Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 22 - Evidence - June 15, 2005
ST. JOHN'S, Wednesday, June 15, 2005
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 9:02 a.m. to examine issues concerning mental health and mental illness.
Senator Michael Kirby (Chairman) in the chair.
[English]
The Chairman: I would like to thank everyone for being here today. For our first pair of witnesses this morning we have Mary Bungay-Gaultois, who is with Roots of Empathy. Ms. Bungay-Gaultois, we have heard about your organization in various parts of the country. Dr. Kellie LeDrew is Clinical Director with the Newfoundland and Labrador Early Psychosis Program.
Ms. Mary Bungay-Gaultois, Trainer and Mentor, Roots of Empathy: Honourable senators, I am pleased to be here today as a non-expert witness. Being invited to bring the work of my associates to this committee is indeed an honour, and I thank you for this opportunity.
I consider myself to be a social educator, and in the past 18 years my life's work has been with young people, supporting them through the process of getting a high school diploma, moving to employment and keeping employment, and moving on to post-secondary training. While this may not seem to be challenging work on one level — it is, after all, the usual processes that young people go through, — what I am involved with is young people who face an array of social and emotional barriers as they make life-changing transitions.
My background is in alternate school environment and youth programming and that is where I have experienced, first-hand, the needs of so many young people that I come in contact with. In helping young people make that transition through those milestones, I have discovered that it takes a whole range of supports and services to conduct that process. Sometimes I feel like the conductor of an orchestra because it takes so many people working in concert to make things happen.
Currently, I work for the Community Youth Network, which is a community-based, not-for-profit corporation and it is organized to bring an array of service to youth ages 12 to 18; primarily youth at risk or living in poverty. In my role as project coordinator, I was responsible, to some degree, for then bringing the Roots of Empathy program to Newfoundland, and it is to that program that I would really like to address my comments.
First of all, I would put in some context the importance of prevention and early intervention programs and what research is now showing us as to why that is an important and appropriate strategy. We know that a growing segment of school age children experience, or are at risk of, psychological and behavioural problems that interfere with their interpersonal relationships, successful school performance and their potential to become productive, contributing citizens. Reports suggest that approximately one in five children experience mental health problems enough to warrant the help of mental health services.
Intervention and prevention programs to promote children's social competence and reduce aggression have grown progressively in the United States and Canada. The past few years have seen a convergence of evidence supporting the need for early intervention via the school-based programs designed to ward off the upscale aggressive behaviours that children experience. Schools have been identified as the context that can play a critical role in fostering children's mental health.
Within the context of those opening remarks, then, I would like to introduce you to the Roots of Empathy program and its founder, a fellow Newfoundlander, Mary Gordon, who I am sure would love to be here today. It is possible that you will have the opportunity to hear from Mary Gordon at some other point. Since its inception five years ago in two Toronto classrooms, Roots of Empathy has grown to 2,500 classrooms, has spread the width of Canada and has also made its presence felt in Japan and New Zealand.
The three key goals of the Roots of Empathy program are to: 1) develop social and emotional understanding in children, 2) promote children's pro-social behaviours and decrease aggression and 3) to increase children's knowledge about healthy, normal development and the parenting process. There is, of course, a curriculum that has been designed around those goals that is appropriate for each grade level.
At the heart of this program is an infant and a parent or parents who visit the classroom on a monthly basis. Through this process the infant, in real terms, becomes the teacher. Children in Grades 1 to 8 learn about normal child development and babies'' growth. They interact with the baby and, what is most important, they observe the loving, supportive relationship between the caregiver-parent and this baby. In turn, the regular classroom teacher then will take what was taught in a Roots of Empathy lesson and incorporate that into the normal curriculum in the classroom.
Embedded in the Roots of Empathy program are components that really help change the classroom environment, so that it is not only the curriculum that is really important but also what is happening in that classroom. The whole notion of belonging, caring, collaborating and students working together is emphasized, and, I guess, the children really learn that being nice to each other is very important.
That seems like a very simple process, but what is happening as a result of this program? Research undertaken at the University of British Columbia by Dr. Kimberley Schonert-Reichl, who has researched the Roots of Empathy program in both Toronto and Vancouver back to 2001, tells us that the immediate results are showing that the Roots of Empathy program is effective in improving children's social and emotional competence. In comparison to classrooms where Roots of Empathy was not being taught — and these are comparative classrooms with children the same age and with approximately the same socio-economic background — what was discovered was that in the Roots of Empathy classrooms, children better understand emotions and were able to regulate their emotions. What is also interesting is that pro-aggressive behaviours are reduced in Roots of Empathy programs and pro-social or the appropriate interactive relationships among students have increased. This has been reported both by the teachers and by their peers.
What was an interesting discovery, I guess, or a learning outcome, is that in classrooms where you would expect the range of aggression to remain the same over the school year, it was discovered that as a natural tendency aggressive behaviours among students are increasing throughout the school year, and this happens as children age. Thus, not only is Roots of Empathy reducing that behaviour, the range at which the behaviour is reduced between Roots of Empathy classrooms and non-Roots of Empathy classrooms is quite significant.
Why are aggressive behaviours among children so significant? The results tell us that empathy as a central core of the Roots of Empathy program, and it is central in terms of people's moral personality, has been identified as the personality trait that prevents aggression. We all know, and it has been well documented, about the effects of aggressive behaviour on one another, and the effects of bullying are certainly well known, and Roots of Empathy has been classified and is well known as an anti-bullying program. However it is also a parenting program for children. We may think that teaching children how to parent begins very early in the process, but it is also important because when children, at a very early age — and this can be from Grade 1 to Grade 8 — learn about brain development and neuroscience, and what is most important they learn first-hand how important the experience of responding to a baby's needs is and what the potential outcomes can be, they witness the bond of love between a parent and a child and how important that is to a child's well-being.
Dr. Allan Schore, who is a pediatric psychiatrist and neuroscientist with the University of California, has published widely on attachment theory and the mental health problems that ensue when attachment goes awry. Mary Gordon presented with Dr. Schore at the World Health Organization conference in Luxembourg, and he said that Roots of Empathy operationalized his life's work. He feels that the Roots of Empathy program is based on sound principles of developmental psychology and he is, of course, now urging Mary to bring that program to the United States.
In my brief, in the notes that I have presented to you, I have noted some other people in the field of child development as well who are endorsing the Roots of Empathy program. Dr. Richard Tremblay, who is a Roots of Empathy advisor, is saying that there is a sleeper effect, and he is engaged in this research. Thus the things that you learn in your early years stay with you, and later on when the appropriate stimulus comes into your life, that will bring out that event. It is suspected — and I am convinced that the research will show this in a few years — that the things that children learn about parenting and how important a role the caregiver has to the child's emotional well-being, when they become parents in turn, I am sure, these life messages will resurface. I am sure that the research will bear this out, and that they will indeed become better parents and support their children along the way.
The Roots of Empathy classroom is oftentimes the only venue where children have an opportunity to witness this wonderful marriage of love between the child and the parent. Other researchers, Dr. Fraser Mustard, Dr. Dan Offord and Dr. Aynsley Greene, are also looking at the Roots of Empathy program and saying that it is well grounded in research and that not only is it grounded in research but it also speaks to the heart of what is needed to help children thrive in our world today.
In terms of my role, I work with youth in the Roots of Empathy program. How does that kind of fit in with the work that I do? Yesterday, when I was here in St. John's having lunch with a CYN colleague and we were talking about her work with youth and some of the issues that they face, I just asked, generally, "What are some of the family relationships between the youth that you are working with and their home environment?" She said, "There is one common denominator: all of the family relationships are fractured." When this happens, I guess, it begs us to ask the question: Is there anything that can be said about the quality of those very significant relationships, and what happens when they are not there to support adolescents and youth throughout their life cycle?
Research is showing us that early experiences play a critical role in shaping a child's health, well-being and coping skills throughout their entire life. We also know that a developing child is influenced by many factors. The prenatal environment is critical to health development, as is the environment in which the child lives and interacts. In Roots of Empathy classrooms, children learn these complex concepts; they understand them.
In my wrap-up, I would like to quote John Bolby, who is the grandfather of attachment theory. He was a British psychoanalyst and his life's work from the 1920s onward really focussed on infant child and caregiver attachment. He said this:
The more we can give young people opportunities to meet with and observe first hand how sensitive, caring parents treat their offspring, the more likely they are to follow suit. To learn directly from such parents about the difficulties they meet with and the rewards they obtain, and to discuss with them both their mistakes and their successes are worth, I believe, a hundred instructional talks.
I believe that the Roots of Empathy program gives children this opportunity and has the power to influence their future parenting practices. There are not many opportunities where you can see adults discussing with little 10-year-olds, in a classroom setting, how they feel emotionally about parenting their child and how difficult that process sometimes is.
All intervention programs have some degree of success, and this is especially true when adolescents feel that the person they are involved with has a personal connection with them and is supporting them through difficult situations. However, many problems can be eliminated, as we know, with early intervention measures. Local, regional and national governments can use new research and proven methods to protect at-risk children and families by understanding the importance of nurturing environments and supporting prevention initiatives such as the Roots of Empathy program.
I will end my presentation by saying that my notes to you also contain some comments as well from Mary Gordon, who could not be here but wished to add those comments..
The Chairman: Thank you. We have lots of questions for you.
Dr, Kellie LeDrew?
Dr. Kellie LeDrew, Clinical Director, Newfoundland and Labrador Early Psychosis Program: Honourable senators, I would like to thank your committee for inviting me to participate in your discussions today. I apologize that I do not have a copy of my brief to submit to you.
I am the co-director of the early psychosis program, and I guess I have many roles within that program in our province. I am also an assistant professor of psychiatry at Memorial University and I am a general psychiatrist within the health care corporation of St. John's. Before I talk about the program that exists within our province I would like to talk briefly about early intervention strategies and psychosis. I apologize if you have heard this before.
In terms of a brief summary about early intervention strategies in psychosis, there has long been an understanding that psychotic disorders such as schizophrenia are persistent and severe medical illnesses that are associated with high morbidity and mortality. The World Health Organization has ranked active psychosis as the third most disabling condition; it is even higher than blindness. Psychotic illnesses have enormous economic and medical costs; however, the human cost of these illnesses cannot be quantified. We often see devastating personal costs to individuals and to their families. Sometimes I think we underestimate the costs these illnesses visit, not only on the individuals from a human perspective but also on their families. Psychotic illnesses are a major public health concern, yet our medical system seemingly has not prioritized them as having the same importance as other physical problems.
Unfortunately, for many years there has been a therapeutic pessimism that has impeded advances within psychiatry and mental health, and has impacted significantly on treatments of and service delivery to individuals who suffer from illnesses such as schizophrenia. Early intervention in psychosis really represents a paradigm shift in the conceptualization and treatment of psychotic disorders. Early intervention in psychosis refers to the current approaches of treatments of psychosis that emphasize both the timing and types of interventions that are used to treat a person experiencing their first episode of psychosis. "Early" refers to as early as possible following the onset of psychosis but even now, within the early psychosis movement, there is some sort of controversy as to the possibility of intervening even before the onset of psychosis in the prodromal phase. "Intervention" refers to comprehensive, intensive, phase-specific and individualized treatment plans for these individuals.
