Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 21 - Evidence - June 9, 2005 - Afternoon Meeting
EDMONTON, Thursday, June 9, 2005
The Standing Senate Committee on Social Affairs, Science and Technology, met this day at 1:16 p.m. to examine issues concerning mental health and mental illness.
Senator Joan Cook (Acting Chairman) in the chair.
[English]
The Acting Chairman: Senators, Ms. Geraldine Cardinal, who was to appear before the committee this morning, is with us this afternoon. We also have with us Mr. Sykes Powderface, Ms. Gloria Laird and Ms. Elsie Bastien.
Ms. Cardinal, do you have a presentation to make?
Ms. Geraldine Cardinal, as an individual: I do not have a presentation to make right now.
The Acting Chairman: Take your time. If you would feel more comfortable, we will move on to the next witness and then you can come in when you are comfortable with speaking. Would that be all right?
Ms. Cardinal: I will answer some of the questions that you may have. I would let you know now that I just came back from my older brother's funeral.
The Acting Chairman: It is a difficult day for you.
Ms. Cardinal: Yes, it is.
The Acting Chairman: Perhaps the rest of the panel could identify themselves.
Ms. Elsie Bastien, Aboriginal Liaison Coordinator, Alberta Mental Health Board: With the understanding that we had five to seven minutes per speaker to make a submission, as a group we got together and developed our submission. We have a formal presentation which the group has asked me to read to the committee. We will then respond to any questions.
Mr. Sykes Powderface, Co-Chair, Alberta Mental Health Board, Wisdom Committee: As Elsie mentioned, we have a written submission that we are prepared to submit, and we are prepared to expand orally on points of concern to the committee.
Ms. Gloria Laird, Co-Chair, Alberta Mental Health Board, Wisdom Committee: I thought before we started we would give you some background on our Wisdom Committee.
The committee is comprised of elders and community people from across the province of Alberta and Nunavut. We have elders and community people consisting of First Nations people, Metis people, and a lady from Nunavut.
Some of the concerns and issues we will be raising have been raised through our committee regarding Aboriginal mental health. We look forward to sharing this information with you.
In everything we do in our Wisdom Committee, we start with prayers and a sacred ceremony. Those form part of the meetings that we have three times a year.
The Acting Chairman: Ms. Bastien, you may proceed on behalf of your group.
Ms. Bastien: Senators, we would like to take this opportunity to thank you for inviting us to speak today on this topic.
Given our present time frame and the amount of material we would like to discuss with you to give this topic appropriate and respectful coverage, we recognize that we will merely uncover the tip of the iceberg and, like the iceberg, what will remain uncovered is immense.
Mental health amongst Aboriginal people can be described as bleak. The quality of life that can be presented through statistics on the socio-economic indicators of Alberta and/or Canadian society does not accurately reflect the quality of life of Aboriginal people.
Although Aboriginal people make up only 5 per cent of the Albertan population and approximately 3.3 of the Canadian population, we are overrepresented in intrusive social programs including incarceration rates of 31 per cent in Alberta, 73 per cent in Saskatchewan, and 57 per cent in Manitoba. In child welfare involvement, Aboriginal children are placed into care at a rate of 4.5 times that of other Canadian children. We are also more likely to have more suicides, increased alcohol and drug abuse, domestic violence, et cetera.
Statistics Canada figures tell us that our Aboriginal population is primarily young people under the age of 25 with little success in the primary education process and unemployment rates of up to 85 per cent in some communities, which is becoming a growing concern for the next generation labour force. Life chances for our children as described in sociologic terms remain poor as the majority of our population lives below the poverty line.
A report by federal bureaucrats states that the high level of social stress and conflict found in Aboriginal communities is morally, ethically, and politically unacceptable. It also reports that nearly half of Canadians believe that the standard of living of Aboriginals is the same or better than that of the average Canadian and that 40 per cent believe that Aboriginal people have themselves to blame for their problems.
A study by Cardinal tracked the usage of First Nations people in Alberta in the year 2000 and compared their usage of the health care system with that of a control group of non-First Nations people in the same category of age sex, and geographic locations. Some of the conclusions that can be drawn from this study include the following: that the statistics representing Alberta Aboriginal people are higher in illness diagnosis, with the exception of cancer, in comparison to the non-Aboriginal control group; that Alberta Aboriginal people are hospitalized for a longer time than non-Aboriginal people for mental health reasons, with a minimum of one week's hospitalization; and that the utilization by Alberta Aboriginal people of all health facilities is higher than the control group, with the exception of community mental health clinics. That is the only facility that is used less by Alberta Aboriginal people when compared with the usage bynon-Aboriginal people.
The present mental health system does not know how to meet the mental health needs of Aboriginal people. Yet, considerable Aboriginal expertise and best practices in Aboriginal mental health are available as a potential foundation for appropriate mental health services strategies.
The answers to this are available through communication with our elders and through the numerous studies and reports that have been prepared after consultation with Aboriginal people, including the RCAP and other data, yet the appropriateness and the accessibility of resources and services continue to be limited.
The solution will begin by ensuring that Aboriginal people are involved in all stages of the collaborative movement from planning, design, implementation and evaluating program delivery. The problems are community based and need to be defined and determined by the community.
Mental health is a concern for Aboriginal communities not because Aboriginal people have higher rates of severe mental illness such as schizophrenia, but because so many show signs of low level yet debilitating disturbances. The indicators of this are the high rates of alcohol and drug abuse, suicide, accidents, violence, as well as educational failure, unemployment and incarceration.
Many factors have contributed to the present situation of Aboriginal people. Prior to European contact, Aboriginal societies were strong and self-sufficient. While Aboriginal people were never conquered, the process of colonization resulted in debilitating losses. Policies of displacement and assimilation, for example, the residential schools, separating children from their parents in the community, the forbidding of the use of their language, and the banning of social and spiritual practices deprived Aboriginal people of their traditional, social, economic, and political identity and empowerment. There is clear, compelling evidence that the long history of cultural oppression and marginalization has contributed to the high levels of mental health problems found in many Aboriginal communities.
There is evidence that strengthening ethno cultural identity, community integration, and political empowerment can contribute to improving mental health in this population.
For the majority of Aboriginal people, it is important to approach mental health from a holistic wellness context where health means balance and harmony within and among each of the four aspects of human nature: physical, emotional, mental and spiritual. Holistic wellness in Aboriginal culture is inseparable from emotional, physical, mental and spiritual health. A holistic approach combines cultural sensitivity and proven clinical practice with traditional healing methods.
Tradition holds, and it is widely believed, that every action in life is centred on the spirit. Spirituality is an integral component of all actions and encompasses all which are prevalent in the world view. There must be balance and, subsequently, a responsibility to seek out ongoing balance and interconnectedness of relationships.
I will now speak to some recommendations. Then we will give you some written responses to some questions in your third report.
The goal of this portion of the submission is to identify key components, within a holistic context, in improving mental health delivery in Aboriginal communities that correspond and complement the diversity of Aboriginal communities. The goal can be implemented through the integration of the following practice methods within the design of mental health in Aboriginal communities: incorporate Aboriginal community values, protocols, into the methodology when working with Aboriginal people, acknowledging that Aboriginal people are not a homogenous group; educate policy-makers and program developers about the unique situation — consider thesocio-economic effects of the historical process of Aboriginal people; identify ways for mental health to be more reflective, holistic, including the socio-economic implications of the human ecology, and the unique needs of the Aboriginal community; explore ways to provide resources and to facilitate approaches to increase Aboriginal communities' capacities. We must increase access to culturally appropriate services for Aboriginal children and families and provide training opportunities for those who serve them.
We should develop resources for Aboriginal mental health to include service provision for families and children with FASD and present social issues that include child prostitution and Aboriginal addictions.
We must explore, coordinate and develop models of integrated services that will combine the best practices of traditional Aboriginal holistic healing methods with mainstream mental health care. We should promote resource strategies for Aboriginal culturally relevant services to Aboriginal people.
We must target research to include a communitycapacity building intervention component that is inclusive of the individual, the family, and the entire community, with a longevity component. At a community level, research has shown that the success of program development and delivery is enhanced when the program includes community capacity-building interventions that encompass the individual, the family and the entire community, and that the process factors in other issues that impact clients' lives such as housing, environmental factors, inappropriate educational systems, poverty, lack of comprehensive and responsible health care, high rates of Aboriginal children being apprehended by Alberta Child Welfare and placed in non-Aboriginal homes; and a lack of traditional culturally orientated parenting skills.
We can no longer ignore the political and economic consequences of the poor mental health of our Aboriginal community and its implications on individual and community healing. These must occur together as the individual is not separate from the community to which he or she belongs.
We will now respond to some of the questions. We have a joint response. In preparation for today's meeting, we focused on some specific questions in your third, interim report, Mental Health, Mental Illness, and Addictions: Issues and Options for Canada.
Question 1.2 on page 7 is: What mechanisms must be put in place to deliver services and supports in a culturally appropriate manner? Research demonstrates that the present level of programming and services does not evidentially impact the continued overrepresentation of Aboriginal people within our health and social systems. One variable for consideration may lie in the definition of a problem that subsequently will limit our solution alternatives. How one defines a problem will provide the options for the solution.
Within traditional social thought, mental health has foundations in the medical model which is based on reducing the prevalence of the disorder or ameliorating the disorder.
The domain of mental health prevention presupposes some natural assumptions about health that are culturally biased. These assumptions guide our solution inquiry and therefore may result in an ethnocentric solution that delivers poor outcomes and that are then subsequently tagged as non-compliance of the participants.
It is imperative that all planning acknowledges that it arises from a philosophical base, and we must begin to take into account the complex interrelationships between the physical, mental, emotional, and spiritual. These mechanisms, once defined as our indicators, will challenge our work and preclude the design of a more holistic approach that is more appropriate for the target population.
Research concludes that the historical governmental influences through colonization, with the subsequent creation of oppressive conditions, is now operationalized as internalized oppressive dynamics which can be significantly found within Aboriginal communities and continue to perpetuate anomie, horizontal violence, and other dynamics that Duran Duran calls "The walking wounded.''
Aboriginal people will predominantly identify significantly more psychosocial and environmental stressors as precipitating suicidal ideation. This suggests that planning needs are more of a holistic nature. When addressing the mental health needs of an Aboriginal community, it is difficult to ignore the impact of social, economic, and health determinants. Any work with Aboriginal people requires an awareness of the historical process that continues to impact present day conditions. Historical awareness is premised on the belief that only through understanding a people's history can an individual begin to develop an understanding of the present day issues. It means that we promote practices that are respectful of people's relationship to the world around them and the ways in which their relative power and prestige shapes their ability to realize their goals.
On page 7, question two, you ask: Is there a specific role for the federal government, given its responsibility for the promotion of multiculturalism?
