in Auckland. They have, in the words of their mental health administrator there, ``a district health board that does not know much about mental health.'' However, they have a coalition of 40 providers, consumers and family groups that come together every year to look at that national mental health plan, bring it down to the Auckland level and ask about where they should be investing their resources. They ask, ``Are we getting the results we need?'' Then they present a report to the district health board, which approves it.
Senator Keon: Steve, if I could interrupt you for a minute. I am reasonably familiar with the system there, and, in fact, I have a niece in that system. The point is that they have a unicameral government, a small population and a simple organizational chart.
When you are there, would you give some thought to how we with our federal-provincial mosaic could find a fit for that very neat chart that they have?
Mr. Lurie: Given the traditional division of powers, the provinces will have to have mental health plans with fixed objectives, funding targets, ring fencing. That is a key ingredient in this country.
If you could get them to agree that you will work on certain things together, and the federal government will cost share, that would be an improvement. In that framework — and Graham said this in 1988, Wilson and colleagues said it in 1999 and 2003 — you will still need regional and local plans to get the work done. Then the funding has to match up with the local and regional plans.
When you get to New Brunswick, you could ask them to reflect on how they have done in mental health care, bearing in mind their experience with the Mental Health Commission. That part of the country moved the fastest and in the most effective way. It is small, but they did have regional divisions in the commission. If they compare the experience with the commission to what they now have, where mental health services have been re-integrated into the department of health, will they tell you that this is better?
The other question is — and I have been struggling to get some data across the country — how does mental health do in a health authority environment here in this country? I remember having a discussion with Glen Rutherford who used to run the Saskatoon Mental Health Centre. About five years ago, he said to me, ``I have the best 1950s mental health service that you could imagine.'' I asked, ``Why is that?'' He responded, ``Because every time we came up with an innovative approach to move money and create community capacity in mental health, the money got scooped into physical health care.''
You have a real dilemma. What you need to do is specify that each provincial government needs to have a mental health plan with fixed objectives, performance targets and a funding strategy. Whether it is within a health authority environment or a separate mental health authority environment, you would then have a track. Are we making progress? Is that menu of services in place, yes or no? Is there service quality, yes or no? How will we know this? You will know by both ongoing monitoring and funding research and evaluation. I do not think you can take a simple cookie-cutter approach.
Some would argue that mental health would get more air time if it were separated. Here in Ontario we are talking about probably $1.5 billion to $2 billion of annual expenditure. That is big enough to be a ministry.
When you are in British Columbia, it will be interesting to ask what their experience is with regard to having a ministry of state for mental health. Has it made a difference?
Mr. Milak: I would like to speak to that question from more of a rural Ontario standpoint.
I have just received the work from the LHINs that I will be situated in which runs from Lake Erie up into Owen Sound. It represents about a million people, only 350 of them are in the city of London, so the remaining population is less than 50 people per square kilometre.
When we are talking about resources across the continuum, whether it is primary health, mental health or even other community support services, I think that population base would be similar to that in many provinces in areas outside of the urban centres. Theerefore, providing access, providing human resources and particularly specialty resources becomes an incredible challenge. With respect to family practitioners, it is an acute situation in those particular areas. Somebody being the gatekeeper to any of those services is particularly important.
It is also important that it be community-based. Obviously, there are unique situations. I agree with Steve that there has to be planning at multiple levels in order to be effective, but it does need to be integrated.
One of the programs that we provide is volunteer visiting. Quite simply, somebody will befriend an elderly person who is beginning to withdraw socially and, left unchecked, there will be health consequences and possibly early admission into a long-term care facility, unnecessarily. It is similar to the situation that the first panel discussed, that is, getting together once a month and dancing for a couple of hours. Mental health issues are the same. It is an integrated community. It is about living independently in your community for as long as possible, and that requires all of those inter-ministerial networks being created. If they are independent, they need to be joined at the hip. If they are put into a super ministry, then it needs to be very streamlined so that the bureaucracy does not consume the resources.
Dr. Links: My comments would echo Steve's. The point needs to be made that there has to be protected resources. Whether it is within or without, it has to be a package of resources that is protected from other initiatives. The point about having the evaluative outcomes is important, and that could certainly drive the field.
Just to reiterate, leadership is very important. When I was in a large university in the States they gave the example of the U.S. strategy. In this large university the mental health worker was the person who initiated primary prevention in suicide until the strategy came into place. Now that responsibility lies with the vice-president of student affairs. Leadership makes a difference.
Senator Callbeck: I just have one question which pertains to a point that Steve made in his brief regarding improving services for the mentally ill who are involved with the criminal justice system.
Bill C-10 is currently before the Senate. It proposes to amend the Criminal Code for those unfit to stand trial and those who are found not criminally responsible for criminal acts. I do not know whether you are familiar with the bill or not, but it gives some more tools to the Review Board to do their job, to the police, and it will allow changes to the way victim impact statements are treated. If you are familiar with this bill, I would like to have your comments.
Mr. Lurie: I am familiar with a number of bills. Colleagues from CAMH appeared before the Commons Justice Committee, and if that is the bill that the committee was studying, then I am somewhat familiar with it.
When you address the issue of involvement with the criminal justice system, I woul say that, since the 1992 Criminal Code amendments, we have seen what some would called an expansion of the forensic system. That is interesting because Ontario has a document that says if unchecked, all the beds in our psychiatric hospitals would become forensic psychiatric beds in a period of five years.
Ironically, here in Toronto where the mental health program has about 220 people under its jurisdiction, that is, people who have committed a criminal offence, 50 per cent of the offences do not involve injury to a third party. Then I look at who is going through the criminal justice system here in Toronto. According to our court support data, we know that, every year, 2,300 people with mental health issues are involved in the criminal justice system. The offences range from a simple offence of, say, cause disturbance, all the way up to murder. They all do not end up in the forensic system but they all have a need for mental health care.
We did a study in this regard, and I can send it to if you would wish. We reviewed the court support services in the five courts here and determined that something like 40 per cent of all the clients moving through the system were having fitness assessments. Luckily, because of the court support program and on-site psychiatrists, those can be done in the cells as opposed to having to send people away for five to 30 days to 60 days to a psychiatric hospital.