The early psychosis movement really started in Australia, and they have been the leaders in early intervention strategies in a number of areas of mental health. Over the past decade, the concepts of early psychosis have gained strength and credibility and have spread throughout the world. Canada is felt to be one of the leaders when it comes to the development of early psychosis programs and research.
The early psychosis movement has really changed views about psychosis and illnesses such as schizophrenia. Psychotic disorders such as schizophrenia have now gone from being seen as chronic and debilitating illnesses to now being possibly even potentially curable. We are certainly entering into a new era of optimism in the treatment of these serious mental illnesses. It inherently makes sense that the earlier you treat someone, the better off they would be, but until recently this really has not been the accepted theory in psychiatry and mental health, and also until recently, there has been very little research done in that area. However, research has shown that significant delays were being experienced by young people who were suffering from psychosis before they started on treatment, and delays lasting up until two years before they were initiated into treatment. Thus people were out there, psychotic, for two years before they were actually seeing a physician or a mental health professional and starting on treatments.
It was the creation and refinement of various service delivery programs that enveloped the principles of early psychosis programs, started in Australia, that really led the way to approving treatments for individuals suffering from psychotic disorders. It has been shown that by decreasing the duration of untreated psychosis, better outcomes are possible. This makes sense, not only from a biological perspective but also from a psycho-social perspective.
There is some controversy as to whether or not the longer you leave someone untreated, will the psychosis be biologically more toxic to your brain? Some would say yes and some would say no. Regardless of that fact, it makes sense that the longer someone is actively psychotic and having an illness that is affecting the way they think, feel and experience the world, the impact on them, psychologically and socially, is more devastating. Thus the earlier you get them into treatment, the better off they will be, and I can expand upon that statement later, if you wish. As psychosis often occurs in adolescence, it often results in a major disruption in a young person's ability to meet the developmental challenges that are required of them. If it goes untreated, it can have a major impact on their life's trajectory.
The early psychosis program in our province was initially started as a pilot project within the health care corporation of St. John's back in the winter of 2001. It was modelled after the Calgary program and it was initially set up by just myself, a colleague and a nurse. In other words, just three of us started it up, and we tried to take pieces of other people's resources that were already there, and we asked if we could have certain people assigned to us to work with our clients. These were not new resources; they were people who were already in the system working with clients who had psychosis, and we asked if certain people could be assigned to our program.
Basically, it was set up primarily as a clinical program with a small research component. This is important, because this was different from many of the programs across Canada. Many of the programs across Canada were initially set up as primarily research programs, so if clients did not participate in the research, they could not be part of the program, or that was my understanding, anyway.
We were fortunate, at that point, because we did receive funding and support through the health care corporation and we did receive funding through pharmaceutical companies to set up this mainly clinical program. We accept individuals experiencing their first episode of psychosis between the ages of 15 and 55. In that way, we are a bit different, too, because we took a broad range of clients. That was a bit of an obstacle as well because we are part of the adult system, and our services initially were for 19 and above, but we were able to talk the corporation into letting us take the 16 year-olds and above. That, in itself, is a barrier because oftentimes difficulties are experienced in making the transition between child health services and adult services.
We accepted individuals who had had less than six months of treatment for psychosis, so that meant individuals experiencing their first episode of psychosis. Our criteria for accepting individuals do differ from other programs across Canada. My understanding is that certain programs will only take individuals who have had less than one month of treatment.
We also differ in some ways in the way that referrals are accepted, not only from family physicians but also from community mental health workers and community workers, and we do allow families and individuals to self-refer. After an article that we wrote appeared in the newspaper, we had family members walking in and referring individuals as well. We do have a program coordinator who does initial screening and assessment and it is usually done within 24 to 72 hours, because psychosis is a psychiatric emergency and I do not think there can be wait times for screening and assessments if someone is acutely psychotic. Thus we have to take down the barriers when it comes to access to mental health services, particularly when someone is acutely psychotic.
We are a community-based program; however, we are located within the Waterford Hospital, which is the provincial psychiatric hospital. That was the space that was available to us and that, in itself, does present some challenges, but we try to keep people out of hospital as much as we can. One of the goals of our program is to treat people in the least restrictive environments, so we try to keep people in their communities, in their homes, out of hospital but we are not necessarily always successful at that. The goals of the program are to promote early recognition of individuals who are experiencing psychotic symptoms by reducing delays and wait times and reducing their duration of untreated psychosis. We try to provide optimum safe and comprehensive interdisciplinary assessments and interventions for individuals experiencing psychosis, but also for their families, and I can tell you more about that as well.
An important goal is to provide recovery and to prevent relapse in an effort to prevent persistent disability. Other goals of our program include the promotion of education to primary care physicians and community health workers, so we try to do that, and that is a small component of our program. We have had some provincial initiatives around that. As mentioned previously, we do have a small research component and some of our research interests have been in the areas of service delivery and health outcome evaluation. We have set up a naturalistic database to study individuals with first-episode psychosis and we are collecting a lot of information. Unfortunately, because our clinical demands are so high, we do not have time to look at that information, but we will look at it eventually.
The components of our program include psychiatric care, case management, and family interventions, and that is particularly important because one of the new resources that we were able to get was a person specifically assigned to work with families in our programs. She has a Masters in Social Work. Her job is to work only with the families. She works individually with families at various phases as the people progress through our program, and on a group level. She has introduced some new initiatives using telehealth for support networking for the families across the province. We also have a part-time occupational therapist and some other people who are involved on a part-time basis including psychology, pharmacy and dieticians.
As stated previously, Canada is a strong member of the international community in terms of its contribution to the practice and research in early psychosis, and there are a number of well-established sites in Canada, as I am sure you know. We feel our program is unique in terms of the population we serve and in terms of some of the strengths of our program.
Certainly, we face some unique challenges. Most recently we looked towards expanding our program to better serve the clients outside of St. John's because my thing is that you should not just be able to obtain services in St. John's, and there are a lot of people outside the "overpass" — that is sort of lingo in Newfoundland. I myself come from outside of St. John's, and I feel that people in all parts of the province deserve the same access to care. Recently, therefore, we obtained some funding to have a nurse/case manager position in western Newfoundland and we are trying to set up a satellite service there for our program.
As well, we look towards using new and innovative ways of delivering the service, such as telehealth and shared care initiatives. Certainly, we are facing some challenges when it comes to geographic issues and mental health provider shortages and lack of other community support such as supported work programs, housing opportunities — I can speak further to all of that, if you would like.
The Chairman: Dr. LeDrew, when you talk about "first episode" and about "early psychosis," how does a parent know the difference between the behaviour of a child that warrants coming for treatment and just a kid having a bad day? From a layman's standpoint, how does someone — whether it is a parent or a teacher for that matter — know that really somebody needs to come and see you? What are the telltale signs? What are the signals that you look for?
Dr. LeDrew: That is a very good question. I think, from an individual perspective, if someone — a particular person had that question, we have a program coordinator, and if the person was suspicious of a change, they could be referred to our coordinator who could ask them a lot of questions, such as, "Are you having this, this and this?" If she thought they warranted an assessment, they would be brought in and be seen by a psychiatrist, and if we felt that they were experiencing psychosis, then they would become part of the program. If we did not, and we felt it was more depression or an adjustment problem, we would send them to another service.
The Chairman: Can you give a layman's interpretation, then, of what you mean by psychosis?
Dr. LeDrew: Psychosis is a brain disorder that reflects an impairment in a person's reality-testing and there is often a change in a person's behaviour, thinking or emotion. Initially, the signs can be very subtle and can be very difficult to detect, and thus when we are trying to educate people around signs and symptoms of psychosis, those can often overlap with other diagnoses such as depression and anxiety. Very commonly, when someone is acutely psychotic, it is easy to tell because people describe hearing voices; they are delusional, have fixed, false beliefs. They may say that someone is out to get them and they are paranoid, and different things like that; they say they are hearing voices, voices of God or the devil or different people. Thus when someone is acutely psychotic, a general practitioner, a community mental health professional, a teacher, or other people can often tell very clearly. However, it is at the stage of the very subtle signs, when you want to get someone early, that can be very difficult to tell.
When we are trying to target interventions, of raising awareness in public education, we do not expect the teachers to necessarily say, "I know this person is psychotic" or "I know this person has depression." We just want to raise the index of suspicion that if someone is having a persistent change or psychological deterioration, then guess what? There is something wrong. The wait-and-see approach is not the right approach; you know this person, and there has been a change; this person's functioning is impaired and they need an assessment, they need to see someone. This is an at-risk person who should probably come in for a screening. We are not necessarily asking the mental health professionals or the teachers to do the assessment but we will bring them in and do the assessments. They may turn out not to be psychotic, but we can help them with where they need to go.
The Chairman: But do you have — and it is probably not as simple as a check list, but something with which you can train a parent or an elementary or high school teacher, for example, to sort of say, "Here are the signs you ought to be looking for."?
Dr. LeDrew: Yes, the early psychosis movement has been very good because the Australians — and Canadians, too, when you look to the B.C. group — have come up with a lot of promotional materials, and people are very open to sharing those materials so it has already developed, and there are a lot of screening tools and a lot of information.
If you notice these changes, a person has become more socially isolated, their marks are dropping, they are starting to act unusually, you should call, and these are the things you should look for. I guess it is not reinventing the wheel when it comes to some of the educational materials because it is already there. It is just a matter of disseminating it, and in the right way and to the right people, to the targeted groups to whom it needs to get across.
We have actually done some of those things with guidance counsellors and people in schools to try to say, "You know what? We do not expect you to be able to make the diagnosis, but if you are concerned about someone..." Just sort of increasing their awareness, because some people may not even have heard the term "psychosis." It is mainly about raising awareness, and there are already established educational tools out there to provide to schools, parents, and the public around psychosis and what to look for. It is just that we have not had the money to purchase a lot of it, and to be able to disseminate it effectively.
The Chairman: If you were able to disseminate it effectively, what are the chances that you would get such a demand for your services that you could not meet the demand?
Dr. LeDrew: Yes, we thought that might be a problem as well, but what happens is that we have a very experienced program coordinator so that if someone calls for a guidance counsellor, she is very good at screening specifically for psychosis, and if she thinks that this may be a young person with depression or a young person experiencing an anxiety problem, she will get them in and do the screening and refer them more appropriately.
The Chairman: You have a triage system that seems to work pretty well.
Dr. LeDrew: Yes, and speaking to that point, I think some people would sometimes refer to early psychosis programs as a boutique service, and really, I think the movement is sort of leaning toward looking at at-risk youth. There must be a hub-and-spoke sort of service for adolescents. There are many at-risk youth and unfortunately, when someone is young, the symptoms of psychosis may overlap with the symptoms of depression, with anxiety, with substance abuse, so if you had a central triage place where people could send at-risk youth, then they could be triaged appropriately, sent to early psychosis services, or sent to addiction services. I think that if we had that in Newfoundland, we could be a little more effective.
What sort of happened here is that because we are so accessible, sometimes people come to us, and we end up sending them back to other places, which takes up a lot of our time and makes it all a little bit difficult.
The Chairman: We found that in, of all places, Brandon, Manitoba; they have exactly the kind of triage system you are talking about. They have a single point of entry for the entire mental health system, run by a nurse practitioner, as a matter of fact, and that covers both the city of Brandon and a substantial portion of rural, northern Manitoba. The nurse practitioner sends the individual to wherever they need to go — is it addiction? Is it just some counselling? Is it psychosis? Thus, exactly what you have described is doable, but you are right, the problem is that you are so available that people skip the first step, right?