The majority of Aboriginal people perceive multiculturalism to reflect the empirical description of an ethnic reality in Canada specific to immigrating minority groups. That includes a prescriptive statement on ideas and ideals that extols their virtues of tolerance and diversity to further economic growth within the global markets.
The main objective of the policy of multiculturalism is to promote the cultural heritage of minorities and to break down discriminatory attitudes and cultural barriers to promote the full participation of minorities in society. The policy is limited, with its focus on cultural barriers with little to no recognition of the systemic, historical, and structural roots of racism and ethnic inequality.
The federal government, within its responsibility for the promotion of multiculturalism, might revisit the focus and acknowledge the systemic, historical, and structural roots of racism and ethnic inequality, which would certainly impact changes in employment practices, housing, and education practices, and which would, in the long term, provide a positive impact on the mental health of all Canadians.
Question three on page 7 is: What can the federal government do to help ensure that language is not a barrier to receiving needed care?
In addressing the mental health of Aboriginal people, one cannot understate the importance of working in partnership with Aboriginal people, provincial health authorities, First Nation and Inuit health authorities and, in doing so, ensuring the need for appropriate translators and interpreters as a necessary component to ensure that language is not a barrier to receiving care. The issue in regards to language encompasses the speaker's responsibility to speak in terms that are based in the listener's reality. As professionals, we need to ensure that how we speak is engaging and not intimidating.
In paragraph 2.1 of your third report, you ask: Should each provincial government establish an agency or a department with the prime responsibility for children and adolescent mental health?
Our response to that is yes. Services for children's mental health are sadly lacking. There are no Aboriginal, culturally specific programs for our children and our youth.
You also ask: Should researchers in mental health devote more attention and resources to issues affecting children and adolescence?
Our answer to that is yes. There are no culturally appropriate services. Children, youths, and families must have the option of being able to access elders, traditional teachers, healers, and medicine people.
The next question is: Who should take responsibility for carrying out an environmental scan to determine what programs exist and identify duplication among governments, departments and organizations, significant gaps in programming, and how best to maximize the effective use of available resources?
"Responsibility'' is typically defined as moral, legal and mental accountability. Within the government it also includes monetary or fiscal responsibility. It is necessary that Aboriginal governments be engaged without abrogating or derogating from treaty and Aboriginal rights, and Health Canada must be involved in providing services to First Nations people.
An environmental scan can be cost shared between the federal and provincial governments through the hiring of an independent, non-partisan Aboriginal evaluator within each province to assist in linking with gatekeepers or stakeholders to respond to the environmental scan. It would be an opportunity to explore questions such as: Why are services not being utilized? What type of programming would be more appropriate?
An environmental scan may include an evaluation of service delivery which, in simple terms, is based on measuring outcomes based on a hypothesis. Typically, poor outcomes are determined as individuals' non-compliance, whereas poor outcomes or errors are the result of an application of an imperfect theory.
An error or poor outcome is an indicator of incomplete data or an inadequate hypothesis that did not result in a successful completion of a certain purpose and/or intent. It is imperative that culturally appropriate program indicators are included within the proposed environmental scan.
We will now touch on other components that may be included. We need to develop baseline data of program and service delivery usage by Aboriginal populations. It is important that mechanisms be developed to systemically collect and analyze longitudinal Aboriginal health information. A centralized focussed approach will be helpful to coordinate, foster comparability, and create linkages among Aboriginal health and data sources. The result will be a strong foundation for decision making in the development and implementation of community-based strategies.
Research that addresses the use of direct service referrals by providers, employers, schools, family members, self- referrals, and others is needed. This research will help communities understand how to make better use of available resources. Augmenting knowledge about service utility rates can increase awareness about who is not being reached and how better to include these individuals.
Stigma also influences utilization rates. Understanding what contributes to the stigma in a particular community and what can be done to minimize the effects of stigma can help the community develop more extensive outreach programs.
On page 14 of your report you ask: What should be the top priorities for the federal government as it starts the process of changing the way it delivers mental health services and addiction treatment to Aboriginal Canadians?
Funding development requires strategies based on the level of need for services for Aboriginal people and their communities. Issues of access, delivery and capacity will inform the necessary level of resources required. Collaboration with existing partners such as Health Canada or local wellness centres can produce creative strategies reflective of local needs and customs.
Integrated community-based service delivery strategies which address the determinants of health and ensure that services are available and accessible in the communities where Aboriginal people reside are integral to successful mental health provision. An integrated community-based service delivery strategy and system are required. We can no longer support an approach that is piecemeal in nature, project based, and with unrealistic expectations.
It also requires that an integrated community-based service delivery strategy and system be developed with culturally-based mental health wellness service providers who are educated to become culturally competent to serve Aboriginal people. Mental health providers can only create an environment of culture safety for Aboriginal people if they have been trained to understand and accept the cultural, linguistic, tribal, geographical, economic, political and community context of the various Aboriginal communities. Failure to grasp the significance of these contextual factors often leads to stigmatization, misdiagnosis, and inappropriate treatment.
Capacity building approaches must identify the strength and recognize the expertise within each Aboriginal family and community. Designing and implementing a human resource strategy would include a comprehensive workforce plan outlining strategic priorities and strategies that encompass the unique needs of Aboriginal staff and consumers/ clients. It would also recognize the opportunities and benefits to the mental health system in training, hiring, retraining, and supporting a workforce that reflects the cultural diversity of our local communities.
Aboriginal staffing at every service level, including traditional healers and elders, must be part of an integrated service provision. Cultural awareness training and orientation should be provided to mental health staff as well as other service providers, including educators, police, social services providers, children's services providers in both facilitating access to mental health services and in providing prior services that support mental health wellness.
Designing and implementing a research evaluation requires that Aboriginal people assume a leading role in research. Evaluation and planning related to the design and delivery of Aboriginal mental health services, requires that the participants be part of the process as it relates to specific communities.
A research guide should be developed and identified for the design, implementation and dissemination of information. It must acknowledge Aboriginal cultures and protocols.
I will now touch on funding development as well as information collection and management. We acknowledge that there is little information on the prevalence of mental health problems among Aboriginal people in Canada. I would refer to your first report which was published in 2004. Therefore, considerable work needs to be done in this area to gain an accurate picture.
An accurate picture would be data not generated from a Western medical model, which is our current practice, but generated from an Aboriginal world view on health and wellness.
Finally, all research and data collected on Aboriginal people needs to be spearheaded by Aboriginal people and be supported by the National Aboriginal Health Organization guiding principles that are Aboriginal ownership, control, access and possession.
Those working with Aboriginal people must follow proper protocols and approach spiritual elders and traditionalists to receive spiritual direction, guidance, and sanctions. Cultural clashes occur when Aboriginal and non-Aboriginal people work together because of their different world views. This creates internal and external differences that interfere with Aboriginal peoples' access to appropriate mental health services.
There is much shame and stigma associated with having mental health problems. There is also a lack of information about mental health issues. Therefore people are not diagnosed or treated until their condition becomes chronic and difficult to treat.
It is important to be able to relay information about mental health issues at a grassroots level. For example, medical terminology is difficult to understand in most societies, including Aboriginal communities. Culturally speaking, it is often considered impolite to ask questions, so one must listen. This often creates misunderstanding.
Urban Aboriginal people have a difficult time obtaining mental health services, resources are often limited, and many urban Aboriginal people cannot afford to pay for appropriate medical services or access traditional Aboriginal treatment due to the poverty and the lack of transportation. Sweat lodges are not available in the cities. Urban Aboriginal people who would choose to follow the traditional way find it difficult to do so.
What would be the most appropriate structure to ensure that Aboriginal peoples have input into the design of services they need? The answer is internal organization and quality control through performance measures. The organization can develop internalized quality control by developing performance measures that include the following: recruitment and employment of Aboriginal personnel in a ratio that is reflective of the potential Aboriginal population served; the development of employee retention strategies to retain Aboriginal personnel that support cultural safety; the provision of culture training programs appropriate to areas served; the development and implementation of appropriate outreach Aboriginal programs; the development of mechanisms to ensure that Aboriginal representatives are members of the consultation process; and the building of relationships with Aboriginals and their communities.
How can the federal government organize itself to deliver those services most efficiently and effectively? The planning and management of effective Aboriginal mental health services requires both formal and informal intergovernmental and interministerial collaboration. Aboriginal governments need to be engaged without abrogating or derogating from treaty and Aboriginal rights. As well, Health Canada must be involved in providing services to First Nation people.
From the outset, the design, planning, and implementation of mental health and wellness services need to adhere to the broad principles that come from Aboriginal people. The Royal Commission on Aboriginal People, 1994, lists four principles. Equity of access to health and healing services and equity of health outcomes is the constant objective. There should be holism in approaches to problems, their treatment, and their prevention. There should be Aboriginal authority over health treatment, promotion, and prevention systems and, where possible, community control over programs and services. The fourth principle is the diversity in design of systems and services to accommodate differences in cultural and community priorities.
Integral to any research, evaluation, or service implementation project is the principle that Aboriginal people assume a leading role. In addition, a guide needs to be developed or identified for the design, implementation, and dissemination of information.
This guide must acknowledge Aboriginal cultural approaches and protocols that are identified and maintained within specific Aboriginal communities. Outcomes, indicators, and measures that relate to Aboriginal programs and services need to be developed in collaboration with affected Aboriginal communities.
You ask: Should the federal government offer financial incentives to encourage Aboriginal Canadians to train to become mental health workers? Our response to that is yes. Research continues to support the importance of increasing access potential for Aboriginal Canadians. Scholarships and/or bursaries need to be developed and awarded to Aboriginal students working toward a whole range of disciplines in the area of medical science and mental health.
The section on homelessness needs to be addressed. The number of Aboriginal people who are homeless and on the streets is increasing. They have been asked to leave their homes or communities because of their addictions and mental health issues and they find themselves on the streets of major urban areas.
In section 7 you ask specific questions about government roles. Before engaging in any of the following activities or decision making it is imperative that Aboriginal governments be engaged, without abrogating or derogating from treaty and Aboriginal rights, and that Health Canada should be involved in the planning and management of effective Aboriginal mental health services. This will require both formal and informal intergovernmental and interministerial collaboration.
We would respond to questions one through five of section 7 in the following statement.
Planning and management of effective Aboriginal mental health services requires both formal and informal intergovernmental and interministerial collaboration. Aboriginal governments must be engaged without abrogating or derogating from treaty and Aboriginal rights, and Health Canada jointly with First Nations must be involved in providing services to First Nations.
The province must ensure that any discussion with the federal government includes Aboriginal people and honour the sovereignty of Aboriginal communities.
I would conclude with a statement that supports the following vision for Aboriginal mental health in Canada. It is the vision of our Wisdom Committee.
The lifelong aspirations and potential of healthy First Nations, Metis, and Inuit individuals, families, and communities are realized through a responsive and accountable mental health system that is recognized as a national leader in Aboriginal wellness and well being.