We found that 70 per cent of the clients were coming back to court declared fit, not unfit. That tells you something. It tells you that the judges saw these mentally ill folks in front of them and did not know how to get them into care Fitness was not an issue when it was assessed. I think the big challenge is access to psychiatric services and treatment. In fact, we have been stepping backwards in this province because the Ministry of the Attorney General is now saying that they will only fund assessments under the Criminal Code in the court support programs. That means that our agency has had to dip into our own pockets to fund general psychiatric assessments in a partnership arrangement we have with the Scarborough hospital so that clients going through the courts can get bail.
Some of this it is not a question of fitness. It is a question of access to mental health care. My colleague from CAMH, Dr. Howard Barbaree, who runs their law and mental health program, prepared a report for our Mental Health and Justice Committee some years ago, the in-custody report. That subcommittee identified that it should not matter where you are, you need decent access to mental health care. If you are in the correctional system and you need to see a psychiatrist, you should be able to see one.
In Toronto, 50 per cent of the beds in the special needs units in our jails are occupied by people with serious mental illness, and they are not set up to provide that kind of service. It is a huge issue. That is why one of my recommendations is that there is a role for the federal government to work with the provinces and territories on what models would make a difference. It is not just all about that small forensic population that has grown; it is about the thousands of people who get into trouble with the law and have a mental health problem and need some support.
Senator Cochrane: Steve, you mentioned that there is $750,000 of funding from the federal government allocated towards finding employment for our recipients. To me, that is an awful small figure because, if you take $750, you should consider what a savings that means to our hospitals, our health care, our drugs and everything else. That is peanuts. This is just to try to provide our people with employment or part-time employment.
Could Gordon shed some light on your new system of front-line coordination in London. I am sure it will be successful when it is continued on through to Toronto. Will you have somebody there to answer questions from immigrants? In Toronto we found out this morning that 55 per cent of the recipients are immigrants. That number appalls me. They are not taken care of. They do not have a voice.
Steve, you talked about your successful home project. The Dream Team made a wonderful presentation, and I supported them. They have a great organization. Are they part of your successful team in housing?
Mr. Lurie: Let me tell you a story about how The Dream Team became established. As you know, they are consumer and family leaders in our community, and we are really fortunate to have them. There was an organization called Boards for Mental Health — they may have mentioned this in their presentation to you — that had been meeting for years trying to bring all the housing and mental health providers together at the governance level. They would let the senior staff attend occasionally. The group was trying to figure out what it should be doing because it was running into problems with provincial funding that it could not seem to resolve. Of course, there were the NIMBY problems that they spoke to you about.
Linda Chamberlain was listening to this discussion and I made the mistake of saying, ``I think we are struggling. Maybe we should try to think about what we might do, and only meet when we have an idea.'' Linda said, ``What are you talking about?'' She told her story in the room just as you heard it. That is when a number of us said, ``My goodness. That is what you need. You need people who put a face on mental illness and who can show that there is hope at the other end. They can talk about the key ingredients — hope, a job and a friend. Raymond Chung spoke to you about those things, which are clearly an ingredient to a successful housing strategy. They are the product of supportive housing funding being available. They are a product of those 2,000 units that were brought on stream over the last 20 years, but we cannot wait for another 20 years for more units.
As to the immigrant issue, DART, the registry of addiction treatment that currently exists in London has access to an instant interpreter service. The front line can speak 70 or 80 languages. If people called in to say that they needed a mental health service, and they do not speak English, the operators can transit the caller to somebody who does speak the language of the caller. At that front end that is critical. Technology exists to do that.
For clarification, because this is a parliamentary committee, the $750,000 I referred to was our agency's funding. Ours is only one agency in Toronto. It is a combination of federal HRDC money and ODSP money. I would imagine that, across the country, a lot more is being spent. However, I would make the comment that we have to reapply for this funding every single year. This is ridiculous. It is not as if people do not need a job next year and the year after. Perhaps they could take a page from the provincial government and create a core funding program for employment supports.
Senator Cochrane: One of the girls was worried about that.
The Chairman: Thank you all for coming. Your presentations were excellent.
I would ask the members of the final panel to come forward, please.
We have in our final panel, three presenters, Dr. Paul Garfinkel, CEO of CAMH, who is today representing the Working Committee on Mental Health of the Ontario Hospital Association; Ms. Florence Budden, President Elect of the Schizophrenia Society; and Dr. Nick Kates, Chair of the Canadian Collaborative Mental Health Initiative.
Our staff, Nick, has spent considerable time with Scott Dudgeon, your executive director, so we are quite familiar with what you are doing.
Thank you all for coming. Please make your presentations and leave us lots of time for questions.
Dr. Nick Kates, Chair, Canadian Collaborative Mental Health Initiative: The CCMHI represents a consortium of 12 national organizations representing family physicians, psychiatrists, nurses, social workers, occupational therapists, psychologists, consumer groups, advocacy groups and family groups with a goal of integrating mental health and primary care sectors leading to better access and outcomes for Canadians with mental health problems. On behalf of the consortium, we very much appreciate the opportunity to be able to present to you today.
We believe that primary care is a most appropriate setting for the delivery of many of the mental health services that Canadians require, and it is something that they should expect from their primary care services, whether those services be illness prevention, early detection treatment, rehabilitation or recovery. The question is how do we bring this about?
Your report acknowledged the contribution that shared care, collaboration between psychiatrists and family physicians, has made over the last 10 years. Our initiative builds on that base, but it recognizes the importance of enlarging the collaboration to include a wide variety of mental health providers, consumers and family members in the partnerships, and we see as a major motivation for our initiative that effective collaboration will build linkages between different parts of the system and move us towards one of your primary goals which is every consumer having access to the full continuum of supports and services, delivered in a seamless fashion.
We think our report comes at a most opportune time. Primary care reform across the country is looking at a reorganization based around ultimate models of funding, the integration of specialized services, chronic disease management models, comprehensive care, and based upon teamwork and collaboration between partners. We see tremendous opportunities at this point in time for moving ahead with the integration of mental health in primary care.
We know from the evidence that there are a number of benefits to this kind of integration. The first is that it can increase access to mental health services for a large number of individuals who otherwise would not reach services. We know that 72 per cent of individuals with a mental health problem receive no mental health care over the course of a year, but 80 per cent of these individuals visit their family physicians.