Dr. LeDrew: Yes, and so people sort of walk in and they will just say, you know, "I want to be..."
The Chairman: "I want to be screened."
Dr. LeDrew: Yes, and that is sort of difficult.
The Chairman: Ms. Bungay-Gaultois, we have heard about your program, which sounds terrific, but you are the first person we have talked to who has worked on the Roots of Empathy program in a rural setting. Although you live in Stephenville, I presume the schools you work in include some pretty rural schools, right?
Ms. Bungay-Gaultois: Very rural schools, as remote as Ramea, which is an hour —
The Chairman: I know where it is. I have been to every fish plant in Newfoundland. Sorry, that was in my old days. I probably should not mention that anymore. I am still not liked for some reasons, for some of the things we said. Margaret Lake is still around, probably, or her ghost.
Do you notice any difference in running your program in a rural setting rather than an urban setting?
Ms. Bungay-Gaultois: I personally have no experience with running the program in an urban setting, and Roots of Empathy certainly has that background in many provinces across the country. What we have discovered is that maybe there are different degrees of cultural diversity in a rural setting, such as rural Newfoundland settings, than in more urban settings.
The Chairman: There are fewer degrees of diversity?
Ms. Bungay-Gaultois: That is correct, fewer degrees. Sometimes the socio-economic conditions are different in rural settings, especially here in rural Newfoundland, but children's developmental processes are often very comparable in urban and rural settings, and some of the outcomes that are being experienced in Toronto and Vancouver are some of the same outcomes that we are experiencing here in Newfoundland. The satisfaction results in the peer and teacher ratings of the program are compared to programs across the country, and certainly what we are learning by comparing Newfoundland teacher and student experiences to those in other places is that they are comparable across the board. If I may say so, our experience here in Newfoundland demonstrates clearly that students and teachers in many categories rate Roots of Empathy programs higher than those in urban settings do.
The Chairman: Do you ever have schools or teachers say that they do not want to do it? I mean, it seems to me so obvious that they would want to do it, but in any event, is your take-up rate limited by the number of people whom you can find to actually run the program? Or do you find that certain school systems are keener than others? This is an interesting place to do that because you have more religious-denominated schools than in other places. Is that an issue?
Ms. Bungay-Gaultois: There are several issues, of course. The Roots of Empathy program operates on many levels. The key is in getting the buy-in from a school board, for example, or the classroom teacher, and in our case the community partner, the Community Youth Network who wants to bring the program to a certain community. There is certainly an interplay of those relationships.
With respect to the limiting factors, there is the cost, as in any program, of bringing that program to an area, having appropriate people trained and having a classroom teacher who is receptive. In our early experiences here in Newfoundland, Community Youth Network absorbed the cost of bringing that program to the province because we believed that once we had a demonstration project to show, in the following cycles we would have more partners who would buy into the cost of implementing the program. That has, indeed, proven to be the case, and we are certainly in a situation now where we need to train more instructors.
However, principals and teachers are coming to us and saying, "We need more Roots of Empathy programs." In my Grade 8 class in Lourdes, for example, the principal reported that the teachers are incorporating some Roots of Empathy issues and programming those into the regular health program. I can also tell you that the sexual practices of young adolescents is changing in that classroom. The teacher will verify that. Young girls who thought that having a baby at the age of 14 and 15 was to have someone to love them, not for them to love the baby, has dramatically changed when they learned that taking care of a child is a very difficult process, and that it is not an easy solution to immediate issues of loneliness and lack of belonging.
The Chairman: I was curious about the lunch you had with your colleagues the other day, who commented on the problems they were having, and the one thing you said they had in common was that they had came from fractured families. Obviously, a number of the people who take your Roots of Empathy program come from fractured families.
Ms. Bungay-Gaultois: A proportion do, for sure.
The Chairman: You did give us some actual research results, but anecdotally, does the program work as well with someone who comes from, what you call the fractured family, as it does with anybody else? In other words, I could understand how it would work in a non-fractured family. I am curious to know whether there is a lesson to be learned, even if the child is already in a fractured family.
Ms. Bungay-Gaultois: I would say an immediate yes to that. We have had some cases where some young children who are clearly damaged by life for the first time witness what that bond of love is like and what a difference it can make to a child's life. Mary Gordon tells a story, in her video, of how one child who was in a foster home setting, a number of foster homes, who cuddled a baby after class and asked, "Could you be a good parent if you have never been loved?" Once a child witnesses that miracle, I think it can have a profound effect on their ability to be a good parent later on in life.
Senator Trenholme Counsell: Thank you both for your wonderful presentations.
Dr. LeDrew, you used the word "cure," I believe. That perked up my ears. What is the research, and to which of the psychotic illnesses are you referring?
Dr. LeDrew: That would certainly be a controversial topic. There is a school of thought that it is potentially curable. However, I think there would still be a lot of people who would not necessarily agree with that.
Senator Trenholme Counsell: I want to know the school of thought; I want to know where this research or idea is coming from.
Dr. LeDrew: I think it may come from some of the genetic research that is occurring. Some people are now involved in some genetic research going on at this point, looking at who is at risk, what are the genes, will we be able to identify genes that put us at risk, and then be able to manipulate our genetic risk.
Senator Trenholme Counsell: So we are talking very long term here?
Dr. LeDrew: Right. I guess the other part of the research would be some of the prodromal research. That is very controversial. Some people believe that if we could identify ultra high risk individuals, or individuals who are at genetic risk, and then have certain other risk factors, for example neurocognitive findings and different things like that, and intervene with medication, possibly, or psychosocial interventions, can we actually prevent people from becoming acutely psychotic? In other words, if we intervene on the prodrome, can we actually prevent people from becoming actively psychotic? Prodromal interventions are very controversial at this point, and there is some work being done in the U.S. and Australia. A Canadian group is also working on it at one institution, but certainly there are a lot of ethical issues, and trying to get research like that through HSC is challenging.
Senator Trenholme Counsell: I know a bit about the genetic research in this area, but other than in very scientific circles, I question the use of the word "cure." I commend your work on early intervention, early diagnosis and promoting that message everywhere, particularly among our youth population, but you are focusing on the schools more than anything. At this point in time, the research is at a very basic stage, is it not?
Dr. LeDrew: Right, it would be very basic. The other thing that people might think is that if you can treat people in the first episode, can you actually prevent them from having a future relapse, and so prevent the persistent disability down the road?
Senator Trenholme Counsell: That is a little different.
Dr. LeDrew: Yes. It is an interpretation of it, I agree.
Senator Trenholme Counsell: It really caught my attention, but the work is excellent. The very fact that you are, as a community and as a province, focusing on very early detection, diagnosis and intervention is all excellent.
I do know quite a bit about this program, and I met Mary Gordon very early on. There is no question that it is excellent. However, I did not realize that it was charitable, not-for-profit, and so I do want to know about the costs involved. I know how difficult it is for schools to buy anything, so I would like you to explain about the costs, just to interpret a little bit more of this charitable, not-for-profit aspect of it.
There are two other concerns that I have. One was with respect to teenage pregnancy. I know how vulnerable young people are, particularly young women, but not just young women. I know some boys who really feel that their life will be more whole if they become a father. I have dealt with this attitude a lot. I suppose it is too soon to have any statistical evidence on whether you are actually reducing teenage pregnancy, but I would like you to discuss that.
The other thing that I wondered about was to what extent you are involving the fathers in this program, because I think — and if this is feminist, I am not a feminist, bus excuse me, gentlemen — that women have a bigger role, and is the challenge to get fathers involved in this whole education of their children and relationships with their children as parents? Those are my three questions.
Ms. Bungay-Gaultois: First of all, when it comes to cost, and indeed you are correct, it is a not-for profit charitable organization and they have staff and they are very much involved in program development, putting together materials that are required in order to train instructors who then go into classrooms to deliver the program. The approximate cost to train 10 instructors for 10 classrooms would be about $25,000. That would include the materials and having a trainer come in to deliver that training. Then there is an additional cost to bring books and toys to a classroom.
How is this negotiated or managed? It varies, depending on the situation in which the communities find themselves. For example, in our experience on the West coast, where the Community Youth Network, again a not-for-profit community organization, decided to absorb a lot of that cost upfront and to have the program delivered so that people could see the benefits.
Then, in turn, during the second cycle you need community partners and that can be government agencies, that can be businesses and it can be schools and school boards or health departments, who then may say, "We would like to train one Roots of Empathy instructor." Or "We would like to make a donation of $2000, $3000 towards the cost of the program."
I was really encouraged the other day when speaking to a colleague out in Alberta — and he is director of a school board there. He told me, "We are bringing Roots of Empathy to our district." I said, "How are you managing it?" I mean, that is the first question that everybody asks, since there is money involved. He told me that the Department of Child Services has, in their budget, allocated $3,000 per training person to have 85 people trained provincially. That is about a $255,000 commitment from a government department into prevention initiatives because they believe this program will make that type of difference. That is just one approach to developing the program, but certainly there are partnership approaches that would be required, I think, in a province such as Newfoundland and Labrador to make that happen.
Senator Trenholme Counsell: What does it cost for a classroom to have this? Is it $2,400, $2,500?
Ms. Bungay-Gaultois: In that range, yes. That would include the training for the instructor, the resource materials and the toys and books that would be part of the instructional tools.
Senator Trenholme Counsell: That would be for how long, one year or two years?
Ms. Bungay-Gaultois: The books and toys last forever, and the instructor who is trained as long as they train, I mean they could be there for a very long time. I have one instructors who has been there now for four years. The cost of the training is $2,000 per person, so if you average that out over four years, the cost is not significant. I guess the cost becomes significant if the person does not stay after one year and moves on for any variety of reasons; they leave the area, or whatever.
Senator Trenholme Counsell: Apart from the training, is a person paid for undertaking this training?
Ms. Bungay-Gaultois: Just to do some comparison, in Alberta some school boards and sponsors do have an honoraria for the instructors. Other models show professionals — it could be health care professionals — who actually do this as part of their job. In one example, in southwestern Newfoundland, we have a family resource centre worker who actually goes into the classroom as part of her job, but in many other cases, in our experience, it is community volunteers.
Senator Trenholme Counsell: Fathers?
Ms. Bungay-Gaultois: Fathers are as important a part of the program as mothers. In the Roots of Empathy classroom, every conceivable child care arrangement is demonstrated so that we have examples of two-parent families, moms and dads. In one classroom we had the mom and dad come in regularly to the classroom so that the boys especially could see the importance of nurturing and bonding with the father, as well as with the baby. In some classrooms we had grandmothers come in because they were the primary caregiver of the child. In some classrooms we have same-sex couples coming in because they are also the primary caregivers of their children. In one classroom we have had a father come into a classroom alone because he was providing care for his child in the absence of his partner.
Senator Trenholme Counsell: This is obviously only one part of what you are doing in the Community Youth Network but you have chosen to emphasize that rather than the other things. I wanted to ask you about your youth information centre in the Community Youth Network.
Ms. Bungay-Gaultois: The youth information centre in Port aux Basques?
Senator Trenholme Counsell: Well, I do not know, it just says here "Community Education, Youth Information Centre." I am always interested in these centres because they are challenging to operate but they are important if they work well.