I would thank you for allowing me this time. I would also thank the Wisdom Committee for giving me the honour of reading their submission.
Senator Trenholme Counsell: I listened in awe to a profound presentation. You have put a great deal of work into it. Thank you all for being here, especially you, Geraldine, on a difficult day.
I wanted to ask specifically whether there is good news about the number of Aboriginal young people who are becoming educated in the health care professions. Of course, today, we are particularly interested in mental health nurses, mental health social workers, psychologists and psychiatrists. To what extent is this education happening? Is it slow, and is there some hope that more Aboriginal young people will undergo training?
Ms. Bastien: I believe we have one Aboriginal psychiatrist in Canada. Mental health and the health field generally have never really drawn in young Aboriginal people.
In the last five or six years the number of Aboriginal social workers has increased. The University of Calgary developed an access program to provide the bachelor of social work training in rural areas. One of those satellite campuses is on the Blood Reserve. There are also some in the Far North. We have increased our numbers but, in equitable terms, our numbers are still very low.
Senator Trenholme Counsell: I know that St. Thomas University in New Brunswick has a specific program where some Aboriginal young people are studying and are graduating.
Do you think that the federal government is doing enough to ensure that your people gain the expertise they need? I know you must have a balance to encompass traditional and elders' wisdom — my grandfather would say, the "schooling.'' However, schooling alone will not do it. Are we doing enough, and if not, what has to be done to empower your people to work side by side with your elders and your community leaders to address these issues?
Ms. Laird: We have an Aboriginal mental health program at the Grant MacEwan Community College here in Edmonton. They bring in elders to work with the students, so the students are taught some of the traditional ways.
A major issue we face in our community is the fact that many of our young people have lost their traditional ways and are seeking to rediscover those. There is a strong interest in those students taking the Aboriginal mental health program. However, since I work with children services here in Edmonton, I know that some of these young people have a difficult time finding employment after they finish this two-year program. Yes, more needs to be done.
Another problem some of our Aboriginal college graduates have — and this applies to even those who have gone on to university — is that they have a difficult time working in a dominant society. There is no real understanding of thegifts of our elders and our traditionalists. It is difficult to bring that knowledge into a dominant society and into large organizations such as children's services. In our region, approximately 54 per cent of the children in care are Aboriginal but only 5 per cent of the staff is Aboriginal.
The federal government needs to do a lot of work with all of our communities, First Nations, Metis, and Inuit.
Senator Trenholme Counsell: How would you rate education itself as part of the solution? Perhaps "solution'' is not quite the right word. What is required to make progress?
Ms. Laird: I have strong feelings on that. There is a very high school drop-out of our Aboriginal children. The children have a difficult time finishing even Grade 9. Few attend high school.
We have one Aboriginal high school in my location, so things are improving. However, many of the children I work with in the child welfare system miss so much schooling that they drop out. It is difficult for the children, especially in the urban areas, to make it to school.
We need more early intervention programs and morecross-cultural awareness programs for the educators themselves so that they can work with our younger children and encourage them to stay in school and support them when they are dealing with a lot of issues at home.
Senator Trenholme Counsell: You mentioned early intervention. I know something about the Aboriginal Head Start Program. What is your opinion of that program as it is in 2005? How well is it being introduced to communities? How well is it being implemented? How well is it being received? Is it getting them off to a good start or not?
Ms. Laird: I have heard good things about it. Last year I wanted to enrol my grandchild in the program but it was full. That is a good sign. It is being utilized.
A major issue we face is poverty. The families need any kind of support that they can get. Many children, especially inner city children, are going hungry. There are many family violence issues and mental health issues to be addressed. Mental health covers addiction and social issues, and those are increasing as drug additions increase. The kinds of drugs that are being manufactured on the street are poisonous and they present a real danger to the children who live in this environment. Many of them end up with mental health problems.
In the outlying communities there is real shame attached to mental health. The mental health office in the northern community is right downtown, so everybody can see who goes in and out of there. Someone told me that she would rather wait and take her son to Edmonton when she could afford it, than have the whole community know that her son has mental health problems. That was in 1995 when I was working up North. I found this to be quite common in many communities.
Senator Trenholme Counsell: I am interested to hear you say that because I think we should stop hanging signs that read: "Mental Health Clinic.'' We should use "Community Health Clinic'' or some other name.
You mentioned scholarships and/or bursaries and awards for Aboriginal students. If we can help more of your young men and women through high school, then there is every chance that they will go on to all these careers. I know of some scholarship and bursary programs for Aboriginal students. However, the real problem is getting them through high school, is it not? That is a bigger challenge than encouraging them to go into the professions and become teachers, nurses, doctors and so on.
Ms. Laird: Both are a problem. Many young Aboriginal people feel hopeless. For one thing, we do not have a whole lot of role models. It is difficult for them to get funding to attend school. The few that do get funding do not like the idea of having to pay back large amounts of money for the rest of their lives. Many have large families.
It is a whole process. The young people who want to pursue their education first have to go back to school for upgrading, and then they spend four or five years in university. However, when they get into the system, they discover that they do not fit into the system and so they cannot work in a particular, specific field. I have seen that a lot.
Senator Trenholme Counsell: I know that some small Aboriginal communities do not have a high school, but I think that all of them do have community centres. Could young people in those communities have access to education through tele-education?
Mr. Powderface: A major problems in this area with First Nations is that it is difficult to have a voice in the education of your children, especially when they go off the reserve. We are not allowed to sit on any school boards. As a result, we have no direct say in the transitions that our young people have to make during their school years.
Another major problems has to do with the representation that is directed by the federal government and not by the community leaders themselves. I am referring to the tuition that is received by the adjacent communities that educate our children. For some reason if our children do not stay in that school, the tuition fees are lost. Therefore, it costs the band more dollars for the children to finish school back home. Funds are not available from the federal government to pursue that. As a result, we are losing a lot of young children with ambition and potential. There is no ability to pay for their schooling.
The federal government should consider how best it can allow representatives from each First Nation to sit on the school board of the school, which is outside the reserve, where our children are educated. A number of suggestions have been made. This is a century-old problem that we have still not resolved. I am referring to this lack of representation and the loss of the tuition fees when the children return to the reserve.
Ms. Laird: In response to your specific question, I think that would be one of the solutions. It is difficult for families, and we have many single parents in our communities, to leave their home communities and travel hundreds of miles to an urban area with which they are unfamiliar in order to attend university.
Getting programs to them so that they can take the training in their home communities, is a step in the right direction. I have heard of several programs like that that have been successful.
Senator Trenholme Counsell: I was thinking of a program at the high school level where kids could stay home and take high school courses at your community centre with supervision from the elders, parents and some community leaders. I do not know whether our federal government is considering that or not. Education is fundamental, is it not?
Ms. Laird: Totally.
The Acting Chairman: Elsie, one question preoccupies me. That is the old issue of the legacy of abuse in the schools that was inflicted on parents and grandparents. How much of that has manifested itself in today's children? How much of that is moving through the continuum, if you like? Do you have any data on that, or have you looked at that research?
Ms. Bastien: There is an increasing amount of research on the residential school impact. It has had a significant impact. My father was four years old when he went to residential school. When my son was four years old and I told his story, and tears came to my eyes because, as a mother, I could not imagine relinquishing my child of four years of age to an institution.
From a mental health therapist's point of view, when you take children from a home and you place them in an institutional setting the supervisor's role is to discipline, it is not to nurture, to have fun and provide the loving things that a mother would for her children.
What our parents lost was the ability to parent. What they learned to be the parenting role was how the supervisors treated them within the school, and a lot of that treatment was very harsh, authoritative. We also know that a lot of physical and sexual abuse occurred in those schools. Children were placed in that environment at an early learning stage and they lived there until they were 18. That is what they took out with them. Then they had their own children. How would they know how to parent their children? The children who went to those schools are now parents. How do we learn how to parent?
As well, there is an enormous impact on a person's spirit when the very person who should be your most significant person, your parent, has no parenting skills and treats you or raises you in a very authoritative, disciplinary way.
I think this has been a huge contributing factor to the alcoholism and to the suicides. Community involvement is most important when considering specific programs.
A story was told to me just this week. In a school in a community — that will remain unnamed — there was a complaint about hygienic issues to do with clothing. The federal government decided that it would buy washing machines for all of the families. However, they failed to realize, that the majority of those families did not have running water, and some did not have electricity. Some of our communities still do not have running water and some communities do not have electricity. When planning for communities we must consider the importance of social, economic factors.
It is difficult for our children to go to school and learn if the poverty level at home is such that they may have to leave home without breakfast. Many of our reserves will provide a hot lunch for their students, but children who are bused off tonon-Aboriginal schools — and I will not mention any community — may not have a lunch.
A number of years ago I worked in a community where we were able provide a hot lunch for the kids, but they had to purchase it. We managed to set up an arrangement whereby the cost of those hot lunches would be covered, but I understand from speaking to the counsellor who is now there, that that has been taken away. This is a basic need.
I think Aboriginal Head Start is a wonderful program. My nephew was able to attend for a year. Yes, their waiting lists are very long and we were lucky he was able to get in. He was four years old. They provide really good stimulus around mental cognitive development. His parents cannot speak Blackfoot, and this little four year old can now pray in Blackfoot. It is just a huge step as far as strengthening his identity is concerned.
For many years we were ashamed to be Indians, and a lot of that stemmed from a fear of discrimination. When we went to school we often became the ghosts in the school unless we could find another group of ghosts to hang around with. Now my nephew, at the show and tell in Grade 1 took a drum to school. His father sings traditional music. He brought a drum to school and he sang for his class. To me, those are the remarkable milestones that can come out of some of our programming.
The Aboriginal Head Start Program is unique in that it gives the community a lot of flexibility about what they will incorporate into their programs and their curricula.
The Acting Chairman: You addressed, in a concise manner, the options and issues that we set out for this study, and they are all worthwhile comments, but is there anything practical that we should consider? What advice would you give to the government today? We cannot turn back the clock, but surely we can learn from our experience. To give back parenting skills to a generation that lost them will take generations to do. What practical things can we do today? How can we begin? Does the responsibility for education lie with Health Canada or Indian Affairs?
Would it help if you had autonomy with regard to education and funding? Your children are not staying in school for a number of reasons. We talked about only one of them, but there are others. What practical steps can we take so that your children and, of course, their parents become well-balanced citizens, if I could use that term?
Ms. Bastien: That is a good question, and it certainly deserves a good answer. I will try to respond to some of it.
Many of our communities do have some autonomy in planning education. The difficulty, though, is the resources. As we said, many resources are provided on a piecemeal basis for short-term projects with unrealistic expectations. Those program dollars only get something started.