We also know that a number of groups traditionally underutilize mental health services such as ethnocultural groups, the elderly, children, individuals with addiction problems, individuals who are homeless or socially disadvantaged, individuals living in rural communities, all of whom we have a much better opportunity to reach if we can bring our services to where the problems are rather than expecting these people to come to our services which may be neither culturally nor even clinically the most appropriate places.
We know that integrating services in primary care can address depression, anxiety which often accompany chronic medical problems, and we know that not treating these problems leads to increased health costs and poorer outcomes. We know that, if we can integrate mental health and primary care, the capacity of primary care to manage problems will be greatly expanded. Primary care providers are willing to take on a broader range of problems because they know support is available and, if mental health is included in primary care, then the mental health system increases its capacity because we will be able to reach a larger number of individuals.
We believe that these approaches have the opportunity to be much more responsive to the needs of consumers. We have heard from our program in Hamilton and from many other programs, that consumers like this model. It is more accessible. It is more culturally supportive, and it significantly reduces the stigma of being seen in a mental health system.
We also think this approach addresses some of the specific issues raised in your third report. First, it opens up opportunities for early detection. Many individuals will present at a very early stage in the development of a problem in primary care. If we can increase the skills of primary care providers to identify these problems at the earliest possible stage, and we have access, convenient access to mental health services to intervene and initiate treatment, we can see many long-term benefits. This is probably one of the most effective ways that early detection will happen.
Second, we think it will allow existing resources to be used more efficiently. Mental health specialists are functioning increasingly but not exclusively as consultants, supporting primary care providers as well as offering a range of other services. It offers unique opportunities for monitoring the progress of individuals who have been treated in order to prevent relapse, or for secondary prevention, particularly in places where there are electronic health records where, at the push of a button, you can identify a group of people who may have a particular problem with, say, being on a particular medication or at risk for a particular event.
In Hamilton we have been able to adapt this model to the workplace. We are considering the same kind of collaboration as a way of working with one of Hamilton's largest employers to bring mental health services to workers.
You raised a number of specific questions in your report related to primary care. We would like to briefly respond to those questions. You asked: What needs to be done to improve mental health at the primary care level?
We would suggest that there needs to be a comprehensive strategy of which a number of the pieces are already underway through our initiative. We believe there needs to be an analysis of the strengths of successful programs, the barriers to integration and how to overcome these. We believe there needs to be the development of specific resources to assist people wanting to set up new programs. There needs to be a training strategy so that the next generation of providers coming into practice will be more comfortable working collaboratively and will understand the principles of collaboration. We see the need for establishing pilot projects which will demonstrate how these models work, and we see the importance of evaluation of all new projects, preferably developing common outcome measures that can be used across the country. We see the benefits of creating a charter that will commit all partners in our consortium to working collaboratively to integrate mental health services and primary care. This is something that we are moving ahead on as we talk. We see the need for new funding strategies, funding strategies that provide alternatives to fee for service, funding strategies that involve changes in billing tariffs to support indirect service, telephone consultation, and funding strategies that will create new funding to bring services into primary care.
Finally, we see the importance of considering ways in which we can incorporate primary health care into mental health services. Many individuals with serious mental illnesses receive very poor primary health care or do not have a family physician. There are few examples of programs where public health nurses, nurse practitioners and family physicians are working with mental health programs, and we believe that this would be an important direction to follow.
As I mentioned, the Canadian Collaborative Mental Health Initiative is moving ahead on a number of the issues that we have already identified. We would also like to address briefly a couple of the other questions you raised in your report.
You asked whether psychiatrists should be consultants or members of teams. We see psychiatrists and other mental health specialists as integral members of clinical teams in primary care, even though they may be in the practice for a limited time.
You asked about the kinds of specialized services that can be incorporated in primary care. We feel that a comprehensive range of services can be included. These would include early detection, health promotion and prevention, consultation, treatment, monitoring, and even some rehabilitation services, but we would stress the need to see mental health and primary care systems as complementary. One will not replace the other. What we need to look at in future research is which problems can be best handled in which sector, and which populations can best have their needs met where, and then make sure the flow between the systems allows people to move to where they need to be with a minimum number of impediments.
We also see the need for a broad range of mental health providers in primary care. We also see the benefits of pharmacists, dieticians, care navigators, peer support programs, as well as the greater involvement of consumers and family members. We believe in a model of client-centred care. We think that primary care is in a unique position to be able to do this. Our concept of client-centred care includes the development of collaborative care plans, seeing the consumer as an active partner in treatment, the development of peer support mechanisms, and involving consumers in all aspects of planning, delivering and evaluating mental health services in primary care.
There are a number of barriers. Attitudinal barriers may be the hardest to overcome. There are also time constraints and funding barriers, but we believe that solutions to all of these problems can be developed.
You ask about funding and the cost of these kinds of initiatives. Each project will develop according to the resources that it has available. If you have fewer resources, then you adjust the kinds of services that you are able to deliver, but you focus on those that you think are the most important. If you have larger resources, then you can deliver a broader range of services. There needs to be flexibility. However, our project and others have worked out specific formulas for the amount of nurse or social work time, the amount of dietician time, and the amount of psychiatrist time to develop effective models of collaborative care.
Finally, we would address the question of how to sustain some of the gains that we have already made, because we feel we have already made substantial progress towards our goals.
One of our beliefs comes from a quotation by Einstein who said, ``Insanity is doing things the same way we have always done them and expecting different results.''
Part of our reason for existence is recognizing that our traditional models are not working as well as we would like and we really need, as part of the solution to the problems of the mental health system, to move in this direction. As I say, we have made substantial progress, but we are aware that our project ends in March of 2006.
One specific recommendation we would make would be for the establishment of a centre to promote collaborative mental health care between primary care and mental health services that could serve as an ongoing resource. It could manage websites, disseminate information, and work closely with governments at all levels because we believe, in addition to the training component, that uptake by provinces and territories of these ideas is the second important key element to long-term sustainability. We see it being as a national resource.
We are fortunate because there is a great deal of cohesiveness in this area. We have been able to develop a national strategy that could be, hopefully down the road, a plank with a much broader mental health strategy. We would like the opportunity to build on and expand this.
Once again, on behalf of all of us involved in the initiative, we would thank you not only for your time today, but for the enormous contribution you have made to the debate around where health services should be heading.