Ms. Bungay-Gaultois: It is a brand new venture for us. We are very excited. It opened in Port aux Basques as of April 1. We have a Community Youth Network staff person who works with youth in the area, but what is really exciting about that project is that a whole array of community partners — again, the concert effort — came together and said, "We need a place for young people to come to get appropriate information on mental health issues, employment, education, general services for youth, and to incorporate a healthy recreational program." When that vision was created by the community, by different players and different departments, a proposal was developed and brought to Human Resources and Skills Development Canada, which really embraced the concept and funded it fully. We have six people who are staffing that organization seven days a week, going from morning to late evening.
It is as yet too early to say how successful it will be. I had a student out there the other day just monitoring the program and he said, "If I ever had an opportunity to work in a place like" — we have now called it the Leap Centre — "that would be my life's work." He said, "The range of visits that you get are just amazing." We suspect that it will be a referral service for students and young people to enable them to drop into a whole range of government agencies to which they would not ordinarily have access, because often you must to be linked to the health care professionals and the employment service specialists who are available in an area.
The answer to you question is yes, it is very exciting work for us, and we are delighted to be a part of it. In about a year's time I would like to report that it has been a tremendous success and that we have gone full steam ahead.
With respect to your third question about teen pregnancy, it is certainly an issue for us. Teen pregnancy is always an issue in terms of healthy parenting. There is lots of research that shows that the earlier you become a parent, the poorer the prognosis for the child may be, rather than if you were a little bit more mature and you had more supports along your life cycle.
That being said, during the 1980s, with lots of AIDS awareness in our area, we found that some of the teenage pregnancy rates were coming down and I think, if anything, AIDS education accomplished that goal. However, we are not seeing as much awareness around AIDS education in classrooms — I cannot speak nationally; I can only speak about western Newfoundland — and we are discovering that the teenage pregnancy rate is now on the increase again.
There are a number of reasons why young boys and girls want to have children. In the higher grade classrooms, around Grade 8, when many children are sexually active, we have had children who are 14 or 15 years of age becoming parents in schools, and our job then becomes to support them through that process so that they still get a high school diploma and can make normal life transitions. However, they are quickly learning that becoming a parent is a difficult process. I was at a presentation on Roots of Empathy last year with mental health professionals in Corner Brook and in the back of the room, one of the psychologists put up her hand. She said, "I have to tell you a story." I said, "What is that?" She said, "Roots of Empathy is really making a difference." We had no connection before this meeting, and I said, "Okay, tell your story." I did not know what the story was going to be. She said, "I am treating a young boy from a foster care background who has been very sexually active from a very young age, and all he talks about when he comes to see me is the Roots of Empathy classroom, the baby, the parents and how difficult it is, and how he understands that it might have been difficult for his parents to raise him as a young boy, and why he has had as many foster homes as he has gone through in his life. He said, "I never, ever thought about getting a girl pregnant before. I never gave it any consideration. Now when I have sex, I use a condom." You could say that it is changing lifestyles.
Senator Cook: Thank you for your stimulating presentation. I had the privilege of meeting Mary Gordon, thanks to Senator Cochrane, in Toronto some time ago. She is many things, I know, but she is certainly a women of vision.
Ms. Bungay-Gaultois: Absolutely.
Senator Cook: Listening to you this morning, you are people with a passion. My concern is that it is a project when the ideal optimum is that it must be an integral program for our young people. Thus I took a look at your funding partners. If one or two or whatever goes down, then you are in crisis.
Ms. Bungay-Gaultois: Absolutely.
Senator Cook: I guess you walk one step at a time, in a lot of ways like most of us do. Because you have an identified constituency, you look at services for youth at risk, or youth living in poverty, so you have your constituency. I am just wondering how you manage to have the message stay with your funding partners, and how you build on it? I am a very structured person. I would like to see this program delivered through health education boards.
Ms. Bungay-Gaultois: That would be the ideal.
Senator Cook: While you are doing wonderful work and you have gone out and made it happen, would it be part of your mandate to ensure that this kind o program becomes an integral part of learning in our schools? Do you think that we could get to that point?
Ms. Bungay-Gaultois: Certainly, on a personal level, I could see myself doing Roots of Empathy work full-time because it takes that degree of effort to make it an integral part of any organization, just as you have schools with teachers and they become critical to delivering educational programs. Absent of that, I guess we must come up with very creative ways to sustain that programming. There is always the likelihood that funding just disappears and that you could lose your programming. I have worked personally on short-term contracts for the last 18 years, so thinking that long-term employment and being an integral part of the programming will make a difference is no guarantee. Sometimes it is the advocates on the outside who have nothing to lose, who just believe in the program, who just make inroads with various organizations to see that it happens.
Is it intensive enough? No, absolutely not. We would love to have a Roots of Empathy program in every school on the West coast. I would love to see it in every school in Newfoundland and Labrador. Native communities are especially longing for the Roots of Empathy programs and are putting resources in place to make that happen as well, because it certainly complements their culture and their understanding.
We just need to keep making inroads, and this opportunity today is to let people know about the programming, who may in turn be talking to other people, who may say, "What other resources can be brought to bear, to make sure that early prevention and intervention programs can be more accessible to all children in schools?" I really am convinced that these programs will make a difference with respect to positive life outcomes for children and youth.
Senator Cook: I am sure that they will, and I realize that I date myself when I look for that structural thing, that I want to keep things safe. I know it is the way of society these days that you find your money wherever you can, but I am sure the passion that you have for this project and the research that you are doing will sustain you.
Senator Gill comes from an aboriginal community. I think this is something from which our aboriginal people could really benefit. May I suggest that you go to the Department of Indian Affairs and do a presentation?
Ms. Bungay-Gaultois: I am sure Mary Gordon has that on her agenda.
Senator Cook: Dr. LeDrew, we are accessible because I suppose there are not a lot of us here on this island, with regards to people. You are the clinical director and you also teach at MUN, or Memorial University. Would you help me understand how big your staffing model is and whether there is someone at our one care hospital 24/7, or is there someone on call?
The other thing I am looking at here, and it jumped out of your presentation, is that you are funded by the health care corporation and a pharmaceutical company. What kind of money did the pharmaceutical company put up — and if that is an inappropriate question, I do not mind you not answering it — for this program?
The other thing I wanted to ask you about is that you said that you deliver your program out of the Waterford, and that that presents challenges. I jumped to a conclusion, so perhaps we could have a conversation about it. Does that reinforce the stigma of mental illness because you are housed in the Waterford? Those are my questions.
Dr. LeDrew: Those are interesting questions. Initially, when we started, it was a pilot program. We had to, sort of, prove our worth and we were allowed, as part of our positions through the university and the health care corporation — myself and Dr. Hogan — to start to develop this program. We also had a nurse, so it was just the three of us. We did receive some money through pharmaceutical companies in the form of unrestricted educational grants — that was when, I think, the pharmaceutical industry was at a different place than it is right now. We received funding of about $50,000 from each of three pharmaceutical companies to hire a nurse, provide training for various people and set up a data base. In total over three years, I think we got about $250,000, or around that, to set up and develop a data base, to develop the research, to hire a couple of people and to do the training. Subsequent to that, we did not receive any further funding from pharmaceutical companies, and all our positions are now funded entirely through the health care corporation.
We have now been given a provincial mandate so that we are able to service people outside of the St. John's area. Initially, we were just allowed to provide case management services to people in St. John's, but as physicians we were still seeing people in Corner Brook and Ramea, or wherever. We were providing a different service to people outside of St. John's than we were providing to people inside St. John's. However, we are now an eastern regional service as well, so we are no longer just a service for St. John's.
In terms of staffing right now, we do have a number of designated people just for the early psychosis program in terms of case managers, a family worker and a program coordinator. We also have a number of part-time people who work with our program, quarter-time or half-time, but also work with other mental health programs. We are always trying to get pieces of people. There are not a lot of new resources that come into our program because, ultimately, all of these clients who have psychosis, they have always been in the community and these mental health workers have had to provide them with services. In other words, it is just a reorganization of the services that we provide.
In terms of funding, right now that is done mainly through the health care corporation, and we also have some funding through the Western Board for one nurse to provide a satellite service to link with our program here.
Your other question with respect to the Waterford hospital is certainly an issue. Initially, when we started, my university position was through the Waterford Hospital, I guess, as was Dr. Hogan's, and the health care corporation gave us the space there and the administrative support, so the pharmaceutical companies did not provide the funding for that. Thus we were based and operating out of the provincial psychiatric hospital. That certainly does provide challenges because most early psychosis programs that are around are based in the community, and that is done so that there is an attempt to de-stigmatize mental health. A lot of youth services are provided in the community in a user-friendly way, at the mall or in a nice street, a nice house or whatever, but we were in the Waterford.
The Waterford in Newfoundland does carry a stigma in itself. It was called "the Mental," and there are a lot of older myths and different things that that carries with it. We have tried to protect and isolate the program in terms of where we are situate, and we have made it a very nice, pleasant space and people just sort of come right up the elevator and you come in and you are isolated. However, for young people, it can be very traumatic to have to come to a provincial psychiatric hospital. When you come in, you do see people who have lived with psychiatric illness for quite some time and are still on older medications that have disabling side effects, and it can be quite scary. It is very traumatic at times, and sometimes it is actually more traumatic for the families, probably, the parents of the patients, than it is for the young people themselves.
We have tried very hard to work with that, and it is a challenge. Oftentimes people do not want to come, so we would like to have a mobile crisis team that we could go out to their houses and deal with them out there. Eventually, once people come in and get to know us, they love it and they have no problem with it, but it is initially getting the people through the door that is very challenging with respect to the Waterford.
When it comes to early psychosis, stigma itself is very difficult. One of the premises of early psychosis is that, as mental health professionals, I think sometimes we, too, can be stigmatizing. Perhaps even the language you use creates problems — and we are very careful with that — because sometimes mental health professionals use stigmatizing language, and so people "live" with mental illness: You are not a schizophrenic; you live with schizophrenia; you live with psychosis. Even the language that you use is very important when you work in early psychosis because there is a realistic optimism and there is hope, and we work really hard with that. However, even if you are in our program and sheltered, you can step outside the door and someone might say something to you that just totally undoes everything that we have just attempted to try not to stigmatize. It is a challenge, and we would like to move to the community, but it is very difficult at this point without additional resources.
Senator Cook: Yes, you go where space is available. I served on the General Hospital Board and then became a part of what was referred to locally as the "Mega Board." We were told that we were to meet at the Waterford, and some people just kind of looked. Nothing was said, but the message was clearly there: We are going to the Waterford.
I want to commend you on your initiative, and I hear from your peers that you are doing wonderful work. You did not answer the question about 24-7. Are you on call, or what happens there?
Dr. LeDrew: Right now, the way that we are set up, our services are from 8 to 5, Monday to Friday, but there is coverage through the mental health services in the city. Right now, there is a psychiatrist always on call, the short stay and a psych assessment unit. For the most part, we are able to provide services in the way that we are set up. I am on a city on-call schedule as well. For the most part, we can manage our clients. We try to manage them within our program, and very rarely do our clients end up going to emergency because they can usually get in within 24 hours of seeing me or Dr. Hogan or seeing our case manager. We manage it pretty well like that so that very rarely do they end up in emergency, although sometimes they do. We do not provide a pure on-call service, because of shortages. There is only myself and Dr. Hogan. We do not do one and two on call; we use the city on-call services.