Our education dollars are limited. For First Nation people under the treaty rights and under the the British North American Act, the government promised education for all Aboriginal people, but the funding that is provided will pay forpost-secondary study for perhaps 10 students, depending on the size of the community. Many communities have long waiting lists of people who have applied for funding to go to school and, because of their grades, they do not qualify for scholarships or grants. Funding often require students to have a certain GPA.
From a practical aspect, right now we should look to increasing Aboriginal staffing in mental health if we are to be equitable in terms of the need of the target population. Then that staff could start to assess the programs. I think that would prevent misdiagnosis. Then they could consider appropriate care and services.
The major issue is lack of resources. Many communities are still struggling with meeting basic needs. Some communities are struggling to provide water in every home. When we look at the hierarchy of needs, that is basic. If you are still at that level, it is difficult to get to the next stage. Resources are a major issue. If we build infrastructures that meet the basic needs, the possibilities for Aboriginal people are something we can only imagine.
Mr. Powderface: In our recommendation No. 8, we list a number of things. We talk about community capacity building, which is important, because if you are to provide some ability to the communities to deal with their particular problems, you must have adequate resources for them. This is where the federal government is lacking, that is, in providing adequate resources to deal with a lot of the problems that are associated with mental health and mental illness.
I will give you an example of the healing foundation related to the impact of the residential school. All the funding related to that does not address the mental state of health that we experience. I experienced this myself. Attending residential school caused me to have a complete mental alteration. I attended residential school at a time when I needed my mother's loving arms and guidance. I needed my parents' guidance to learn how to be a person and how to live the kind of life that was intended for me by the Creator. I was sent to a residential school. Had I been with my parents, if I had had a problem, I would have gone to them and they would have shown me love and compassion. They showed me passion, and I learned from that, and I am a passionate person. Instead, in residential school, I had to fight my way through all my problems. I learned to be violent. Now the impact of residential schools extends to third generations.
I do a lot of work with young people who are struggling to deal with the violence in their lives, alcohol abuse, substance abuse, poverty, suicides and gangs. They tell me, "It is nice for you to tell us about traditional teachings, but how can I teach my children what I have not been taught by my parents because they were in residential school?'' They were totally alienated and dissociated from the teachings of what life is all about.
We point to this lack of traditional culturally oriented parenting skills and we make recommendations in that regard. Many of our young people do not have the skills to raise their children to be responsible, respectable individuals. we have been asking for program funding. We develop programs but they are not funded because they are seen to be outside of the scope of funding policies. That is most unfortunate.
If we are to give communities the capacity to rebuild with adequate resources, that will be a start, because we have to deal with not only two generations, but three generations of our people and try to get them out of the mess that they ended up in because of residential schools.
The Acting Chairman: If I understand what you are saying, the capacity that is needed to build must, of necessity, come from within not without?
Mr. Powderface: That is right. Throughout our presentation we talked about the community base and about involvement. We talk about the joint ventures that have to take place with First Nations directly, with the people from the community, because it is not somebody from the outside who identifies the problem. We know what the problems are. We can identify the problems, and if we can be resourced, I am sure we can find the solutions.
The Acting Chairman: We are at Maslow's theory where basic human needs are not yet met, so the first step will be capacity building within your own community with the appropriate personnel. How much of that do we have? We will have to walk in solidarity with others until we build that capacity within your culture and your communities. Am I correct in following that line?
Ms. Bastien: If you are asking if the community has the people to do the work, the answer is that yes, we do. We have the people to do the work; we just do not have the funds.
In my home community, people are taking training through an addiction program in Alberta. Alcohol services pays for their education and then they volunteer. That is available. However, now the Social Services program has changed, and people who are considered employable need to look for employment or fill out cards so they no longer have time to volunteer. They will not accept volunteering.
We have the people and the capacity. We have the wonderful support of elders. The difficulty, though, is the resources. We have elders who have to take on two jobs. They are not available to go into the schools and teach the children because they are working night shifts at different programs because they do not qualify for social assistance and their pension dollars are not adequate.
There are few jobs in our communities. Many of us have to seek out employment. In seeking out employment, we lose the support that we have at home. The racism around housing issues and employment issues make it difficult to live in an urban area.
As Gloria said, we have a wonderful mental health program in the North but, yet, students cannot find employment within our Alberta mental health system or within our mental health system. Responsibility for that is now with the regional health authorities, and that is really very sad.
How do we deal with increasing employment? In Alberta we have a policy that looks at working with Aboriginal people and to have that as part of the program planning. If we considered something like that around employment, that would be another way of going.
Senator Callbeck: Elsie, I am wondering if I misunderstood. You told us that people used to volunteer. Then you went on to talk about the employment card, and now they have no time. Has there been a change?
Ms. Bastien: It has to do with the Welfare Act and social services. Most of our people are unemployed because there is no work. Our unemployment rate is at 85 per cent. The community looked at funding people to take training so that they could then volunteer to work in some of the programs. However, at the beginning of this year, the federal government changed the Welfare Act to reflect, I believe, what the province has, and so many of those people who would have, could have, been doing some of the community work, because we do not have the dollars to pay them, now cannot do that because they have to be looking for gainful employment. They need to demonstrate that they have been seeking gainful employment before they get their welfare cheque at the end of the month.
Senator Callbeck: I understood it correctly then. Thank you.
Senator Cordy: The detailed report that you have given us will be very helpful. I recognize that it was not written in a short period of time.
What we have heard from you is something we have heard from many people, that is, when we make changes it cannot be top down, we have to consult with people who will be directly affected.
I liked what you had to say about taking a more holistic approach. That is true whether we are talking about Aboriginal peoples or about mental health over the whole spectrum. You cannot look at mental health in isolation.
Elsie, you talked about nutrition, housing and employment but you made no mention of the justice system in spite of the fact that the justice system is a major consideration. We have said that the prison system and the streets have become the psychiatric units of the past. You are nodding, Gloria, so I think you would agree with that.
I would like to touch on the area of Aboriginals who are living in urban areas. When I grew up, my uncles and aunts lived two streets over or whatever, and there were always family members around. However, young people find the need to leave home and to go to urban areas where they do not have those support systems in place. They do not have the elders, the family members, and they do not have the healers or the medicine people in close proximity. How great a problem is this for Aboriginal youth particularly, who are living in urban areas?
Ms. Laird: It is a problem that is growing. We have quite a number of gangs in the urban areas, Aboriginal gangs, and some are quite violent. Once young people get involved in the gangs, they cannot get out. We have no kind of resources in place to help them other than a couple of ex-gang members who volunteer to help these young people get out of gangs. The gangs are becoming more sophisticated. They are reaching the First Nations and to our Metis communities in the urban areas and recruiting these young people.
There are a number of gangs here in this particular city. I think this is a part of all these issues that we brought forward to do with mental, physical, emotional, spiritual health, the lack of parenting skills, and the lack of traditional and spiritual awareness. Many of these young people have nothing to look forward to.
I have heard stories of parents supporting these young people who are 14 and 15 years old and who are involved in gangs because they bring the money into the home and support the family by putting food on the table. You cannot approach the families and talk about how dangerous it is for their youth being involved in gangs when they are totally dependant on them for finances.
I have heard that gang members are doing a lot of recruiting in the outlying communities across Alberta. That is a major issue.
How do you deter people when they are getting good money, are living well, are well dressed, and they have all their colours? My belief is the lure of the gangs gives these young people a place where they belong. They do not belong anywhere else. They are not accepted anywhere else. They are faced with racism. They do not fit into the school system. In a gang, they have the tribal mentality. They belong somewhere; they fit in somewhere.
We need to turn that around so that they belong, even in the urban areas, to a community. We need to help them develop their self-image. As Aboriginal people we have the history, the mentality of being ashamed of who we are. We are still dealing with that. You still see that in the schools.
Another major problem is child prostitution. Where there is child prostitution, you will find that over 50 per cent of those children are Aboriginal.
For a number of years I have been advocating for a holistic healing centre. That has not been supported. You can talk until you are blue in the face, but there is no change. The young people are saying that they want to go out to the country and they want to have elders present. They say they want to do sweats and they want to clean themselves up. They need something different. They need to get out of the cities.
Who will open a holistic healing centre for those young people who do not have a voice? These children are getting younger and younger; 10 and 11 years old. It is difficult to get out of that lifestyle if you are addicted to drugs such as crystal meth. It is a real problem. They come into the child welfare system. They come in one door, and they run out the other. Many of them get lost. They can support themselves. Some of them have told me that they do not need the system. They say, "I don't need anybody to support me. I can make a living myself, and I have a lot of friends out there that will help me.'' You hear a 12-year-old kid saying that we have got some major social problems out there.
Mr. Powderface: You have to realize where they come from. Because of our reserve system, our communities are in confined areas. They come from our communities that are closely knit, family-oriented societies. In many cases that creates some problems for them in adapting to urban life. Moving from this type of a society to a hierarchical corporate structured society is very difficult for them. The structure advocates individualism.
I will give you an example. We are used to family living. If I moved into a city, the only accommodation I could afford would be a one- or two-bedroom apartment and, because of my close relationship with my family around those family values, many family members would visit me and would like to stay overnight. However, I would be stuck with strict stipulations on the size of the home that we live in. This makes it very difficult for our people moving into the urban areas.
Senator Callbeck: You have given us a detailed and compelling presentation. Your statistics in the first part are devastating and certainly unacceptable.
You say that Health Canada must be involved in providing services to First Nations people. Is Health Canada not involved?
Ms. Bastien: They are involved. When we looked at some of the questions in your report, it seemed that Health Canada was not identified. I think for Aboriginal people, because of the sovereignty rights and the agreement with the federal government, we just want to ensure that, whatever we do to move forward, we continue to honour that relationship. We need to keep them involved. That is what our Aboriginal leaders are working towards. We just wanted to ensure, by putting it in here, that it was acknowledged that they be involved.
Senator Callbeck: They are involved now, and you want to keep them involved.
Ms. Bastien: Yes. We want to keep them involved. Health Canada is involved with First Nations and in Inuit health. I will let Gloria speak for our Metis people. The Inuit have some contracts with Alberta.
However, if Bessie were here, she would talk to how very sad the situation is for Inuit people. She sometimes, tongue in cheek teases, says that her homeland is called Nunavik, and that what it really is, is: "none of it.'' She tells us that they do not get anything. They have a really tough time.
I will let Gloria speak to the issues around health for Metis people.
Ms. Laird: When you mention Health Canada not working with the First Nations people, I think that people are beginning to look at a health service for Metis people. Therein lies a real problem also.
We would have access to Alberta Health Care. However, we have such a high unemployment rate in our community, many Metis people do not have access to Alberta Health Care. They have no access to health services because they do not have the health care card. A few fortunate people have Blue Cross, but unless your employer helps you pay for Blue Cross then you do not have it. The majority of Metis people do not have that. That is a real issue in our community.