The Chairman: Thank you, Dr. Kates.
Next we have Ms. Florence Budden, President-Elect of the Schizophrenia Society of Canada. With a name like that I would make the assumption that you are a Newfoundlander.
Ms. Florence Budden, President-Elect, Schizophrenia Society of Canada: Right on, and very proud of it.
The Chairman: Even if I had not recognized the name, I would have recognized you as a Newfoundlander from your remark. We have two Newfoundlanders on our committee, and I am pretty close, in the sense that both my parents are Newfoundlanders. You are among friends this morning. You may have gone down the road, as the movie said, but you are among friends. Please go ahead.
Ms. Budden: Good afternoon. As you may know, SSC is a national registered charity that works to alleviate the suffering caused by schizophrenia and related mental disorders. Using a federation model, we work with 10 provincial schizophrenia societies and over 100 community-based organizations to provide a better quality of life for ill individuals and their families.
In addition to pursuing our own initiatives, SSC is a founding member of the Canadian Alliance for Mental Illness and Mental Health and is an ardent supporter of CAMIMH's pursuit of a national mental health action plan.
Two important aspects of a national action plan would address the role of family caregivers and decriminalization of the mentally ill. These two most very important issues were addressed in your committee's Issues and Options report. Today I will give you SSC's perspective on the role of caregivers and decriminalizing individuals with mental illness.
In section 5.4 of Issues and Options, you pose questions relating to adequate access, to resources and caregiver preparedness. The simple answer to your question is, no, caregivers do not have enough access to resources for helping their loved ones nor are they sufficiently equipped to deal with their relatives' illness. It does not take a scientific report to understand how high unemployment rates, holes in treatment services, inadequate mental health acts, suicide rates, and the relationship of mental illness and crime significantly impacts family caregivers who are often the sole support for their ill loved ones.
Respite programs, educational materials and programs, such as SSC's Strengthening Families Together, public awareness campaigns and income supports are all tools that would better support families and recognize their role in the care of mentally ill individuals. These tools would help to ensure that families are mentally and financially equipped to support their ill loved ones and would help ensure that these individuals remain productive community members rather than inmates, patients and homeless.
These types of initiatives will also empower families through education and better position them to effectively participate in the formal mental health system. Facilitating the inclusion of family caregivers in programs such as COMPUS and Minister Tony Ianno's roundtable discussions will go a long way to ensuring the expert knowledge of caregivers is recognized and implemented systemically.
One final point is this: Resources and education will be useless to families unless medical professionals formally recognize the integral role they play as caregivers and laws allow professionals to share information. If a doctor treats a person, not just an illness, then the family can be included as a vital part of the treatment team, and this will help ensure a better outcome for the ill person.
In relation to decriminalization, in section 7.1 you ask how interjurisdictional collaboration can be enhanced in the delivery of mental health services for federal inmates. This is a key step in decriminalizing the mentally ill and ensuring persons with a mental illness receive treatment, not punishment.
SSC has the following suggestions: Include an amendment in the Criminal Code that would regulate mental health courts as a means of diverting individuals with mental illness into a system that is better able to serve their needs. This interjurisdictional collaboration would need to occur as the Criminal Code is administered by provincial governments.
Whereas the court can order psychiatric treatment under the Criminal Code to restore a person to fitness to stand trial, there is no similar authority to order treatment for a person found not criminally responsible by mental disorder. We strongly recommend an amendment to the Criminal Code that would allow the Review Board to order treatment where an ill individual refuses the treatment necessary for his or her release.
Amendments like these would help address inequities that exist in provincial mental health acts and work to ensure that individuals receive the best possible treatment either in a hospital or a forensic system. It is important to note that legislative amendments should also include laws that encourage early treatment and treatment in the community when the illness precludes the person from accepting voluntary treatment and significant harm will occur if treatment is not provided.
SSC has captured these themes in a model mental health act paper, and we would be happy to share this information with the committee if you think it will be useful to your research.
In conclusion, I would thank you, Senator Kirby, and members of the committee for the opportunity to present to you today. The recognition and inclusion of family caregivers into the formal mental health system and improved interjurisdictional collaboration will go a long way to improving the lives of ill individuals and their families.
We would encourage you to also consult with our provincial societies as you travel across Canada. With such a range of issues outlined in your report and taking into account regional diversities, there will be variances in the priority of issues and preferred solutions. These consultations can provide you with a wonderful opportunity to gather all this information and truly make a difference in the lives of the mentally ill Canadians and their caregivers.
The Chairman: Thank you, Florence.
Would you please proceed now, Paul?
Dr. Paul Garfinkel, Chair, Working Committee on Mental Health, Ontario Hospital Association: I would begin by thanking you for inviting me back. As well, the OHA would commend you, senator, and your committee, for the outstanding work in your in-depth review of mental health issues in this country. We are at a cross-roads and you are shining a very important light on what could be some exciting changes.
When I visited last year, I highlighted four areas of critical need in terms of quality of care, access to care, continuity of care and accountability. It is clear to me that you heard comments on those issues clearly from everybody over and over again. I will not repeat them.
Behind that is the whole issue of stigma and the terrible manner in which we were all brought up to understand mental illness, and it is clear to me you understood this too, and the magnitude of the problem.
Last time, I talked about the importance of early intervention in terms not so differently from the model that Dr. Kates was just describing. I talked about the importance of health promotion, prevention and early intervention, and the need to invest in determinative health from a comprehensive point of view. These issues are as important as they were a year ago, but at this time I would like to focus on three other issues, and that is the national action plan, research and development, and data collection and information. I would stress that the others are not any less relevant, but I believe you have heard a lot about them. To me, an action plan is critical.
I understand your study has taken you to a consideration of the situation in New Zealand, for example, and you realize how impressively a plan can produce results country-wide. We believe this should come from the federal government, with a lot of collaboration. We have national organizations that are the appropriate partners in this, but we need national standards to be established for a whole range of activities including promotion, prevention, education and treatment.
The partnership should be federally funded and establish clear roles and responsibilities for the provincial, territorial and federal governments. We believe that the broad view of health — I think you have heard this articulated many times — including the determinants of health, employment, client support, housing, social support, are critical in any plan that is to be developed.