Senator Cook: Mr. Chair, we have not talked very much around this table about the contribution that pharmaceutical companies play in this whole delivery of health care. The many pilot projects that they are funding cause good things to happen. However, as I said to Ms. Bungay-Galtois, we must move beyond projects into programs if we are to make a lasting change in the lives of people. I firmly believe that there have to be programs and in that way there is a kind of protection for it. I thank you both.
Senator Cordy: I would like to go back to the issue of stigma, particularly with regard to teenagers who are not undergoing any mental illness or pressures but who very often have difficulty with low self-image and a lot of insecurities. When you are dealing with teenagers who are suffering from a mental illness, I am just wondering if in fact part of your treatment or dealings with them is on how to deal with how society relates to people suffering from a mental illness?
Dr. LeDrew: Yes, we actually do a lot of work with that, and we do have some groups for individuals. We are fortunate because the early psychosis movement itself has done a lot of work from that angle, so we have a lot of educational materials that we can use. However, it is important that our team be consistent in what we do because if one team member is saying something totally different from what the other team members are saying, it can, in itself, perpetuate stigma. Thus we are very careful in what we do.
I will give you an example. I had a patient with whom I was sort of working a lot with, and he was really resistant in not taking the pills, that he did not believe that he was ill and the whole bit. One day I just sat down with him and I said, "What is your understanding of why you come to see me? Why are you so angry all the time?" and he said, "Well, you just said I am a psycho." I said, "I never said you were a psycho. I said you had psychosis." You just have to be so careful in everything, because what you say and what people actually hear are sometimes totally different things. It is a lot of work and I am so careful with all the words that I use. You find that you have to go over and over it with the patient.
Also, I think it must come in so many different forms: from the doctor, from the case manager, from the groups, from the information that you give. Thus I am even careful in what pamphlets I give to them, from the different pharmaceutical companies or whatever, because people have to be ready to accept certain things. As a team, we are very consistent in what we say. However, I do think that, in terms of stigma, education campaigns are very important, and the B.C. group has done a lot of work in terms of Psychosis Sucks, a campaign that is really targeted at young people to make it more acceptable. The Australians do really good work but if you want to look at a Canadian standard, the B.C. group has really done a lot of good work.
I just had a client recently who realized he has psychosis because somehow one of our parents had some information and put it up in the school, and it was a "Psychosis Sucks" poster that said, "Look," so and so "I think you got that." And so the friend actually told his friend that he thought he had psychosis, and he did. That result came from reading the poster, so these kind of things actually do work. It is not really reinventing the wheel because it is all out there. It is just that you have to have some funding in order to be able to disseminate that kind of information throughout the province. We need the funding, and some help to be able to disseminate some of this information, because it is really all there. Stigma is something that we work on because self-stigmatization is certainly a big problem in this particular group of people.
Senator Cordy: I was really interested also when you said that one facet of your program is dealing with families. I was an elementary school teacher for 30 years and, certainly, families can also find themselves in crisis when one of their children is suffering. Then it seems that the whole family suffers. Could you explain what your program for families involves?
Dr. LeDrew: We are a little different than some of the programs in Canada. We model ourselves after Calgary versus some of the other ones in Ontario. We actually have a particular person assigned just for families. In mental health, for a long time in my opinion, families were excluded; you could not get information, you could not figure out what was going on. Right from the beginning, then, families are included. Individuals may not consent to having a release of information but that does not mean that the family has to be excluded. The family can still receive education types of support without breaching confidentiality. Thus, whoever the person assigns as their primary support can still have access to our family worker, even if the client says, "You know what? Do not tell my mother anything. Do not tell her anything." The families can still have access to information around psychosis, the Mental Health Act and different things like that.
At times when the client will not come in, the only person that I have been able to have contact with, or a family worker has contact with, is the mother or the father or both. When the client comes in, they do not just come to see the doctor, the traditional model; he gets the team. In other words, you cannot see me without seeing everybody else, that sort of thing. When you come in, you have the team; you get the case manager, you get the family worker and then the other things, depending on your situation. You come in, you meet me, you meet your case manager and you meet the family worker. The families get as much or as little as they need, but most times families are in crisis, and in the acute phase they may get a lot of individual work and then, as the person recovers, the families may need support and so there are groups that they can go to. We are actually trying to link up our families across Newfoundland using audio conferencing right now. Ideally, we would like to have video conferencing because even people in the smallest parts of Newfoundland can actually hook up and get support through their libraries, through their town hall or through various other places. That is the newest thing that we are sort of working on, our support groups for families.
Every family has access to support because, ideally, the primary support for the individual is their family. These are new people coming into a system and unfortunately, like so many of the people that I see in the general practice, their illness and the results of their illness have been that they have isolated themselves from their families and have lost their families. We try to keep the person functioning within the context of their family. I think many times we underestimate the burdens that are placed on families. If you want to look at the cost of mental illness, oftentimes we underestimate the indirect cost of mental illness. Many of these mothers — and oftentimes it is the mother — have had to take time off work. I have had to give numerous notes for mothers who had to take time off work to stay home so that the son does not have to go into the hospital. They do not want to leave him because they are afraid something will happen. The indirect cost on families is very much underestimated, so we actually have someone just assigned to work with families.
Senator Cordy: I was wondering, Ms. Bimgay-Gaultois, about your program. It sounds absolutely wonderful to me, having been a teacher. I am just wondering how difficult it is to get school boards to buy into the program?
Ms. Bungay-Gaultois: My personal experience is that the school boards, once they see the benefits of the program, buy in readily to the program. That has not been our experience everywhere, but as Roots of Empathy grows — and the research is showing that it is really making a difference and that classroom teachers are reporting that the classroom environment is changing, that children's behaviour is changing — the word is spreading. Principals talk to principals and superintendents talk to superintendents, and the word is getting around that, "You need to take a closer look at this." In the five years that Roots of Empathy has come on the scene, on the Canadian landscape, We are discovering that there is more of an interest in Roots of Empathy now, of course, than before because of the number of programs now existing, but mainly because of the communication.
Our program really supports all of the research, the biological and neuroscience research for early experiences and how taking care of an infant in the early years of life can be a platform for what happens later on in life, and because that research supports the program, it is a perfect match. Yes, I think school boards, generally speaking, are more open to this program and are embracing it. The big question still comes down to is: how can we afford to have this program?
Senator Cordy: My understanding is that you have instructors who go into the schools to teach the program, but is there follow-up for teachers to do with the students? You have instructional toys, tools and books, but do those materials stay with the classroom or does the instructor take them away?
Ms. Bungay-Gaultois: The instructor basically takes them from the classroom, but occasionally there are times when a book is left behind, when the teacher wants to re-read it to the class. The links to the curriculum are through art and in writing projects, so again, even though the lesson may concentrate on a specific theme, such as a child's temperament for example, then what a supporting teacher will do is take that theme and let us see what we can do with it in terms of creating art in our art class, or let us create some music around that. We have children writing songs, creating poetry, drawing pictures, writing letters home to baby, talking about what they learned from the baby today. The answer to your question is yes, it is certainly transferring across the curriculum.
Senator Cordy: Is there a program for teachers, that is left behind with the teachers, or is it just up to the individual teacher how they would follow up on what has been done in the classroom?
Ms. Bungay-Gaultois: No, there is not a program that is left behind with teachers. I guess the program evolves by meeting the teacher at the beginning of the school year and the teacher being given an overview of the program. The teacher is then part of the cooperative strategies for delivering that program in the classroom. Then, as you say, it is up to the teacher to be looking at opportunities and avenues through which to integrate that program into the curriculum.
Senator Cordy: How difficult is it to get a parent with a baby to commit to that amount of time in schools?
Ms. Bungay-Gaultois: In some rural Newfoundland communities there are no babies, and that is the number one problem. We have had to close down two programs because of that. That is unfortunate. In other communities, again because people communicate about a good thing, the word goes out. We will have two or three pregnant moms come to us in the spring of the year and say, "I want my baby to be the Roots of Empathy baby next year." It is not only because they want to be part of the program, and that there is a commitment — I mean, a mom and a baby, or a dad and a baby, or a grandmother and baby are coming to the classroom once a month for nine months through the school year — they also realize that the child is adopted by the students, and in a small community the baby becomes a celebrity. Thus when a mom or a dad or both are walking down the street with baby Jordan, for example, you have lots of children coming up and saying, "That is our baby; that is our baby." There is a big socialization element, and many parents with just one child now want opportunities to help their children socialize. I have talked to lots of moms who say, "My child is so outgoing after one year," because they have been going to a school with 20 or 30 children, that they are not scared of anybody and that they love children and want to be around children.
I would say that, yes, it is almost like having a superstar status for the baby, and I really think parents benefit. Lots of moms have also said that they learned a lot about parenting that they just did not know about before. I am a parent of three, and I have certainly learned a lot about parenting that I wish I had known 20 odd years ago.
Senator Cordy: My last question has to do with research. The program is only five years old, so it is pretty new, but are you making an effort to keep statistics or anecdotal evidence? Evidence has been collected on early intervention and those kinds of things which you can tie in but are you actually collecting evidence of your own from the program?
Ms. Bungay-Gaultois: Do you mean in our location?
Senator Cordy: Yes. What is happening in Newfoundland, for example.
Ms. Bungay-Gaultois: Each classroom is evaluated as part of the national strategy and our results are all sent off to Toronto. Then, as that turns full cycle, the results come back to us. The anecdotal evidence is some of the stories that I have told you here today, and we know that on some levels —
Senator Cordy: You are recording those, I hope?
Ms. Bungay-Gaultois: Yes, and that it is making a difference. On the national scene, they just record everything that supports the program.
The Chairman: May I thank both of you for coming. We really appreciated your being with us this morning.
Senators, we have three representatives on our next panel. We have Geoff Chaulk, Executive Director of the provincial Canadian Mental Health Association, Ted Callanan, President of the Psychiatric Association of Newfoundland and Labrador, and Jocelyn Greene, whom many of us met yesterday, who is the Executive Director of the Stella Burry Community Services.
I will begin on my right with Geoff and go across the panel, asking each of you to make your opening statements and then we will turn to questions. Thank you all for coming. The only thing I have to remind you of is that you must press the little white button in order to be able to talk; otherwise, the translators and the recording system cannot capture what you say. Geoff, over to you.
Mr. Geoff Chaulk, Executive Director, Canadian Mental Health Association, Newfoundland and Labrador Division: Thank you, Senator Kirby, for the opportunity to appear here today. Our association certainly appreciates being able to share some of our ideas with you.
The approach that I have taken in terms of this brief is to give you a little bit of background on our organization in this province which, as a CMHA, is unique in the country. I will tell you a little bit about the work we do and then I have selected a number of issues or questions from your Issues and Options Paper to which to respond.
The Canadian Mental Health Association, Newfoundland and Labrador division, is a non-profit, voluntary charitable organization established in 1964, and promotes the vision of mentally healthy people in a healthy society. Our division promotes improved understanding of mental health and mental illness through education, advocacy, research and community development.