I used to get a lot of calls for assistance. I no longer get very many because I was not able to help very much. People come into our Aboriginal agencies that work with families. We have only one in Edmonton, the Metis Child and Family Services Authority. Metis people with mental health problems will to there. They have a tremendously difficult time finding resources for these people. Usually the obstacle is financial. I just want you to be are aware of that.
Senator Callbeck: On the multiculturalism issue, you said that the federal government might revisit its policy which could bring about some changes in employment, housing and education. Could you elaborate on that?
Ms. Bastien: Aboriginal people do not see multiculturalism as specific to Aboriginal people, because Aboriginal people perceive themselves as the first people of Canada. The multiculturalism policy speaks to people of other cultures who are entering Canada as immigrants. That is how Aboriginal people perceive that.
They see that the momentum behind the policy is to build in some tolerance and some diversity, but it is based on enhancing economic growth within the global economy. Initially, it was intended to deal with structural and historical racism within Canada. However, that has never been its primary focus. Given that that was written into the policy, if we were to look at multiculturalism from an Aboriginal perspective, that would be an appropriate place for multiculturalism to start. What are the historical structural racisms? Those are the racisms that you do not see, but you feel them and you know they are there. Our statistics show that racism is there. Going by the number of people incarcerated, there has to be structural racism. People are responding to racial profiles.
It is obvious. In anything that we do, if we do not examine the systemic or the structural components of racism, systemic racism and inequality will remain. Anything that we pile on top of it, if that is the foundation we build on, it will change nothing.
Affirmative action may have created something, but did it actually work to reduce racism? A recent study done about racism in Canada was just reported in the last couple of weeks. A study was also done by the University of Lethbridge — the area where I live — that documents the fact that racism is prevalent.
Senator Callbeck: When you talked about the most appropriate structures to ensure that Aboriginal peoples have adequate input, you listed a number of things. Has there been any progress on any of those things you listed?
Ms. Bastien: Which page?
Senator Callbeck: Page 9, Question 3. These are the things you list for the appropriate structures to ensure Aboriginal people have adequate input into the design of services they need. Has there been any progress on any of those items you have listed?
Ms. Bastien: No.
I worked as a therapist in the community clinics when they were under the governance of the Mental Health Board. At that time we had 10 identified people of Aboriginal descent on staff. I think we had two First Nations on staff. That was in Alberta. I am sure the statistics across our provinces would reflect the same situation. I work with the commissioner for the redesign of children services in Alberta, and in our work we have noted that our Aboriginal staffing does not reflect the population that we serve. The numbers are very low.
With respect to all of those items on our list, I would say no. We have some short-term piecemeal projects, but they do not have a significant impact.
The Acting Chairman: Thank you all very much for such a compelling presentation.
Senators, we now welcome Dr. Alan Gordon, Mr. Peter Portlock and Mr. George Lucki. We will begin with Dr. Gordon.
Dr. Alan Gordon, Regional Mental Health Program: Thank you for inviting me to meet with your committee. I am a psychiatrist with the Capital Health Authority, which is the regional authority here in Edmonton that is responsible for providing health care services.
I have drafted three recommendations that I would hope you will consider incorporating with any other recommendations you may make.
The first one is to improve funding. I recognize, however, that you are keen on reform, but I do not think that reform will work without improved funding. The first recommendation is as follows:
Given the prevalence of mental illness and addictions, and the associated mortality, morbidity, and disability, the committee recommends that the Federal Government should set a target for funding for mental health services at X% of total health expenditure.
This would be a meaningful statement coming from the committee. It would impact on the provinces. It would set a guideline. It would achieve press interest. It would meet your goal of raising the profile of mental health services.
I leave you to decide what the X percentage should be. I, personally, given the amount of mental health issues, illness, and so forth out there, would like to see 20 per cent. However,15 per cent would be a good start.
The second recommendation is to reduce the stigma attached to mental illness. It states:
Individuals with mental illness and addiction are often subject to a life of poverty, exclusion, and early death, facing stigma and discrimination in relation to housing, employment, insurance, education, criminal justice, parenting and health care. The committee recommends that the Federal Government set aside X dollars over 10 years to fund a national anti stigma campaign.
That would be a meaningful thing to do. It is something that the federal government could achieve, and it would make a difference in all of those areas I mentioned.
Again, I leave it to you to decide what X dollars over 10 years should be. I would point out, though, that $1 billion over 10 years is only $100 million per year, which translates into $10 million for Alberta. It may sound like a lot but, if you are serious about reducing stigma, then the federal government needs to take the lead, and this is the way to do it.
The third recommendation is to set clear mental health goals. I preferred personally to go this route rather than a national mental health plan. We can talk about that in the discussion, if you wish. The recommendation reads:
The committee recommends that the Federal Government provide leadership in mental health by setting national goals to encourage the provinces to focus more on specific and crucial mental health issues. These should include:
1. A reduction in the suicide rate.
2. Improved outcomes for serious chronic mental illnesses such as schizophrenia.
3. A reduction in alcohol and drug use.
4. Improved streamlined access to mental healthservices —
The key is access. There must be access to assessment in a number of ways, including in primary care and in specialized services. There should be access to treatment, both hospital and community treatment, and crisis treatment as well as support. That includes access to housing, income, living skills, social skills, vocational programs, counselling, psychoeducational programs and family support.
These are the necessary components of a mental health system. We should be emphasizing access to all of these components. If you have improved access, then you need not worry about who runs or who funds the institution, the key is whether people can access them, and access not just the assessment but access treatment services and these crucial support services. This applies to children, adults, seniors, and particularly to populations with greater and special needs. For instance, Aboriginal people, immigrants, people with dual and complex diagnoses, rural and remote populations, people in prison, the poor and homeless. Those are your special groups, your special needs groups.
My third recommendation continues:
The committee recommends that the Federal Government support and encourage the use of outcome measures and informative databases to achieve these goals.
If you are asked for brief recommendations, I think these are those. I believe that they capture the essence of what you have tried to achieve in your report. I think it is catchy. I think it is doable. I think it raises the profile of mental health. I think that it gives the federal government some responsibility in this without treading on the toes of the provinces.
I submit it to you for your consideration.
The Acting Chairman: Thank you. These are the challenges we are faced with as the committee in developing a mental health strategy from a federal perspective but which can be implemented province by province. Therein lies the challenge. We hear you well.
Mr. Portlock, you have the floor.
Mr. Peter Portlock, Executive Director, Canadian Mental Health Association, Alberta Division: Madam Chairman, senators, ladies and gentlemen, I would like to thank you on behalf of the Alberta division of the Canadian Mental Health Association for the opportunity to appear before you this afternoon. I have speaking notes which I will try to abridge in the interests of time.
This is the best time to be working in mental health. In large measure, your work has made it so, and it would be remiss of me to move on to my presentation without acknowledging, with appreciation, the efforts of the committee to date in focusing Canadian's attention on the opportunities to improve our mental health system.
More than any other initiative, the consultations and interim reports of this committee have brought mental health into the kitchen, onto the stove, indeed onto the front burner where we are committed to keeping it until our collective work is done thoroughly and well. Thank you for getting us there.
You are probably aware that yesterday in the House of Commons a motion was introduced by MP Steven Fletcher and received nearly unanimous support from the Conservatives, the Liberals, and the New Democrats. In part, the motion reads:
That, given a national strategy is needed now to reduce the growing human and economic costs of cancer, heart disease, and mental illness,...and given that Canada is one of the few developed countries without a national action plan for effectively addressing mental health and heart disease, the government should immediately develop and initiate a comprehensive national strategy on mental illness, mental health...
I submit that such a motion might never have been entertained let alone passed without the diligent and visible efforts of this Senate Committee, and for that we thank you as well.
We have prepared a written submission, copies of which I have distributed. In this brief presentation I will deal with three areas that are dealt with in more detail in our written submission. We will not mirror in our presentation the presentation made by our national body, which you have heard, and I think has been echoed to some degree by our regional affiliates across Canada.
This afternoon I will talk about the appropriateness of national leadership in bringing about necessary improvements in the Canadian mental health system, measures to improve the information available on the prevalence of mental disorders, and measures to improve access to the mental health system.
I would also offer a word of caution in respect of one of the downsides in the move to regionalize the design, delivery and evaluation of mental health services and programs.
With regard to national leadership — and I am glad my friend Dr. Gordon mentioned national leadership — mental health, which is the orphan child of the health care system, does need its champion at the national level. Yesterday's motion in the House notwithstanding, the provinces and territories have required little encouragement to address on their own the importance of heart and kidney disease, diabetes, obesity, and other physical conditions. Existing in the shadows for so long, mental health and addictions can only gain a place on the priority health agendas of the provinces and territories with focused and enduring national leadership.
Such recent initiatives as the appointment of a special advisor of the Minister of Health on mental health in the workplace, the creation of an interministry team at the federal level to address mental health issues in the federal workforce, and the federal government's commitment to set the example to public and private sector employers nationwide through how it addresses the mental health needs of its own clients, the military, the RCMP, Aboriginal populations, and federal prisoners, will do much to legitimize a renewed focus and emphasis on mental health at the provincial level and to maintain its profile. For us, it is all about profile at this stage.
Other initiatives might include legislating greater equity between physical and mental illnesses as well as mandating at least one of the regularly scheduled, periodic meetings of federal, provincial, and territorial ministers of health to deal exclusively with mental illness and mental health issues, and even creating a ministry of state for mental health as has been done in British Columbia.
The value and power of federal leadership initiatives in mental health cannot be underestimated.
Concerning measures to improve the information available on the prevalence of mental disorders, we strongly support the more frequent repetition of the Canadian community health survey and the expansion of the survey base to cover a wider range of mental disorders, age groups and population sub groups, notably among Aboriginal peoples, the homeless, and the prison population.
Similarly, we support the creation of a national information database on the prevalence of mental illness and addiction and an information system necessary for measuring the mental health status of Canadians, a system that we currently lack.
Regarding measures to improve access to the mental health system, we deal every day at CMHA with people who have summoned the courage to ask for help, who are repelled by the system either because that system is so fragmented it is difficult to discern the appropriate entry point, or because their ability to articulate their specific needs is somehow compromised. In our experience, there is an absolute need for mental health advocates to assist individuals in accessing needed support.
CMHA Alberta division is preparing a proposal to introduce a centralized one-stop ombuds-type service in this province on a trial basis whereby individuals will be supported and helped in their attempts to successfully access the mental health system so that they may receive appropriate interventions sooner rather than later. We look forward to reporting on the success of this initiative in due course.
The final point I would make concerns an unanticipated downside to regionalization of mental health services and programs which we believe deserves mention.
Provincial organizations such as CMHA have generally derived some of their infrastructure funding from the provincial entity responsible for mental health service delivery, whether it is the provincial ministry of health or, as in Alberta, formerly the Alberta Mental Health Board. We have, in turn, allocated some of that funding to our regional branches to sustain programs at the regional or community level which, in many cases, they have offered by agreement with the RHAs.