On my second point, research and development, I would say that we know more about the brain from the research we had done in last 10 years than we know from the previous 100 years. It is an exciting time in neuroscience. It is also an exciting time in psychological and psychosocial science in being able to properly tease apart variables that could be of relevance. At the same time, we know very little about the causes of mental illness. Understanding mechanisms will be hugely beneficial to treatments down the road.
We also have areas of treatment evaluation and health service delivery that are crying out for research. This are has not been properly addressed anywhere in our country. We need to develop benchmarks to improve system performance. We need to strengthen accountability and encourage the development of new evidence-based approaches to treatment.
We also have an important knowledge translation function that has not been well addressed. At the center where I work, we have some outstanding basic neuroscientists and clinicians, and the interface between the two is a rare clinician scientist who has to be nurtured to be able to translate the basic new information.
We strongly agree with your assessment that Canada lacks a national information system. We need to measure the mental health status of Canadians. We need to evaluate policies and programs, and we need to share information better.
We strongly urge the development of a national information system, and we recommend that you review the evidence with regard to one type of assessment called the RAI, the Resident Assessment Instrument. This is a most useful, standardized comprehensive data collection system that helps you understand the individual client. It helps you understand your unit of care, and it helps you understand a system of care if you are planning one.
All Ontario hospitals will be implementing the RAI in October. We have collected data on thousands of people working up to this, so we have a lot of experience, a lot of knowledge in how it can be beneficial. We do think it could serve as a foundation for a national system. As my handout indicates, work on the RAI is being studied internationally; and there is a lot of experience in five or six other provinces.
I would just conclude by saying that your work to date has had a huge impact on energizing our community, and we thank you for that. As you have heard, over and over again, everywhere you go, we have serious problems. We are now an active therapeutic field. We can help people tremendously if we can put it together, and I think with the right national action plan, with the right research and with the right accountability, we can put it altogether. Thank you.
Senator Cook: I am looking at this issue through the lens of rural Canada, in particularl. Where I live, services are not readily available and there is a shortage of human resources. Would you elaborate on the role of the nurse practitioner?
You talked about funding strategies, and about the need for research and pilot projects. Is this an area in which the federal government can play a role, given that health care is delivered in a provincial jurisdiction? Would new public health agencies be a part of that? I would like your opinions on those two issues.
Dr. Kates: With regard to rural or underserved areas, you might consider different models of collaboration. That is not the only solution, but it may be the most significant, particularly now when we have new technologies. For example, a psychiatrist can be available to back up a nurse practitioner or family physician in any part of the country. We can have models where mental health specialists can be linked with a group of providers by email or through a web-based program and exchange clinical information almost in the same was as is happening with Telehealth Ontario.
There is no question that we need to think differently about how we use the resources. Certainly, nurse practitioners are able to perform many functions with support and backup. I believe there is a project through Health Canada with the First Nations' branch looking at nurse practitioners who are providing specialized consultation to nursing stations in communities in each of Canada's provinces. They, in turn, have backup available.
We need to look at step models, that is, we examine how we can provide the maximum support to those in the front line, whether it be in person, whether it be through flying, whether it be through telecommunications, and that they know that they will have support and resources available and not be hung out to dry, if you like, that there is a sequential system that works its way through.
Senator Cook: We look for funding in the strangest possible places. I am always looking for a solution. Do you see your pilot projects under an umbrella called ``research'' and, if so, what role could the federal government play in your funding?
Dr. Kates: From our point of view, one of the critical teams is in the Primary Health Care Transition Fund which has not only supported programs like ours but it has also, for example, in Ontario, allowed for the development of about 120 projects which have a research evaluative component. When you put together what those projects consider, I think we have an almost unequal picture of the potential of a reformed primary health care system.
The answer to your question is, yes, definitely. There are a number of different components. One is research and evaluation. Another is considering how models of shared care can be adapted to meet the needs of different communities and different populations. The third is a kind of demonstration project that could come up with models that other people may be interested in starting. I would look to any of the resources that are available to fund those kinds of initiatives.
I believe that the federal government has a major role to play both in funding and as a kind of an engine to drive some of the provincial activity.
Dr. Garfinkel: With regard to funding, senator, you mentioned the new public health agency. As an example, the CDC in the United States allocates over 9 per cent of its funds to the mental health behavioural health area. We see a huge area of opportunity there.
With regard to the nurse practitioner question, I certainly agree with Nick, and I would push it even further. We provide the mental health services in Baffin Island and we have done a fair bit of work in Sri Lanka where there are few psychiatrists and, in fact, few doctors. The Sri Lankan mental health system is hugely dependent on community mental health care workers who are trained and knowledgeable. The same applies to Baffin Island. You require really good training and, as Dr. Kates emphasized, you need the backup, whether it is by Telehealth, by email or by direct contact. When they need it, these people need help immediately. They can do huge amount of work if they get that help.
Ms. Budden: As a nurse myself, I have had the opportunity to work with primary health care nurse practitioners in the mental health system. The advantages are obvious. These nurses have a knowledge of mental health as well as primary health care and they provide services.
For example, the Waterford Hospital in Newfoundland was a provincial psychiatric facility and they had three nurse practitioners who were primary health care nurse practitioners in the mental health system because they were having difficulty recruiting family physicians to their programs to provide mental health services, to provide the primary health care services. They funded education for three nurses who had a background in mental health and many years of experience, and now they provide those services on a short stay assessment unit, and on acute care units. They also provide some outpatient services to clients who would normally not have family physicians in the community. These services are very beneficial and essential. They work collaboratively with the family physicians and the psychiatrists. Although the road initially was difficult, it did work out well and I must it is because of the professionalism of three individuals. Senator Cook knows one of them very well.
I would like to see more of that in Newfoundland in a primary health care model and a mental health services plan. The hope is to bring nurse practitioners into the primary health care model to provide primary health care services, but particularly those who have a background in mental health.
Nurse practitioners have a great understanding of the role families play in the care of clients, so they would utilize families very well and include them as part of the treatment team. That is something that we want to see.
We do have primary health care nurse practitioners throughout rural Newfoundland but, unfortunately, many of our recent graduates do not have jobs, and have had to go back to working as registered nurses until jobs become available. I think the federal government needs to move forward and push the strategy for nurse practitioners as a good alternative for primary health care services and a necessity in the communities, especially in the rural areas. Many of these nurses who work in rural areas want to stay in the rural areas. They have the background and the understanding that is needed to work in those communities. We should encourage the federal government to encourage the provincial governments to move the strategy forward.