In fiscal year 2004-05, we received government funding in the amount of $80,000 on a per annum basis. This was after a ten-year absence of core government funding other than our receiving project grants. Our division established a fund development foundation in 1997 in order to raise funds for us to do our work. The funds raised came, in large part, came, through the generosity of our fellow Newfoundlanders and Labradorians. The division has an annual operating budget of $240,000 and four full-time staff: myself, an education coordinator, a resource centre coordinator and an office and finance administrator. I should say in all fairness to the provincial government, because our fundraising came up short last year, that they offered us a $50,000 grant this year so that we could continue with our education coordinator position. CMHA Newfoundland and Labrador Division is one of two jurisdictions that I am aware of in the country that is without a branch structure to support its work in a vast province with a rural population.
I would like to mention one of our main services, which is a provincial resource centre that handles a minimum of 120 calls and drop-ins per month from people looking for information on mental health and mental illness, information and referral. A large part of my coordinator's work right now is related to advocacy in cases where people are running into barriers in terms of getting the services that they require.
I have some responses to selected questions raised in the issues and options paper. CMHA Newfoundland and Labrador Division agrees with the committee's position that the mental health and addiction treatment system be seamless, accessible and offer high-quality, coordinated and integrated services. We further support the position that the system be patient- or person-centred and focus on recovery. CMHA Newfoundland and Labrador Division believes that the latter two points cannot be overstated. First, as I gather the senators are well aware, the person-centred system is central to the community resource-based model, which is part of the new framework for support for people with serious mental illness as developed by the Canadian Mental Health Association at the national level.
Further, recovery from mental illness and enjoying good mental health we now know is possible. Bringing recovery into the mental health/mental illness lexicon also brings hope to those of us who battle different types of mental illness. The community resource-based model with the person at the centre of the system also addresses the essential elements for successful community living and recovery, including adequate housing and income, work, social connections and mental health services and supports.
Coordination and integration of services and supports is an issue that has long plagued mental health and addiction services to the point where it is sometimes inappropriate to refer to a "system" of services and supports. In a recent local study that was conducted in relation to the need for a "clubhouse" in St. John's, it was recommended, with the number of services and supports available, although still not adequate to meet the needs, that funds be sought to have a coordinator work with the services that are currently being provided, such as employment-related services and social supports. This idea was proposed in order to ensure that there be clarity among service providers and consumers as to what services are available, and that a range and menu of services be offered with clear criteria for entry to the programs. It was determined that one assessment and perhaps one point of access for employment-related services might also be appropriate.
In terms of integration and coordination of services, the above might be an example of a way to go. Further, partnership agreements and formal memorandums of understanding among service providers may be helpful in making services and supports more connected and accessible from the consumer's perspective.
I had experience in this area in my work in Ontario, which spanned about 17 years, where the Ministry of Health essentially, in some cases, strongly recommended and/or strong-armed partnership relationships among service providers to reduce fragmentation and limit the number of doors a person had to go through to try to get service.
On the point of early detection and intervention for children and adolescents, I think the answer here is multifaceted but the cornerstone is education in relation to what constitutes good mental health and what is mental illness. Efforts to educate within the school environment at the earliest appropriate age and with age-appropriate material would help children and adolescents learn some of the important actions and behaviours that can maintain good mental health and perhaps avoid the onset of illness.
The other benefit of providing mental health education in the schools is that the material developed could help with breaking down the stereotypes and myths about mental illness, which would, in turn, help to reduce stigma. CMHA, NL Division, like many of our partners, is of the opinion that stigma remains a considerable issue in society and can negatively affect the lives of people dealing with mental illness and prevent people from seeking help when it is needed.
The Canadian Mental Health Association here in the province has had previous experience in providing educational sessions to high school students on mental health and mental illness, and in the year 2000 produced and distributed a video entitled, Out of the Dark: Youth and Depression. This video was distributed widely across the province. However, our efforts were somewhat hampered in terms of follow-up by a lack of human resources or a corresponding travel budget. More work can be done in this area, especially in partnership with schools and the Department of Education, but only if we have the necessary resources to provide the service. By working in partnership, more could be accomplished and CMHA's expertise could be used in terms of developing educational products, training those professionals who would use these products in local communities and providing back-up consultation when issues arise.
A few months ago, we released through our national office a website called Mental Health in High School and we disseminated that by way of information through the Department of Education to all the school boards and schools as a mechanism for young people who are technologically literate enough to find for themselves information in terms of mental health, mental illness, what are some of the signs and symptoms, et cetera. In partnership with the Department of Education, we got that message out there.
With regard to the issue of caregivers of elderly parents, the issue of most significance here is the lack of community-based supports and services, including housing, in-home support and case management. A provincial review of the community mental health system indicated that more resources were required to meet people's needs in communities across the province. It is expected that the provincial government will soon release its plan for mental health and addiction services in the province. Release of this plan and allocation of the required funds to implement services should assist people who are living with aging parents.
Further, the Luther inquiry into the deaths of Norman Reid and Darryl Power also pointed to inadequacies in the community-based support and service system. Judge Luther made numerous recommendations that, if implemented, could improve the lives of people with serious and persistent mental illness.
In relation to family supports, CMHA NL was recently provided with a $5,000 grant from the provincial government to look at ways of increasing supports to families in the province. Two of our board members who are involved with our current family support group, which meets on a monthly basis, will assist in the planning of this initiative.
CMHA NL will also be launching the Family-to-Family support group in the fall of this year. It is a particular model that has been developed by NAMI, THE National Alliance for the Mentally Ill. We received a $1,300 grant from the Health Care Foundation of St. John's to launch this initiative. Ongoing funds to maintain the program have not yet been secured.
With regard to the issue of federal income security programs, yes, we think the federal government should change the CPP Disability Plan in order to allow people to receive partial or reduced benefits while working part-time. Such a revised program would enable people to reap the monetary and non-monetary benefits of employment. However, there must be an incentive in the financial sense so that the person is better off economically upon taking part-time work.
In relation to income support programs in general such as social assistance in this province, there are also barriers that need to be removed so that the person with mental illness can benefit from employment without losing such benefits as a drug card. We all know the costs of many psychiatric medications and there is an allowance made, I believe, for the card to continue for a period of time, but for many people, medication is a life-time requirement.
Combating stigma and discrimination is an issue of great significance, and a Canada-wide approach with input from consumers and families in particular as to key messages to bring to such a campaign would be essential. CMHA here in Newfoundland agrees with the elements proposed that would make up such a campaign, and further agrees that a national strategy for suicide prevention must be implemented.
With regard to the primary care sector, primary care renewal in the country must consider the provision of interdisciplinary care. Primary care should consist of more than a physician and/or a nurse practitioner. Members of other disciplines who would be appropriate team members include social workers, nurses and occupational therapists. In this province, I believe 40 per cent of MCP billings pertain to mental health. Mental health and addictions, as you are well aware, can be complicated areas for intervention, and access to other disciplines with defined areas of expertise could take the burden off the individual physician and better serve the consumer. Of course, physician remuneration and billing code changes or alternative payment arrangements would need to be considered in order to allow the physician the time and opportunity to consult with other disciplines.
CMHA NL would agree that more uniformity in the training for community support workers and the police would be to the benefits of all concerned. To be on the front line is demanding and stressful work and training can help ease the issues and provide a better service to the consumer.
As an outcome of the Luther inquiry, CMHA Newfoundland and Labrador Division is in the process of completing an eight-module training program that is DVD-and experientially-based. The program has been designed for front-line workers from a variety of settings, such as police officers, ambulance attendants, home care workers, to name a few. The models cover all the major mental illnesses and consumers speak on film about various aspects of their illness and the related impacts on their lives. The program also focuses for participants on improving their communication skills and knowledge, so that if you are on the front line and you are in a situation where you are dealing with someone who is obviously experiencing distress in relation to their mental illness, you have a better toolkit to operate from in relation to trying to intervene. The program has been through the pilot phase and so far we have received excellent feedback, although the final evaluation report is not yet available to us. The project is due to be launched officially in September and we will be using the trainer approach to be able to get the material out to our colleagues across the province, and we wonder if there may be national implications for use of such a program. To our knowledge, it is one of a kind.
Most of the funds for this project came from the federal government's crime prevention strategy along with contributions from the provincial government, GlaxoSmithKline and the Rotary Club of St. John's Northwest.
Inadequate funding of mental health supports and services, especially at the community level, has been an issue in this country for many years. The problem essentially started with the deinstitutionalization process when appropriate levels of funding did not follow former patients into the community. In some jurisdictions, this translated first and foremost into inadequate housing and follow-up care. Dedicated funding for mental health services and supports that are predictable, sustainable and equitably allocated would enable the development of a more complete community mental health and addictions system, especially for those with serious and persistent mental illness.
As a recently repatriated Newfoundlander who worked as a social worker and then with the Ontario Public Service as a policy and program consultant related to mental health services, I was greatly surprised at the range of services and supports that are available to Ontarians, but not to Newfoundlanders and Labradorians. The playing field needs to be levelled and attention paid to the discrepancies between the "have" and the "have not" provinces. These discrepancies translate into a poor quality of life, especially for those people with severe and persistent mental illness.
The Chairman: Thank you very much.
Dr. Ted Callanan, President, Psychiatric Association of Newfoundland and Labrador: I would like to begin by offering a strong vote of support for Mr. Chaulk's eloquent comments and the issues that he has raised with respect to the delivery of mental health services.
Thank you very much for the invitation, senators. I am speaking today on behalf of the Newfoundland and Labrador Psychiatric Association. We are a small psychiatric association with approximately 50 members throughout Newfoundland and Labrador, although no one is actually based in Labrador. That represents about two-thirds the number or, that is to say, one position in three is vacant for psychiatrists throughout Newfoundland and Labrador, based on the population norms established by the Canadian Psychiatric Association. Psychiatry is a medical specialty and it is unique in the sense that it is perhaps the only specialty whose premise and sometimes very existence is questioned, some aspects of mental illness being viewed as being a product of social phenomena and not being part of the medical domain per se.
Mental illness is a frightening phenomena because it strikes at the very core of one's existence as a person. It affects thought, mood, perception, judgment and, what is very important, it affects behaviour, and it is changed behaviour that is the most visible part for others and for society to observe with respect to mental illness. It is the changed behaviour that is sometimes unacceptable and frightening that I think gives rise to stigma.
Acute psychiatry is affected by how mental illness is perceived. The person and the family members see the change in behaviour often as being wilful and therefore controllable and blameworthy. They do not see it at first as illness, and this delays seeking help for illness. I think you have heard already the importance of early intervention with respect to the long-terms goals for recovery. Thus when the illness is seen, the stigma can sometimes further delay efforts to seek help.
Over the course of the last 20 years, acute care psychiatry as practised within the hospital and community setting has changed, and it has changed as a result of some of the observations that Mr. Chaulk has just pointed out; that is to say the deinstitutionalization of many individuals who were previously cared for in large mental institutions. I think it is clear from the research that quality of life and satisfaction with services are much higher in community settings. However, there has to be an adequate transfer of funds to the community in order to create the sorts of teams that are needed to give a broad-based community follow-up.
To the extent that the hospital remains a part of the spectrum of services required by the mentally ill, it has become true that those who are admitted to hospital these days are often admitted to smaller units with pressures for shorter lengths of stay. What we refer to as the "case mix" within the hospital has become very much more diverse; that is to say you will see individuals suffering from early stages of dementia being admitted for work-ups, you will see individuals with first episodes of psychosis and you will see individuals with other major mental illnesses being admitted in acute phase or an out-of-control phase of illness. Actually, there is some good research pointing out that the higher the case mix, the less satisfaction occurs among individuals receiving care in hospital.