With the move to regionalization and the transfer of responsibility for mental health services from a central authority to the community, our regional branches have forged new alliances with the RHAs which, while not historically accustomed to providing funding support to outside agencies, that is, outside the health authority, have accepted that responsibility and have entered into funding agreements with our regional entities for local programs and services.
The central authority having divested itself of its funding responsibilities to provincial organizations, those organizations are left without sources of infrastructure funding at the provincial level. Our branches are doing fine relatively speaking in their new funding partnerships with the RHAs.
The provincial head office, however, is less fortunate. In promoting the divestment of responsibility for mental health service delivery from a central authority to a regional or community service model, we would urge the committee to note that some mechanism must be retained by which the important and necessary function fulfilled by non-governmental organizations such as CHMA can be funded and therefore sustained at the provincial, not just the regional, level.
The Acting Chairman: Thank you very much.
Mr. Lucki please proceed.
Mr. George Lucki, Chair, Alberta Alliance on Mental Illness and Mental Health: Madam Chairman, senators, thank you very much for the invitation to present to the committee this afternoon.
I will speak from rather than read the notes that I have provided. We have also provided some additional reading material relating to work that we have done on issues that we believe in Alberta have paralleled some of the interests of the Senate Committee in your fine reports.
I will just take a moment to describe the organization and to introduce myself. I am George Lucki, a psychologist by trade. I work in private practice, but in a volunteer capacity I chair the Alberta Alliance on Mental Illness and Mental Health, a coalition established in 1999 that included at that time, and has continued to include, the major stakeholders in mental health in the province.
The Alberta Alliance on Mental Illness and Mental Health is a unique provincial coalition of all of the major mental health professions, the not-for-profit agencies dedicated to mental health advocacy and community support, associations representing mental health consumers and family members. We comprise all of the large stakeholders in the mental health field outside those charged with financing and delivering mental health services. We came together with some concern about the state of mental health in the province of Alberta and about some significant deficiencies both in funding and the way in which systems were organized.
Our first paper, of which I provided a copy to you, was titled very aptly, and I think from our perspective addressed the crux of the problem, "Good People... Good Practices... No System.'' We lacked in this province a system of mental health care, a condition that we believe exists in other provinces across the country.
Our attention as a coalition was first of all addressed to the matters that we held universally. The strong consensus that developed among these divergent interests was amazing regarding what the problems were and what needed to be done.
The solution started not with examining the funding or the services, it started with an examination of what was happening at the top of the system. We recognized that we needed a system of governance of care that would address the problem. Services were fragmented and insufficient. There were significant gaps in services, in equities. Some people could get services that other people could not.
Wherever we looked, we found ourselves targeting only a portion of the real mental health problems, because outside of even developing the best possible services for people in sufficient quantity, unless we also address the social determinants of health, of mental health — poverty, homelessness, income support, family problems of various sorts — we will be unable to tackle the problem effectively.
We were also concerned in this province that mental health had found itself in a bit of a dead end — a cul-de-sac of sorts. We can use the analogies of stove pipes or silos, but mental health was separated from the rest of the health system, and mental health problems do not exist separate from problems of the body or problems of the soul or problems of interactions with people.
We need to work to integrate services, not only across the social determinants of health but effectively integrate health and mental health services. There is not a health service that does not have a mental health component, and we need to be able to effectively organize services so that they address the whole person and the real needs that contribute to dysfunction or disease or less than optimum performance.
We are pleased that we have had a couple of excellent health ministers in Alberta and real support through the Mazankowski report, through the initiatives of the Mental Health Board and the provincial health department, to move the agenda forward in mental health in line with the recommendations that the alliance and alliance member organizations have been making.
It is time for us to take this even further. It is time for us to move from passion to action.
I provided you with a copy of a document that looks at how we rationally separate issues of the governance and the operation of the mental health system, and how we evaluate, after a period of time, the outcomes of our efforts.
We also developed a blueprint for reform which is a checklist or report card to help us determine whether we have, in fact, had a positive impact on the system of care, not just on the funding and the services that are delivered.
Today, I come to speak to you about your Issues and Options paper and to make some, hopefully, welcome recommendations. Our interest has been largely as a provincial alliance, but some of what needs to be done in mental health requires the efforts of the federal government. It requires a pan-Canadian, an interprovincial, a national approach.
We believe that the federal government has important jobs to do. The first is that the federal government must lead by example as a quality and a policy leader. The federal government does have responsibilities in mental health care that do extend into our province as well, and they need to do as good a job in that area as we hope to do in terms of our own provincial responsibilities.
You have heard about the care for individuals in the Armed Forces, and those who are police officers. Very passionately you heard of some of the difficulties with Aboriginal care. These are all areas of direct federal mental health involvement.
We are concerned about a two-tiered health care system, but we have tolerated two-tiered health care in mental health. Those issues need to be articulated and there needs to be a debate across the country about that deficiency.
The Canada Health Act excludes mental health care. There is no federal legislative protection for public mental health care. We need a federal mental health act that addresses these considerations; an act that supports provinces in delivering comprehensive mental health services.
I do not believe any dedicated transfer payments have been made to the provinces to help fund or encourage the funding of needed mental health care. Mental health funding needs to increase so that the services provided better reflect the burden of suffering and disability related to mental health. That has not yet occurred in our province or in many parts of the country.
A pan-Canadian mental health strategy also needs to consider a mechanism to provide equitable funding to help address the needs of those affected by mental illness.
The federal government is also a leading purchaser ofnon-insured benefits that provide those who work for the federal government or those whose health care is a federal responsibility with mental health care that is not available to the people of Canada at large. These services themselves are often not particularly well coordinated with other health services that are delivered by provincial authorities. We believe that these programs should be comprehensibly reviewed to ensure that they reflect best practices, address the mental health needs of those they serve, Aboriginal people being probably a priority.
Mental health services need to be provided to the same degree to those who have the private insurance that the federal government affords its own employees or provides in non-insured benefits. Those benefits are available to all Canadians.
Through income support, employment, housing and many other federal programs, the government plays an important role in supporting mental health care outcomes, but these programs need to work well together and work well with provincial programs operating in areas that relate to mental health. There is a lot of work to be done in that regard.
The federal government can be a champion for mental health reform and a strong supporter of all of the community initiatives in that regard.
Mental health needs to stay on the policy agenda. It has at times briefly been on the national policy agenda, but not on a consistent basis. Federally, as provincially, there are good people and good programs, but there is no system of care. Services are fragmented and insufficient.
We need a mental health system and we need a plan. The plan needs to be developed with the active participation of everybody who is involved. A first ministers' conference dedicated to mental health is needed to set the policy agenda, but then everybody needs to be involved, because mental health requires the involvement of coalitions such as our own and the diverse groups across Canada whose needs are unique and particularly relevant.
We cannot develop a mental health system with a one-size-fits-all model. We must take into account individual needs and the preferences and requirements of the people that we serve.
How we build the system has to mirror the sort of system that we want. The plan has to be integrative and transcend traditional boundaries. Mental health crosses so many jurisdictions, so many departments, so many mandates, that we do need to find some way of pulling those all together.
Even within health care, mental health and addictions are tied together. A significant proportion of all primary care visits have a mental health component. Hospitalizations are not without their mental health component. Addictions and mental health together account for a significant proportion of morbidity, absence from work and social problems in this country.
Excluding mental health care from health care may lead to the stigmatization of the mental health components. We need to develop new ways of delivering mental health care in our communities.
The services need to be coordinated. They need to be consumer centred. One consumer said quite eloquently that the system is so complex that you have to be a healthy person to be able to navigate through it. There is truth to that. Mental health issues are complex, but we need to create a system that, from the consumer's perspective, is easy to access and easy to navigate. Services need to be equitable. I believe I have addressed that.
Mental health care is not a supplementary health benefit. Credit does need to go to employers that have provided plans to address the large gap in services in the public health care system.
How would Canadians react if we were comparing notes and speaking of employer-funded cardiac care? What would the reaction be if employees had to pay 50 per cent of the cost of bypass surgery? Yet, we do this with our mental health care by providing it as a supplemental health benefit.
Finally, I will deal with the question of stigma. Stigma is built into the system. Addressing stigma is more than just funding a public education campaign or a media campaign with posters and television commercials. The existence of a separate mental health care system with poor legislative protection, with poor funding, emphasizes the stigma.
In many ways, government policy has underscored that mental health problems are different from other problems and less worthy of our support and attention. Addressing stigma can occur by bringing mental health considerations into the main stream of health care and by effectively funding and integrating mental health and other health care delivery.
Stigma is also heightened by the experience of other social problems. When you are poor, homeless, unemployed, when you have involvement with the justice system, these conditions all add to the stigma, and these are all correlated with poor quality, less coordinated mental health services. We need to be able to see that connection, that is, addressing those problems will help reduce stigma.
Empowering consumers to help lead mental health initiatives will reduce stigma as well. Mental health consumers have been the passive recipients of services and we need to provide an opportunity for them to have their own voice, choice, and the greatest possible opportunity to direct their own care as they do in other areas of the health system. The development of apan-Canadian strategy with new services and national discussion will help reduce stigma.
Education and the dissemination of research will obviously increase not only self-awareness of the problems that people face, because there is a large gap in self-awareness sometimes, but also the awareness of the problems that others face.
Finally, perhaps, in response to a very timely question, I spent much of the morning reading Chaoulli v. Quebec (Attorney General), and many Canadians are probably asking themselves, not quite knowing, today: What does this decision mean for me? What does it mean in terms of the health care that I receive?
The experience of Canadians seeking mental health assistance may be informative here, because the question that concerns Canadians today is the one that we have been living with for quite a while. Mental health has forever been outside of the Canada Health Act, and though that legislation is set up as an expression of our health care values, it does exclude mental health. The issues that were determined by the Supreme Court give people access, perhaps, in some cases to private insurance. Private insurance is the only way that Canadians have been able to purchase needed psychological and other services in the past. That has been the only way to avoid waiting lists and program limitations.
Employer-funded mental health programs make up a significant portion of all mental health expenditures. By some estimates, the employer-funded mental health programs approximate half of all of the publicly funded mental health expenditures.
There has been little incentive for or little demand for governments to provide these same sorts of benefits to all Canadians. Canadians with means have purchased these additional mental health benefits. Vulnerable Canadians have not, and they have often not had a voice in this matter. Even those who purchased such benefits may not have received optimum care because these supplemental benefits have not been well integrated with other health and social programs. They are better suited to those whose needs are moderate rather than to those whose needs are significant or severe. They fall through the cracks.
Again, how would Canadians feel about cardiac programs available only to those with private coverage in addition to public coverage? Mental health consumers have had to face thattwo-tiered mental health system all the way along.