When a class graduates in rural Newfoundland, since we have many rural communities, no nurse practitioner should be out of work. Jobs should be available.
The federal government definitely has a role in funding strategies. I also believe that the public health agency has a role but that they need to work collaboratively with other parts of government who provide services for individuals with mental illness and somehow find a way to integrate the funding together so that all aspects, housing, support, medical services and everything is funded appropriately. The federal government has to work collaboratively too ensure that they are funding things appropriately and not just a little bit here and there.
Senator Pépin: Dr. Kates, you said that many groups do not use the centres. Why is that? Is it because of difficulties of accessibility or a lack of personnel?
You spoke about minorities. Do they run into difficulties because of the language and the culture of a group? Could you elaborate on that?
Dr. Kates: As you mentioned, there are many reasons why there are problems with access to mental health services, some of them are barriers that we put up in terms of making it harder for people to reach our services. However, there are some other barriers.
For example, for ethnocultural groups, language and cultural sensitivity are major factors. I will deal with the primary care setting. When we talk about primary care settings, we are not just thinking of family physicians, we are including in that community health centres, home care, activities that take place in the person's home. Sometimes these people are in shelters for the homeless. In those kinds of settings, people may choose a family physician because the physician is familiar with the culture or the nurse in the office speaks your first language. It makes it much easier to be seen because there is someone there who is familiar with some of the context of your problems and who can serve as a guide to the mental health worker. The mental health worker is learning at the same time as he or she is helping. That is one of the nice things about collaboration — we are broadening our skills and our understanding as we go.
Other groups face different problems, for example, teenagers. Even getting them into family physician offices is a problem. However, they are more likely to visit their family physician's office and have a problem picked up if the family physician says, ``Would you mind speaking to the counsellor who is in the office because they may be able to help with that problem?'' The teenager is much more likely to follow through in that instance than if the family physician were to say, ``I want to refer you to a mental health clinic. You you will probably have to wait six months before you are seen, but I think it will be very helpful.'' I think some of those barriers can be overcome again by bringing services to where the individual or where the problem is.
As Paul mentioned, stigma is a major factor — stigma in accepting that you may have a problem, stigma in what you might imagine people will think, even though it is not the reality if you contact a mental health service. Again, it is much more comfortable to be seen in primary care.
Senator Pépin: How is your organization structured? Do you have people coming to you from different communities, such as the multicultural community? Do your workers identify themselves so that your organization could tell a consumer that you have people from that person's community working in your office? I ask this question because many people feel that they do not have accessibility.
Dr. Kates: I think both models have a place. If there are places where there is a natural gathering point for individuals, then that would be a logical place to bring services, for example, in Ontario some of the community settlement organizations. Again, what we are looking at is how we can integrate services into those settings and provide treatment onsite.
In smaller practices there are many individuals who have connected with a family physician either because they feel comfortable because that family physician is from their own culture, or because there is a group of people to whom they can relate, and in those situations, wherever possible, we would consider trying to find counsellors, psychiatrists who are familiar with both the culture and the language, who can provide those services in the individual's environment. Our experience has been that most of those services can be provided as effectively as in mental health services. Not every problem, but many problems can be dealt with, and a larger number of people can be seen. They see a large number of people who would never reach mental health services.
Another population for consideration is the homeless. A project in Toronto looked at working with family physicians who are going into shelters supported by a psychiatrist to see individuals who may not want to see a psychiatrist, but are willing to see a family physician. The psychiatrist serves as a consultant to the family physician. This is, again, a way of providing mental health services appropriate to the culture of the individual rather than either forcing them into our model or forcing our model on to the individual.
Senator Callbeck: Florence, in your paper you mentioned the importance of the Review Board being able to order treatment for people found not criminally responsible for an act, and you go on to talk about a model mental health act paper. Was that paper prepared as a response to the House of Commons committee on the amendment to the Criminal Code regarding this issue?
Ms. Budden: No. I chair the National Advocacy Committee. Part of our strategic plan is decriminalization of the mentally ill. We were very fortunate to have as our president, John Gray, an expert on mental health acts, because of the differences in every province. Many provinces now have mental health acts that are under review. I come from a province where the Mental Health Act dates back to 1971. We are still waiting for new mental health legislation.
This paper provides information to individuals, families and groups who want to work with government to pursue a mental health act that best meets the needs of individuals with mental illness. We developed a model mental health act paper — we can certainly give you a copy of it — in which we looked at matters like the definition of mental disorder and involuntary admission criteria, procedures for involuntary examination and admission, authorization of treatment and consent, taking into account community treatment orders and considering the rights of the individual. By that I mean the patient's freedoms, rights and freedom of thought rights.
We also took into account the refusal of treatment by someone who is not mentally competent to make that decision and the fact that that can result in more harm to the individual. Starson is an example of this. We considered assisted community treatment, and rights and protections.
This was based on a book called Canadian Mental Health Law and Policy by John Gray, Margaret Shone and P. Liddle that was published in 2000. We developed this because every province had different mental health acts. Our provincial societies were asking us for support as their provinces developed these new acts, and we felt that certain components needed to be in all of the provincial acts, so we developed this paper based on that.
Senator Callbeck: I raise the matter of the Review Board being able to order treatment because that issue is dealt with in Bill C-10 which is now before the Senate and will soon be referred to a committee.
Ms. Budden: Yes. The Schizophrenia Society of Canada made a presentation to the Justice Committee on Bill C-10. This was one of the issues we raised at that time as well.
Senator Callbeck: Do you remember what other issues you raised?
Ms. Budden: I did not attend the committee meeting, but I can certainly give you a copy of the presentation so that you can see what issues were raised. The issues were similar to those I mentioned here as they relate to decriminalization. We suggested that the Review Board could order treatment when an ill individual refuses treatment which is necessary. In some provinces, Ontario for example, they can be ordered to stay in hospital, but they cannot be treated. In Newfoundland it is different. We can treat. Under involuntary admission, we can provide treatment.
We must consider, however, the rights of the individual. Our outlook is that we should not force treatment but, instead, work with the individual so that he or she will accept treatment. However, we can administer treatment under our act. In that respect, it is quite different.