With respect to services in the community, I know that one of the things referred to in the Luther report, which you will no doubt be reviewing, is the revision to the Mental Health Act in Newfoundland and Labrador. The Newfoundland and Labrador Psychiatric Association would like to see incorporated into the changes of the Mental Health Act the capacity to intervene early for individuals with severe and persistent mental illnesses in the community before a certification for a return to hospital may be required. The implication of that is what is often called in some jurisdictions, such as Saskatchewan, Ontario and possibly Quebec, "community treatment orders". I do believe there is room for a selected population of individuals who, as a characteristic of their illness, lack insight and would benefit from an appropriately monitored/watched/guarded, respectful system that would help bring them into care when their illnesses become more problematic.
I have one other general comment before I move on to couple of responses to what is in your third report publication and that is with respect to medications. The regime varies between provinces with respect to access to medications, and the medications available for the treatment of major mental illnesses are significantly fewer in absolute terms than they are in, say, cardiology or other significant illnesses. I think our patients are best served when the patients have unrestricted access to the few medications that we do have.
I wanted to comment on a couple of points from the Issues and Options for Canada document, volume III, and that is with respect to the question asked, "How can collaborative working relationships between primary health care providers and mental health care professionals be encouraged?" Interestingly, this was the topic of a panel this past Saturday held with the representatives of the Canadian Psychiatric Association and the Atlantic Provinces Psychiatric Association. We heard of a variety of different models that exist across the country for sharing of care. I think one of the steps that could be most critical in fostering this approach is the development within the medical schools, pharmacy schools, social work schools, nursing schools, and within the schools and domains that take on rehabilitation work in psychiatry, of shared curriculum about interprofessional collaboration. I think that we have a number of models because we have individuals who have stepped forward and started working together collaboratively. They would like to see more of it. When we did a round table at the conference on Saturday, there were just a handful of examples, and they were based upon individual leadership. I think in order to see greater collaborative practice we must start training in collaborative care from the first day of admission to health professional schools across the country.
One other comment I would like to offer is with respect to the questions you have raised under the topic of "Knowledge Translation". I think this is relevant here with respect to Newfoundland's rural and remote communities and the role of telehealth and telepsychiatry. Of the various studies that have been done, looking at the ways in which remote services can be delivered via distance technology, it turns out that psychiatry has extremely high levels of concordance between diagnoses that are offered by a psychiatrist remotely via video conferencing compared to the same individuals being examined on site. Psychiatry, perhaps, can offer the greatest range of its services efficiently and adequately via distance technology versus any other medical specialty. However, we are not having the buy-in and I do not quite know why that is. I think that is an area for research. Given that we have good evidence to say that we can do it remotely, why is there such a preference to staying in the same consulting room? Perhaps what comes to mind is an anecdote from Josh Billings, who says, "Ignorance is not the problem. It is people knowing so many darn things that are not true." I think the effort to incorporate tele-technologies into mental health care services is critical for the future and especially for jurisdictions like Newfoundland and Labrador.
The Chairman: Thank you. I liked that quote. That will inevitably find its way somewhere into our work.
Ms. Jocelyn Greene, Executive Director, Stella Burry Community Services: Good morning, and thank you again for the opportunity to meet with the committee.
I think Senator Gill and Senator Trenholme Counsell were the only two members who were not at my presentation yesterday on Stella Burry Community Services, so I will not go into a detailed description of the programs and services. Perhaps, Mr. Chaulk, you could just pass the copies of my brief over.
Conscious of the five-to seven-minute time frame, I have tried to focus on certain elements in which I believe our organization has a degree of experience and expertise. What I have done in terms of the handout is, again, just put some of my comments in point form and attached a copy of the executive summary of an evaluation of one of our core programs that I think has some value for the committee.
In terms of context, Mr. Chaulk mentioned this because, as he said, he has recently returned to Newfoundland, and we are glad to have him here, but I wanted to just go back over some of the things that I think have had a significant impact on the status of mental health services in Newfoundland and Labrador. One of the things that Mr. Chaulk alluded to that I would echo is that I remember going to a number of national events in Ontario when the delegates there would be moaning about all the cuts that had occurred with respect to housing and support services, and I remember thinking, "Well, they have lost more than we ever had." What I mean is that we started with very little.
I certainly think a significant factor was the elimination of the Canadian Assistance Plan, along with national standards. While the federal government has funded us with this introduction of CHST, the Canadian Health and Social Transfer Act, that, as we all know, was a reduction in overall funding and also eliminated the guidelines in terms of how monies had to be spent. That had a catastrophic effect on mental health in this province, in my view. In particular, in 1995, the cutbacks from the federal government funding resulted in cutbacks in this province in health care and, in particular, the closure of 97 out of the 127 long-term beds at the Waterford Hospital, which is our provincial psychiatric facility. It is not too strong to say that none of those savings realized from the closure of those beds went back to the community. Wherever they went, they certainly did not come to those of us who work in the community.
If you were a patient on the long-term unit at the Waterford, clearly you had some significant problems in terms of mental health. Subsequently, some of these individuals with a history of severe and persistent illness in this province ended up in slum housing and boarding homes, but many ended up in prison. As a result of the breakdown in their ability to cope, the only place that they could be sure that they would be held and supported was in prison and, in particular, for women in our federal institutions.
As I shared with many of you yesterday, Stella Burry Community Services, SBCS, is a recognized leader in this province and actually nationally in the provision of residential treatment services for mental health consumers and for homeless young women. In particular, because we guarantee two beds to Correctional Services of Canada, CSC, and have partnered with them since 1985, we are recognized as having done some particularly good work in supporting individuals that go back to the community. We actually have a satellite housing agreement with them and rent a number of apartments and provide support services to them.
As a result, in 1999, we were contracted by Correctional Services to develop a range of support services and housing options for a group of female offenders who had complex mental health problems and who were due to be released from federal institutions during the next year. We researched the literature and visited supportive housing models across the country and, building on our own success, we made a series of recommendations to the four provincial ministers responsible for health, housing, income support and justice, as well as senior Correctional Services officials.
SBCS subsequently piloted an innovative community support program based on a home support model somewhat similar to ACT teams that you have referenced in your reports, but with some significant differences in that many of the ACT teams in places like Ontario are more institutional models moved to the community. Ours is very much rooted in the community and then linked back to our support services. An evaluation of the program has shown a dramatic reduction in hospital and incarceration rates. As I said, the executive summary, which you all have, offers an explanation of the program but the highlight is the decrease in prison days, which was 73 per cent, and the decrease in hospital bed days, which was 39.2 per cent. If you costed them out, those percentages reflect significant savings in both those systems, never mind the chaos of lock-ups and the involvement of case management workers, and so on, as I referenced yesterday.
I think the cost benefit analysis was important to do. I think we need to do more of that. It is difficult to access those records, and our evaluators really worked hard. In addition, the quality-of-life descriptions that are peppered throughout this document, the 12 stories, one of which is attached, are a profound reflection of the change of life for the people involved.
When we started this process, I kid you not, we sat around with people from all the systems who said, "They are not my problem," or, "They were in federal institution and they were not on our soil." In other words, we started with really no buy-in because this is the group of people that drove everybody crazy. I cannot emphasize that enough. Now we have significant buy-in from psychiatric and social systems and from the short-stay unit, but we still have a ways to go. We certainly need significantly more funding and we are hoping to expand the program.
The links to housing and employment are critical. Again, I described those to you yesterday, so I will not belabour that point.
I should like now to address some conclusions that I did not speak to you about yesterday. While I think there has certainly been a lot of progress in the formal mental health system, such as the Early Psychosis program, Dr. Callanan's comments about interdisciplinary collaboration, and so on, we need to take it even further. The formal mental health system is still too hierarchal and pathology-based. Yes, obviously, there are severe, legitimate mental illnesses that need treatment and medication, but I think we often fail to factor in the systemic roots of many mental health problems, such as poverty, abuse, discrimination, the lack of child care and affordable housing. I think if a lot of those issues were addressed, certainly a lot of the people who are coming through our formal systems would not need to be there.
The formal system is often ineffective and, unfortunately, frequently compounds individual's problems. Some of my colleagues here were at meetings when we were looking at our new mental health strategy, and doctors themselves were saying, "We need to close the Waterford. It is damaging to the patients." There is a need to train health professionals differently across the board with respect to the systemic roots of problems as well as responding to individual client issues. I am not saying that we do not need to treat individuals, but we need to be doing it in a broader context.
We need to be developing community resources. We have an absolute lack of community development. Years ago in this province, with the extension service, we probably led the country with respect to community development. It is a very important resource and it has kind of gone off the radar. We speak of community capacity building, but where are we training professionals? When I did my master of social work degree, I could not do a stream in community development other than asking them to allow me to do some specific course work.
Securing the resources of a full-time community development worker in this community was a critical factor in the success of the local homelessness initiative. We had one of the most successful initiatives in the country. We had a full-time community development worker who brought everybody together, government levels and community services, and we made a plan that said, "What are our priorities? How are we to deal with the situation?" and we supported each other in doing that. Without somebody to do that work, we are missing the boat.
I want to give a little example. Most of you have heard about the crisis in Harbour Breton, and it is not difficult to see what will happen down there with everybody out of work. We will get reports of increased alcoholism, increased depression, family violence. There are three ways to respond. We can set up a charity model and give them food banks and income support. The Health Care Board can send in a whole pile of mental health and social workers and doctors and treat them for depression and help them with their alcoholism on an individual basis, and maybe some of that is necessary. However, we could also be funding a community development worker who could go in and bring people together and say, "You have every right to be angry, but how are we to find a new infrastructure, new ways of working and work with that anger?" What I mean is, we need to do all three. People need to eat, people's needs must be addressed, but we do not do the third one very well at all, and nobody is funding it.
There is a need for vastly increased funding for supportive housing and employment programs. Government departments must work collaboratively and break down silos. We are trying to do that provincially. In terms of joint Treasury Board submissions, if you give me money to do housing, I am saving you money in your mental health system. People need to talk to each other. The strategic social plan in Newfoundland has begun to implement elements of that. How do we make it operational? The federal government has failed dismally at this. The delivery systems are too cumbersome and inefficient. We get great responses from people like you, from the ministers, but the federal bureaucrats put up so many barriers to getting any funding. I am telling you, this is a bad week for me. There are huge proposals to fill out, and then resubmissions, and then estimates. Obviously, there is a big problem there.
The SCPI model was actually very effective. I thought it would be cumbersome but I have since realized that it actually worked very well and maybe it should be considered as a model for delivery of funding for community-based mental health initiatives.
I have some recommendations based on a reading of your report. I do think we should adopt a national action plan. However, I think the federal government needs to get out of the way. It needs to provide targeted and significant levels of funding for mental health services with provinces only able to access the funding if they deliver programs in line with national standards, with no "ifs", "ands" or "buts".
Funding and training is needed for specialized home support services. That came out of the Romanow report. It has not materialized. Our program shows that that is a very effective use of resources. However, these people need to have equitable salary, training and benefit packages. Paying people $7 an hour to stay overnight with people whom the Waterford Hospital can barely manage is a bit ridiculous.
We must provide enhanced resources for community groups. I do not know how we will do it because of all the bureaucracy, but groups like us need access to funding for housing, comptroller functions and project development. We have 45 units now. I need a housing/tenant relations officer. My budget is $3 million and I have 71 employees.