If the federal government is serious about a universal, publicly funded health care system, it might start by trying to provide additional funding through transfers and payments for the full range of mental health services the provinces need to offer.
A Canada mental health act should be enacted that places mental health on as strong a footing as the Canada Health Act places the health system on. We need that pan-Canadian mental health plan. It is sad that we are one of the few developed countries that does not have such a strategy, that does not have such a plan.
Finally, we cannot ignore the two-tiered health care that is there for people with mental health problems while purporting to care about two-tiered health care altogether. We are pleased that the opposition has taken the initiative, brought forward a motion, had a day's debate on mental health and other serious health concerns and has called for a national strategy on mental health care. The federal Liberals, the government party, has also adopted that motion.
Now we must take immediate action to address the problem. It is time to move from passion to action. We would be happy to be a part of helping you in the next steps along that road.
The Acting Chairman: I would thank all of you most sincerely, particularly Mr. Lucki. I want to personally thank you for helping me to roll away that stone called stigma. I appreciate the insight that you have shown regarding stigma.
Mr. Portlock, I would like to know more about yourombuds-type service.
Dr. Gordon, you used words of our esteemed chair who said that money is not necessarily the answer and maybe we need to look at reallocation of the funding that is in the system. However, as we did in our study on health, where we saw the need for change, we did not hesitate to cost it out. You will see that if you refer back to our reports. We hear you loud and clear on that one.
Senator Trenholme Counsell: I have not had a chance to read the debate in the House of Commons yesterday, but I will do that tomorrow. It should be interesting to see how the other House is dealing with this matter. It is good news to know the matter is before the House.
Mr. Lucki, could you expand on your statement that the Canada Health Act excludes mental health care. I practised medicine for 27 years, and during those years, I am sure I admitted hundreds of patients with a mental health diagnosis, and I saw thousands of patients in my office with a mental health diagnosis, and I was paid an extra 30- minute fee for counselling or psychotherapy.
I agree with you totally that there have been parallel systems where many people benefited from services outside the system. However, how can you say that the Canada Health Act excludes mental health care?
Mr. Lucki: Senator, provincial health plans have provided for physician reimbursement, for hospital care and for hospital programs, As a psychologist, I worked for about 20 years in the publicly funded system and was paid to see individuals and help them with their difficulties.
The Canada Health Act, as far as I understand, specifically excludes psychiatric institutions from that system. It makes no specific provision for that. The legislative side in the federal legislation is separate from what provincial plans pay for.
This was first brought to my attention in the mid-1990s working as a psychologist in Red Deer, when the hospital was able to successfully introduce significant user fees for psychiatric patients. Psychiatric patients were required to pay up to $100 a month to access various aspects of the program.
Senator Trenholme Counsell: An inpatient program?
Mr. Lucki: An outpatient program.
The outpatient-inpatient program is in modern institutions as an integrated approach to treatment. It had turned out that this was in accordance with the requirements, because those services were not mandated through the Canada Health Act.
Physician services are only a small component of what we need to be able to protect legislatively if we are to have legislative protection of standards of mental health care.
That is the position that I would take on that.
Senator Trenholme Counsell: Through the Canada Health and Social Transfer many services in mental health clinics are covered.
Mr. Lucki: As far as I understand, none of the transfer payments are specifically directed to or targeted to mental health. They say that provinces must offer mental health services in order to be able to obtain those services.
By targeting programs towards other health fees such as Pharmacare or home care, it has fostered the development of those programs. Transfers that are targeted towards mental health care could close a part of the gap in services and funding.
In particular, one of the difficulties we face is that mental health does not typically have strong advocates, people with a strong voice to say that certain services are necessary. For a variety of reasons, other health care services often are able to muster more public and media attention.
The burden of disability associated with mental health problems receives, in many provinces, considerably less than what would be a proportionate amount of care.
Senator Trenholme Counsell: Do you think there is any risk in having a Canada Health Act and a mental health act? My preference is to have a mental health strategy which I think we desperately need. Do you see any risk in separating the two?
Mr. Lucki: Yes, I do.
Senator Trenholme Counsell: You are recommending it.
Mr. Lucki: There is risk. Some of the things we recommend have an upside and a downside to them.
The risk is the one of creating something that is not well coordinated with health overall, which is something that we would not be supportive of. The upside is that it does allow for the opportunity to look at the uniqueness of mental health in a more modern way than the legislation that we have in place at present. Those would be the advantages and disadvantages.
If someone were to recommend reopening the Canada Health Act so that it would include a comprehensive coverage of mental health care, we would also support that.
Senator Trenholme Counsell: Personally, I would see that as much more positive, because if you think of the mind, body and spirit as being one, there is a real risk in separating the two. I mean, risk and funding, risk and perception, risk in everything.
I read in a few places that there is no system. I do not think that there is no system, but it is a weak system. It is fragmented and needs so much improvement. I think my province would say that we have a system, whether we have a pan-Canadian system is another question. Many of the provincial ministers of health and wellness would say they have a strategy, but I also think we should strengthen the system.
Mr. Lucki: We are in agreement we can do a lot better in creating a system of care.
Senator Trenholme Counsell: These are excellent papers. Thank you.
Senator Cordy: Mr. Portlock, you talked about creating a ministry of state for mental health, and I fully understand why you would want to do that. We also heard evidence the day before yesterday in Vancouver that a ministry of state would not be a good thing. We heard, in fact, that it would marginalize mental health. Since it would be considered a lower level ministry, the main goal of the person who would be in that ministry would be to become, perhaps, the Minister of Health or the Minister of Transportation or the Minister of Finance. That person may not have the ear of the premier, or if it is federal, the Prime Minister.
Did you think about the pros and cons when you were advocating that we have a ministry of mental health? I am not saying it is right or wrong, I am just saying that we have heard conflicting evidence.
Mr. Portlock: I can understand that there would be conflicting views. I think it is all in the definition of the mandate and the definition of the right person and the reporting relationships.
The association's view is that the advantages are likely to outweigh the disadvantages. There is the notion of creating the optic of separateness, which is always troublesome, but we believe that it is time, in the evolution of mental health that it is brought in from the cold, as it were, and that such separateness could work to the advantage of advancing the kind of reforms we want to see.
Yes, it is true, the setting up of a ministry for mental health could be perceived as according some kind of lesser or separateness type status to mental health, but with care in the way the mandate is defined, we believe it is possible to meet much of that objection.
I think it is worth the effort. I have talked to some of my colleagues in B.C. about the experience. It has been variable because there have been some changes in incumbency, and there has been some confusion about roles and reporting and to whom that minister is responsible.
I think that it is a concept that probably deserves a much closer look before it is enacted. We point out in our presentation that, unlike the physical health system that deals with physical ailments, which does not need leadership at the federal level — heart disease, diabetes and obesity do not need champions to tell the provinces what they need to do — we believe that mental health still does. These kinds of mechanisms serve mostly to sustain the provincial file that has been so hard to achieve, and I think, on balance, there is much more to be gained by singling out mental health for that special distinction with its own ministry.
Senator Cordy: That sounds like a rationale. I think we not only have to sustain it but also increase because we have a long way to go in the area of mental health and mental illness.
Mr. Portlock: Indeed we do.
Senator Cordy: Getting back to your comments, Mr. Lucki, about two-tiered health care in the field of mental health, I certainly think we are still in the hospital-doctor mode in terms of what is covered by our medicare system.
If you are outside the medical doctor, hospital situation, then indeed many services such as consultations with a psychologist are not covered. Those who have supplementary health benefits, have about 80 per cent of those fees paid. I am not sure of the percentage.
However, there has not been a big hue and cry about this. There is a tendency to believe that very few people suffer from mental health conditions, whereas the reality is that one in five people at some point in their lives will be affected by a mental illness of some sort, or poor mental health of some sort, whether it is stress related, whether it is schizophrenia or whatever. Unless those people have coverage through a workplace private plan, they will be unable to access certain treatments. That is particularly so if they are dealing with other social problems such as poverty.
Mr. Lucki: That is correct. We have a serious problem, if only about half of the folks who experience episodes of depression seek help of any sort, including help from their family physicians. The first gap is one of stigma; the second is one of access.
People have a different expectation about being able to access health care for a broken foot as opposed to accessing health care for a broken mind. We need to face that particular expectation.
Accessing mental health services is more complex than accessing primary physician care which primarily takes the form of short visits with physicians and prescription of medications. Other forms of basic mental health care require a referral which in our aspects of health care is often reserved to more specialized services.
When we recognize that primary health care reform will likely evolve into different sorts of supports for the family physician, whether it is through the shared care model — specialists working together with family physicians, or interdisciplinary teams involving nurses and others — that approach holds true in spades in the mental health field. We need to be able to deliver it differently.
Even for those folks who can afford supplemental health care and can access it, the care that they receive may be limited by program funding. The 80 per cent coverage may only cover, for example, five visits, which may not be sufficient to address the problem, particularly if the problem is significant.
It may mean changing providers at some point in the care, moving from the private to the public system, or trying to combine the two. Care is not always well coordinated across those care systems.
There are excellent publicly funded mental health programs in hospitals and in regional health authorities and, if an individual can access those and the program is appropriate, they can get excellent care.
There is another limitation in terms of the appropriateness of care. For example, when I worked with individuals suffering from AIDS and the psychological problems that involves, many things often interfered with a person's capacity to keep an appointment at, say, Thursday at 10 a.m. halfway across the city. The person might not have the bus fare to get there. We need to be able to address some of those other obstacles. Besides agreeing with you about private, public, two-tiered care, there are significant other accessibility issues that we need to tackle.
Senator Cordy: Medications is one of them. Across Canada, 98 per cent of people have a medical pharmaceutical plan of some sort, but in Atlantic Canada, over 20 per cent of the people have either little or no pharmaceutical coverage. People who are suffering from a mental illness have to be on medication.
Mr. Lucki: The same thing occurs in Alberta. For supplemental health care you have to have a good job or no job. The folks who are struggling in low-income jobs orlow-benefit jobs are the ones who have limited access to a variety of programs, including drug benefits.
Senator Cordy: You said that there are good services and programs out there, and I agree. Travelling across the country we have heard of some wonderful programs in the different provinces. We heard about the wonderful, dedicated people, many of whom are working at low salaries, who are working in the field of mental health.
I remember hearing a departmental witness in Ottawa showing us a list of all the programs that were available provincially and federally, and my comment to the person was, "If somebody suffering from a mental illness came to me and asked, `Where do I start?' I would not be able to tell them.'' Is that what you mean when you say the system is fragmented and difficult to access?
Mr. Lucki: A road map through the system is a complex series of boxes connected by lines, but you have to put your glasses on to be able to decipher which one is what. That already shows that we have a fragmentation problem.