Senator Cook: My background is education, so a lot of children have gone through my hands, and some of them have landed here in Ontario. Now, since they have come here, I understand that a few of them have been diagnosed as schizophrenic.
Is there a symptom that educators can look for to recognize this illness so that, if there is a problem, teachers could be aware of it and children could be guided towards treatment?
Ms. Budden: The Schizophrenia Society of Canada has a reaching out, educational program for junior high and high school students about schizophrenia, and it is also a complete program for teachers. It gives them all the information they need about schizophrenia. It helps educate the teachers and the students. Teachers will often notice changes in their students but sometimes, because of large class sizes, symptoms might be missed. Peers are more likely to notice changes. Their friend may suddenly become withdrawn, makes bizarre statements and start to do bizarre things. Peers understand that these things may be a symptom of mental illness and they will talk to a teacher or a counsellor and encourage the individual to get help.
We are trying to destigmatize mental illness in the school system and, to that end, we have this program. I know from Newfoundland's perspective we have managed to get it on the curriculum as a recommended program for study. It is also on the curriculum of some other provinces. We need to educate the teachers and we need to educate the students. Some of the symptoms that an individual may exhibit in early diagnosis may appear to be teenage changes because a lot of teenagers become withdrawn and they may do things differently. This program will help people recognize certain symptoms. We are not ringing alarm bells with regard to all teenagers, we are just making the information available. We are telling people where they can go to find this information, and telling them what services are available to them if they need help. That type of information is very important.
Dr. Kates: I believe this also applies to primary care. Family physicians are in a unique position to be able to recognize, when they see a 15-year-old or a 16-year-old kid, that there is something different about a certain kid. They may not be able to put their finger on it. The patient may not be exhibiting psychotic or even pre-psychotic symptoms but the physician may be aware of change.
Families that are in contact with their family physician may express concern about one of their members. Primary care will not to rush to a diagnosis of a psychotic illness, depression or anxiety, but the physician is in a position to keep an eye on a kid and make sure that, from time to time, he or she comes into the office so he can monitor any changes. When you have collaboration, the family physician can then get a confirmatory opinion from someone else.
We know from the literature that, if family physicians have supports available, they are much more likely to detect and diagnose a problem. If they do not know what to do with it or there are no resources available, they are more likely to let it pass or wait and see what happens down the road. There is a lot of literature around addiction problems. With that kind of partnership, the family physician or primary care provider has a longitudinal understanding of the individual.
This also applies to the school system. It is important to have someone who is in a position to notice that something is going on. That person may not be sure what to do, but we do not have to wait until a kid is sick enough to require mental health service.
One small anecdote, I was asked by a family doctor to see a five-year-old girl in his office who I thought had obsessive compulsive disorder, and I discussed it with the family physician. He told me that he had not realized that young people could get OCD. The next time I was in his office, there were three other children under the age of eight all of whom he had concerns about. He could not put his finger on what it was and two of those did actually have some symptoms of OCD. In a partnership we can bring in community resources.
Dr. Garfinkel: Your question is a good one. We know that, the earlier you recognize schizophrenia and treat it, the better the outcome. However, we need to be in a world where not only one place can recognize it. It may be the family. It may be the school. It may be the workplace. It may be the primary care physician but we should all be alert to what is unusual.
I would also mention that we do not know how to prevent schizophrenia, but we have done some high-risk studies. If you have one or two parents with schizophrenia, you have a very high risk of developing it. We are running some intensive preventative programs for these people, but we do not know if we can prevent schizophrenia.
Senator Keon: Dr. Kates, I am sorry I missed your presentation, but I understand that you have done a good job of looking at the integration of health professionals. Have you put the same effort into the integration of health resources in the community, in other words, looking at not only primary care as it relates to mental health, but also at community care, emergency services, social services and so forth? Have you addressed issue? If you have, and you have spoken to it, I apologize for asking the question.
Dr. Kates: I did not mention it specifically. The key is that collaborative models are built on certain principles, personal contacts, respect and care that are truly client centred, with an emphasis on recovery and optimizing the potential of the individuals, and trying to break down structural or attitudinal barriers. Rather than taking a model and trying to make it work somewhere else, if you apply the principles, there are many examples of where collaboration can take place. One aspect would be the integration of medical specialists into primary care. For example, there is consideration of a program for the treatment of congestive cardiac failure, that is, cardiologists, respirologists and pediatricians working as part of the primary care team.
You mentioned community resources. Some of the Western provinces have gone a lot further in linking or integrating primary care with mental health with community programs. In our vision of what primary care could look like, it would include not only the traditional providers of care, but also, perhaps, someone from the EI office or Workers Compensation who would come in once a month to help individuals who are having difficulty completing forms. It may include someone who works in one of the community self-help groups who brings a program into the primary care setting. It may be a family member who again can be supported to develop a program in the primary care setting.
All the other interfaces you mentioned, such as emergency, with primary care or mental health, all present unique problems. However, there are a lot of common elements based around the kind of things I mentioning before. We have to consider how we can sit down together and look at this as a common problem rather than your problem or my problem and of put aside the past come up with new solutions. That is how the kind of projects that we have been involved with and the kind of solutions to the problems you are talking about can evolve.
Senator Keon: Ms. Budden, everybody I think is tremendously supportive of the expanded role of the nurse. In my own professional life, I have had extensive experience with clinical nurse specialists, nurse clinicians and so forth who did a wonderful job.
The main problem confronting you, is that you have a huge wave of retirements coming and your output is far below the 12,000 that we in the Senate committee recommended. How are you going to deal with that? Will you try to recruit nurses abroad?
Ms. Budden: I am not here representing the Schizophrenia Society, not the nurses association, but I can personally speak to your question. We need better recruitment and retention strategies. As an educator, I believe that we need to find ways to encourage our young people to stay in Canada. Some leave for financial reasons, but some leave for educational reasons. I think we have to show them the value we put on them, and we must find a way to reduce the stress that nurses face in the health care system. Those are complex issues. I do not know if the Canadian Nurses Association would be happy with me giving my opinion on that officially, but, personally I think we do need to improve our recruitment and retention strategies and we need to find a way to keep our young nurses. In Newfoundland, I teach a class of over 100 nurses, and I would say that we will lose 50 to 60 per cent of them to other places in Canada and to the U.S. because they provide better practices. These students want to go on. Life-long learning is important to nurses, and those other locations provide those opportunities to them. It is unfortunate for Newfoundland.