How do people move through the system? There are some significantly difficult spots. Access presents a difficulty. Admission to hospital is difficult. Getting the right bed at the right time for an individual presents a difficulty. Discharge from hospital causes a real crisis for certain individuals, and community services are often not available to step up in a timely way to provide the supports needed by people when they are discharged from hospital.
We are making good strides, provincially, here in trying to integrate these services on a regional basis. We have moved away from the system where we had two separate mental health systems, one that was run through the Mental Health Board and the other through regions. We have a more integrated system now, and we are starting to address some of the issues of integrating with health care.
There has been some progress, but the problems are still there. There still is an imbalance, at least in our province, between institutional services — the reliance on hospitals — and the services that would help prevent hospitalization, would help keep people in their homes and connected with whatever supports they have in the community.
Hospitalization in the mental health field is often a crisis not of a person's symptoms but a crisis of our ability to serve them in such a way that will help them manage their difficulties without having to resort to hospitalization.
Senator Cordy: You said that Alberta is making strides in the integration of services. Does the integration depend on the personalities involved in the various systems or is it built into the system?
Mr. Lucki: It is both. One challenge along the way will be the training of individuals to work within the integrated system that we hope to have. In particular, how do we support through training this broader and more complex job that people will have to do? Family physicians will be in particular need of good access to those supports so that they can discharge their responsibilities in an integrated system.
It applies across the board. The panelists before us spoke about the lack of front-line Aboriginal mental health workers and the need to train people to deliver culturally appropriate services in ways that make sense to the individuals who will be receiving those services and in ways that will be accepted by the communities that they are intended to reach. There is a huge gap between the way we train individuals and who we train and who receives the services.
A considerable amount of work has to be done in each of those areas, and we can point to steps we are taking in this province and likely in many others, but there is still a great deal more to be done. If we had an overall action plan that would target some of the things that are lagging in particular ways, we might be further ahead.
Senator Callbeck: I want to go back to the question of a minister of state for mental health. Is this the position of the Canadian Mental Health Association or is it Alberta's position?
Mr. Portlock: This is an Alberta suggestion.
Senator Callbeck: Has any other province had this?
Mr. Portlock: Apart from British Columbia, I am not aware of any others.
Senator Callbeck: When was it put into effect in British Columbia?
Mr. Portlock: From what I understand it was to address precisely the sort of situation that we are encountering elsewhere, the sort of second class, second rate, out-of-the-shadows,second-solitude nature of the mental health system. From the few conversations I have had with people in BC, I understand that this was seen as a strategy to try to elevate the profile of mental health and get it some attention on centre stage.
Senator Callbeck: I understand that. The question was when was it put into effect.
Mr. Portlock: It was two years ago, I believe.
Senator Callbeck: Was it endorsed by the people working in mental health in British Columbia?
Mr. Portlock: That is my understanding, yes.
Senator Callbeck: Mr. Lucki talked about getting rid of stigma. Dr. Gordon mentioned a 10-year national anti- stigma campaign. Do you have any comments to make about what you think that might entail; and do you know of any successful programs?
Dr. Gordon: I think you have looked at some in the course of preparing your reports.
My comment, which ties in with some of the discussion that has been going on, is that sometimes we miss the goal we are aiming for in all of this. For instance, the problem of fragmentation of services is a problem of access. The patient does not care who is providing the funds or who is running the program, the patient wants to be able to access it. If access is the problem, then let's identify it as such. The solution to the problem may be to integrate services, but the problem is access.
The profile of mental health is one of stigma, and one way to solve that problem may be to put a minister of state in charge. However the problem itself is that it is stigmatized in relation to or discriminated against in relation to other branches of medicine.
Let us identify the problem from the patient's point of view and focus on the problem. The solution may be to appoint a minister of state, although I do have some concerns about that. I have changed my mind over the past 15 years on this. Fifteen years ago I was in favour of separating mental health services from health services in order to protect. Now I believe that we should go for integration, as full integration as we can. However, we must raise the profile by dealing with stigma and discrimination.
In terms of the nuts and bolts of how to do that, others are more expert than I am in that area. People tell me that it needs a long-term strategy; that it needs support at a high level; that it needs a commitment over a long period of time, which is why I have suggested 10 years; and that it needs to be multifaceted, that is to say, looking at education, workplaces, media and attitudes within the health care system.
One of the core issues is that of stigma, and I think the federal government can take a significant lead in that.
Mr. Lucki: Addressing stigma is no different from trying to tackle the problem of racism. It is not easy. It requires a determined effort because it can present itself in insidious ways.
We will not be able to address the issue of stigma — or shame from the person's own perspective, the shame that they feel that they have the difficulties that they do — unless we act in a way that is consistent with the idea that there is no shame involved in having mental health difficulties. Sometimes, inadvertently, we convey the message that there is shame.
If, in addressing the issue of racism and said, for example, that people of colour do not experience the same educational opportunities as other Canadians, and our approach was simply to give more money to the separate schools for coloured children, then we would be way off base with that approach. It would never work.
We need to examine where, systemically, stigma has arisen in the way in which we approach the problem, how we value it, and if we find that we are not approaching it in the same way that we approach other social or other health problems, then we need to address that first.
Stigma will likely be with us for a long time because attitudes are not easily or quickly changed. There are numerous other sources of stigma besides those that are structural.
I believe that this is an area in which government can take a lead role in terms of eliminating some of the attitudes that are within its purview to address.
The Acting Chairman: Mr. Portlock, when you have an opportunity to get your proposal on the ombuds service down in black and white, we would like to have a copy of it.
Mr. Portlock: We would be delighted to give you a copy of it, senator. It is still in the formative stage. It comes in partial response to a number of realities.
There are mechanisms in Alberta for people who are in the system to help them adequately pursue and seek redress respecting complaints or concerns about access or supply of treatment, or communication, or whatever. The provincial ombudsman's mandate, which previously excluded hospitals, now includes hospitals and the people in them.
The mandate of the mental health patient advocate in Alberta, as defined, includes current formal patients within the system.
The health quality council of Alberta has now completed two annual surveys of Albertans on their views of the adequacy and the responsiveness of the health system and, for the most part, the responses were favourable. This past year, for the first time, the health quality council survey included mental health. For those who were able to access the system and receive services, there was a 62 per cent level of satisfaction with the mental health aspect of our health system.
However, across the board, I believe that 83 per cent of all respondents expressed concern and, in fact, considerable anger with regard to how complaints and concerns about the system and its responsiveness generally are addressed.
My colleagues in the regions and I pretty much deal every day with people who have tried to access the system having, as I expressed in my presentation, the courage to come forward, and for many people it takes courage to finally say, "I am need help.''
Some of these folks are not often at their best when they try to access the system looking for help for a mental health issue, and their experience, as I record in my dealings with them, is such that we believe there is a need. I believe volume 3 of your last report deals with some form of advocacy to assist people in accessing the system and to pursue concerns or complaints about the system when it has not responded in an appropriate way.
We are developing a proposal that will provide anombuds-service. A classic ombuds-service must involve a neutral person, that is, a person who is not in the chain of command and who can investigate a complaint or a concern and can assist an individual in resolving it and, in certain models, have the power to make recommendations for changing in the system in order to make it more responsive.
This will be done on a trial basis. There are other mechanisms that deal with formal patients, people in the system, and operated under the auspicious of the CMHA. It is not the responsibility of one particular RHA, which would bring all sorts of other complications to the table.
What we require, apart from the funding to run the project for the year — and that is what I am currently engaged in trying to secure — is the buy-in and the cooperation of the RHAs, because in the furtherance of the investigation of complaints and concerns by people who would access this service on a 1-800 basis, it would be a central point of response and approach, if you like, for people who have tried to access the system and have had difficulty or simply do not know where to access it.
It is more of a patient advocate or patient representative kind of function. We would require the approval or at least the consent of the RHAs to be active in their territories, because it would require us or the ombuds people employed in this trial to deal directly with the RHAs, if there is a concern in a specific area.
We initially conceived this idea as something people could use to address concerns they had with services provided by the CMHA at the regional level. In talking about the idea we soon saw that it, in fact, could be and perhaps it probably should be larger in scope.
We are to gear up to this. I have experience as an ombudsman in the health system so, of course, I have a particular interest in this. We are trying to introduce this in on a trial basis across the province. The fallback position is to try it within a couple of RHAs. Failing the system-wide approach, we will try it within a couple of RHAs and see how it works.
We would be glad to provide you with the proposal. It is an idea whose time has come, given the results of the HQCA survey. We hope that it will find some responsive and friendly ears.
The Acting Chairman: If any one of you has a closing statement, we will hear it.
Dr. Gordon: I should like to follow up on what Peter said about access which I take to mean not just front-end access and access to assessments. Only 38 per cent of people with mental health access their GP. They know that there is a 6 to 12 month wait to see a psychiatrist and to have access to mental health clinics. These are front-end access issues. There are also treatment access issues. You can only get into a hospital now if you are deemed to be dangerous. It is most unusual to have an elective admission to hospital.
Equally important is access to support services. It may take six months to access a support service that deals with housing. Why do we have to wait four months to get AISH? Why are some people waiting for months and even years to get into vocational rehabilitation programs?
Access issues are not just front-end issues — walking through the door of the mental health clinic — they include access to the range of treatment services and also the range of crucial support services.
The Acting Chairman: Mr. Lucki, do you have any closing comments?
Mr. Lucki: I would simply reemphasize the importance of undertaking an inclusive process to build a system and a plan that will mirror the plan we hope to create. I believe that each person we listen to, each group we listen to, informs us of another important aspect of what it is that we need to create.
A system is not simply built around the psychiatrists, the psychologists or the nurses who provide the treatment, a system of care includes a whole range of supports, many of which are not even within the health care system. We need to do this inclusively so that those who are most affected by mental illness have a strong voice in creating the sort of system that reflects their needs, their values, and that realistically supports them not just in a way that works for the providers. I think we have done a better job of creating provider-driven systems of care than client-centred, consumer- centred systems of care.
Mental health needs a champion. Your committee has been such a champion for a number of years now by raising the issue of mental health on the national agenda, and that is very supportive to our efforts on a province-by-province basis, because it keeps us in touch with some of the issues that resonate across the country. It points to the fact that solutions may be different in each province. It gives us an opportunity to explore ideas that we may be able to tap into or be able to model.
Hopefully this will see light at some point as a comprehensive mental health strategy for the whole country, one that we will hopefully gladly adopt, because it is in our interest as a nation, not only from a health and a social perspective, but also from an economic perspective for those who like to think in terms of dollars and cents. It is nothing but to our advantage to get this one right because the costs of not doing it will be far greater than we have ever been able to calculate, on a social level, a human level, or in financial terms.
I thank you for the opportunity to present and wish you well in the rest of your hearings and in developing the important recommendations which, hopefully, we will see implemented down the road.
The Acting Chairman: Thank you very much to the panel. This has been a real learning experience.
The committee adjourned.