Dr. Garfinkel: I want to emphasize how inconsistent we have been about nursing policy and recruitment over 30 years. There is a wave where we want more nurses and, as soon as there are cutbacks, we cut back nurses. My understanding is that, in Ontario next year, there will probably be a loss of about 750 nursing positions. In our circumstances, many nurses decide that they would like to try another profession, perhaps real estate or business. They do not want the headache of investing their time for two years or so and losing their jobs again.
Senator Keon: Ever since President Kennedy started closing asylums in America, there has been a phenomenon of decanting hospital resources into communities. That is continuing, but Ontario has a long way to go. About 20 per cent of hospital resources, in the opinion of the senior bureaucrats here in Ontario, have to come out of the hospital system and go into the community. How will you cope with that in the hospital system?
Dr. Garfinkel: This is a question we struggle with every single day. The mental health system has to be strong in four areas: The first, as you have heard from Nick, is the area of primary care, and I believe significant strides have been made in that area in the last decade. The second is in the community. The third is in acute care, general hospital. The fourth is in the mental health system.
On the last three, we have significant problems. We have problems in integration. What we have learned from our past, not from the United States, is that you can close a mental hospital and put none of the resource into care. We closed the Lakeshore Hospital in 1971 and turned patients into street people because the money was scooped for other phenomena.
I believe the level of community care is outstanding. We should normalize care for people as much as possible and admit people to hospital only when required for safety or security reasons. However, community care is not cheap care. Community care requires specialized resources with knowledgeable people who provide care and treatment.
We have a treatment program for psychosis involving 100 people with schizophrenia. Our team goes out to the homes in Toronto and keeps these people at home, very successfully. It is an excellent treatment program. It involves 100 people who, for sure, would have been in hospital. However, it is expensive. You need a doctor. You need a nurse. You need a social worker. You need a whole team.
I believe for the first time, the hospital system and physicians in the last five or seven years have been looking more broadly at the determinants of health and what it means to have an illness and to have a decent quality of life. Physicians and hospitals no longer say to their patients, ``You're out of my care. I've treated the psychosis for the last month. It's now somebody else's turn. Here's a subway token. Good-bye.'' That no longer happens as it did before. People are interested, but the connector at the other side is rarely there.
Ms. Budden: I believe family members need more support in the community because they are often the sole supporters of an individual with mental illness. Not only should we include it in health human resources and other human resources, but we also need to find the supports to assist the families in the community. It will take a burden off the health care system if we support the families. We know from research that individuals who have family support are more likely to have a better prognosis, a better recovery and, therefore, they would not be hospitalized as much. We need to support our families in the community as part of the treatment team and not as a body outside the treatment team.
Dr. Kates: I think the concept of ``hospital or community'' is an anachronistic one. It belongs to an era of 50 years ago when people did live either in the community or the hospital. We have to view hospitals as community facilities; and hospitals have to see themselves as part of the community and they must make services more mobile, not limited to the walls of a facility. A hospital must be able to exist within a community, even though some of the services are delivered in non-traditional locations.
A simple example is hospital specialists, not just physicians, being able and willing to spend part of their time working in community settings as part of their hospital responsibility. We have to think about that division completely differently.
Dr. Garfinkel: To go back to your original question, we need transition funding to do this properly. You don not just close a hospital and say that you will build supportive housing over the next eight years. That will cause the same problem we had in the 1970s.
The Chairman: First, Dr. Kates, about 45 years ago New Brunswick got around this problem by coming up with a wonderful idea which they called the ``extramural hospital.'' This was in the old days when the federal government paid 50 per cent of hospital costs. They effectively redefined ``hospital'' to include the homes of individuals who had been discharged from hospital because they wanted to provide home care. Maritimers are terrifically creative at figuring out to get around situations. It seems to me that the challenge will not be for policy-makers to think of the hospital as the community, it will be for the people in the hospital to think of themselves as part of the community. That raises one question in my mind.
In your report you mention the need to encourage GPs to move into the shared care model. This is just borne out of frustration. At some point will we be prepared to stop encouraging and to actually require? I have to tell you that, when I look at the OHA data in particular, I note the lack of progress at moving into shared care models and the huge resistance on the part of a significant number of the GP population to do this. However, I an cognizant of the fact that they are paid out of public funds and that the reality is that it is both inefficient and ineffective, relatively speaking. At what point do those of us in government stop being nice and make this a requirement?
Dr. Kates: I am reminded of the comment of Yogi Berra, the Yankee manager, when asked what the secret of managing a baseball team was, and he said. ``It's to keep those who hate you away from those who are undecided.''
We need a two-part strategy. The first stage would be to work with those who have not yet made up their minds, and then to develop models that work and be able to demonstrate that this is an effective way of delivering care and that people who work in these models believe that this is a rewarding way of delivering care.
The Chairman: All of which I believe. I believe that, in a sense, real progress is being frustrated. As my wife would tell you, I do not have a lot of patience for that kind of thing. It does seem that at some point government will have to get substantially more assertive than it has been to date.
Dr. Garfinkel: We have made huge progress in education and having people appreciate what treatment will be useful and is required, but the funding mechanisms work entirely against it. I believe that primary care reform is our number one issue in Canada, and not just for the benefit of the mental health system. It is for all of us.
The Chairman: Senator Keon has been saying that.
Dr. Garfinkel: I will be long gone by the time we have primary care reform, so I would support a tougher stance.
The Chairman: We will take you up on your invitation to explain to us your information system which, as you described it, applies only to people in psychiatric beds. However, the reality is the vast majority of people receiving mental health care are not in those beds, they are in the community. You say that you will try to develop a similar type of database for those people.
Dr. Garfinkel: We have this system, and we are experimenting with it in a number of communities in Ontario. We have a modified version that can be used by the physician in his or her office. If the physician makes an inquiry, he will get information about his patient's needs, including housing and a whole range of items. It is not just mental health information. It is a very exciting model and I would be happy to spend some time explaining it to you.
The Chairman: We would like to understand that.
I would thank all of you for appearing before our committee today. We appreciate you taking the time to be here.
The committee adjourned.