Again, funding must be provided for community development and to assist systems and organizations in the transformation from a rehabilitation approach to one of radical renewal. This is critical so that we are not limited to an individual-based approach. Mental health services must truly value and engage consumers in the solutions to their problems and truly work with them. We must also concurrently address the systemic roots of many mental health issues; otherwise, in terms of treating people for their depression, or whatever their disorder is, we are simply keeping them comfortable in their misery. That is unacceptable.
The Chairman: May I thank all three of you for your thoughtful and provocative comments.
Ms. Greene, I have three questions for you. First of all, I get so bogged down in acronyms. What does "SCPI" stand for?
Ms. Greene: Supporting Community Partnerships Initiative.
The Chairman: I have two related questions. First, what made it so effective? My gut tells me, and please tell me if I am wrong, that what really made it so effective was the minister as opposed to the program.
Ms. Greene: Certainly, Minister Claudette Bradshaw was a force that believed in the —
The Chairman: Was a force to be reckoned with. Trust me, if you were inside the federal system, she was a force to be reckoned with, which was awesome.
Ms. Greene: I tell you, I have been hugged by her to her bosom for 10 minutes while she gave a speech in Ottawa. I was thinking, what do I do now?
What was the community planning process? Some of us debated this in the beginning, but the program stated that there had to be a community plan that brought together all stakeholders from municipal, federal and provincial levels involved with housing, income support, health and so on — all the players, as well as community groups that had a stake in this. The group we hired actually used consumers to do some of the research. We wrote a plan that said, "These are the priorities for our community." One of the priorities that we indicated was to hire a community development worker, and we hired one of the best in the country: Bruce Pearce was a very skilled individual who really brought people together in true community development style to help people bring their own issues to the table while, at the same time, fostering true collaboration. That was the key.
The other thing I want to mention is that I thought the delivery system would be cumbersome but actually our requests went right to the secretariat. Once we decided, okay, these are the proposals that we want, a shelter for this or the urgent needs proposal that we did at Carew Lodge, it went through a local committee, which was very effective, and then we did not have to go through HRDC, which we now have to go through as well as other layers. We actually had a very good city facilitator here. He was a Human Resources Development Canada employee, but he was extremely knowledgeable and on side. Then it went directly up to the secretariat, and I have to tell you, not only was Claudette Bradshaw there but her executive assistant was a Newfoundlander who was very skilled. You know that all of these Newfoundlanders at your table are your own roots. So it worked; it went there, it got through the system and the funding came out. I have since realized that while I thought that the system was cumbersome, subsequent layers have now been added to the process making it truly cumbersome. However, I think the key elements were that it was established by the community, we had buy-in, and we supported each other. For example, the Salvation Army just got $1.18 million for the Wiseman Centre. I needed $800,000 for Rawlins Cross, but there is no question that we needed to redo that Wiseman Centre, so the rest of us said, "Fine, that is priority one. This is priority two." We came together and we did that and then we had a fairly efficient delivery system, even though, as I said, I thought it was extremely cumbersome at the time. I have since realized, having now dealt with other government agencies, that for the federal government it was probably not too bad.
The Chairman: My second question really deals with the work you have done with inmates.
Ms. Greene: Yes.
The Chairman: I think it is fair to say that most of us were appalled, and that is being generous, at the description given by Corrections Services of Canada officials in their own description, in their own words, of the lack of mental health treatment they give to their inmates. It is truly unbelievable, and it stems from all the evaluations they have had done of their system, so this is not an outside commentator.
Ms. Greene: Yes.
The Chairman: It is truly appalling. It may also be true that they think they are one of the best in the western world. By the way, those two statements are not inconsistent when you think of chain gangs and work crews that you see if you are driving through the southern United States, and so on.
Having just skimmed through your report and talked to you yesterday about the cost effectiveness of your program, which is enormous, can you tell us, why is it that a program such as that, which seems to work and, what is more important from the bean counters' point of view, is very cost effective, is not happening all across the country? I assume this is true because we have not heard about it anywhere else. Why is that, and is it possible to extend your program? I know you have worked with some men, but is it seen as a predominantly female issue?
Ms. Greene: No, we will be equal on that. We have extended it to men.
The Chairman: Is there some reason why you focused on women? It is because the male cases are harder to deal with? Why is it not happening elsewhere?
Ms. Greene: Actually, we started with women because, as I said, Correctional Services of Canada had identified back in 1999 that they had six or eight women with mental health issues. Newfoundland had the dubious distinction of having the highest per capita number of women offenders with complex mental health needs in the federal justice system at that time. When we went to Kingston Penitentiary before they closed, they had one unit still open with only 10 women. Two of them were Newfoundland women on this one high-needs unit.
The Chairman: Two out of 10?
Ms. Greene: Yes. One reason that they kept Kingston Penitentiary open so long when there was hardly anybody left in there was because of trying to decide what they were going to do with these 10 women. In terms of what we are doing, then, it becomes an issue of policy. I mean, we still have no policy. Our provincial government's official policy is that there is no home support system for mental health consumers. We literally got this started because of one woman, whose story is the first one attached to this report, who had had a horrendous history within the mental health system. She said, "I cannot be alone. I have been in an institution so long, and kept coming out and revolving and revolving." We said, "We need to advocate for home care for you," so she phoned the supervisor, who was Brian Addison, 60 times a day and he literally went to the Health Care Board afterwards and said, "I approved it," apparently because he is a good guy and realized that this woman has been —
The Chairman: Is it Tina Marie's story that is at the back?
Ms. Greene: Yes. It started with one person and we have built on it. I actually testified at the Luther inquiry concerning the impact of this program, and as a result of that, actually, our provincial government did provide more funding for us last year. I suppose it is like anything else, but this is a good example of needing to get buy-ins from all the different departments and the need to have this coordinated. You are dealing with all these different bureaucrats in different departments — housing, justice and so on. It comes down to resources as well. One of the things on my list is to try to get a presentation made to the four new provincial ministers.
In terms of what is happening across the country, there are certainly programs that are somewhat similar. Again, this comes down to resources. Corrections gave us money to research this area, and we actually went across the country to several jurisdictions. Calgary is doing some really good work with their forensic unit. In B.C., one of the models was the Intermin(?) Stereo project, which was similar to the one we developed with people coming together, the one-to-10 caseload, their coffee fund, just funding people to do this hands-on work. Thus there are some models across the country and we have some funding now from crime prevention to write up the elements of this project and to further extend it. We hope to look at what is happening across the province and what we need to get more buy-in. Oftentimes, however, it becomes a question of resources and this whole issue of bringing people together and educating them. I mean, that is what community development work is all about.
The Chairman: Dr. Callanan, I have two quick questions. What you called "community treatment orders," is that what other parts of the country call ACT, assertive community treatment?
Dr. Callanan: Assertive community treatments? No, the community treatment orders, also sometimes called "mandatory treatment orders," are the provisions in provincial mental health acts wherein individuals in the community can be required, under the statute, to continue their follow-up for psychiatric care.
The Chairman: They are required to continue to take medications?
Dr. Callanan: They are required to take medications and to attend appointments. Programs for assertive community treatment are voluntary programs. They tend to be interdisciplinary teams and would be an ideal group to serve the needs of individuals with severe and persistent mental illness. They would be a well-suited group to be mandated to maintain the contact with the individual who has the community treatment order.
The Chairman: I know you are correct with respect to Ontario at least, but are you saying that in some provinces you can be required to take this treatment, but that you are not legally required to take it in Newfoundland? Is that correct?
Dr. Callanan: That is right, and it is also true in Saskatchewan. I believe Saskatchewan was the first province to establish this and Quebec is very close to having something similar. Their approach has been to have it incorporated into the act for individuals who had been involuntarily in the hospital, to have leave from the hospital.
The Chairman: It seems to me that this immediately gets into the whole issue of mandated programs, privacy and a lot of other issues. That is what creates the resistance to doing it, I assume?
Dr. Callanan: Yes, I believe that is true.
The Chairman: Very well. My second question is with regard to tele-mental health. By the way, somewhere very early on in this process, although not in this session, somebody referred to it as "Greyhound therapy" because there was no telehealth and so the individual had to get on a Greyhound bus for two hours in order to go for a counselling session. Intuitively, it seems to me that tele-mental health ought to work better than almost any other area of the health care system because the procedure is essentially the same. You do not need a hands-on procedure. You indicated that it did work well?
Dr. Callanan: Yes, and the data is there for that, too.
The Chairman: Have researchers actually attempted, in some sense, to go beyond my natural intuition that it is right? In other words, you said that it does work?
Dr. Callanan: Oh, yes, there is published data.
The Chairman: Can you give our researcher some data on that?
Dr. Callanan: Yes, I certainly can.
The Chairman: That would be helpful.
Mr. Chaulk, I have two quick questions, since you happened to have come back here from Ontario. Number one, we heard from witnesses yesterday that, in the richer provinces, there are number of services available that are not available here.
Mr. Chaulk: Yes.
The Chairman: Could you send us a list of those? It would be interesting for us to be able to actually document the discrepancy or the inequity, if you want, in services from one province to another, and since you have worked in the Ontario service, that would be useful.
Mr. Chaulk: Yes.
The Chairman: Could you also send us a copy of your high school video, Out of the Dark? I realize that it was done five years ago, but it would nevertheless be useful.
Mr. Chaulk: Yes, I will get you one.
The Chairman: Finally, you raised the issue of a "clubhouse" concept. What do you mean by a clubhouse concept?
Mr. Chaulk: The clubhouse concept is a model of service delivery that goes back probably to the last 1960s or early 1970s, and it started out as sort of a social/recreational-type approach to giving people who had been in psychiatric hospitals a place to go while they are in the community. They expanded that to include things such as transitional employment programs so that people could become employment-ready and then go into the community to do periods of work. They did not usually end up with full-time, permanent work as a result. It was more along the lines that Canadian Tire would give the clubhouse a job, and then clubhouse members would kind of cycle through that job. They branched out into —
The Chairman: Sort of like a co-op training program?
Mr. Chaulk: Yes, very similar. If indeed the individual could not attend work at Canadian Tire on a particular day, a staff person from the clubhouse might go in and actually do the work of the client or the consumer on that day. In recent years they have expanded into supported housing, permanent housing. I was a program consultant for Progress Place in Toronto, which is probably Canada's largest clubhouse. I would not consider it to be a current model of service delivery. I lived, actually, very close to Progress Place in downtown Toronto, and what it tended to remind me of was a bit of a mini-institution in the community, and that people were going there for some very basic needs, such as food, because the clubhouse might offer a catering service or a café or a restaurant, so a cheap meal could be provided. That is the reality for a lot of people with severe and persistent mental illness. When their incomes are low, some of the basic needs, of course, have to be addressed. However, although there are some strong proponents of the model and it is accredited world wide, et cetera, I feel that we have moved beyond that. For example, when you talk about what is not available here and what might be available in Ontario, you probably know of examples like A-Way Express, the courier service that is totally run by consumers.
The Chairman: Right.
Mr. Chaulk: Those are the more modern and current approaches to addressing some of what the clubhouse tried to address through its temporary employment program.
The Chairman: You would then regard a Mill Lane-type venture as more modern in the sense of a better direction in which to go?
Mr. Chaulk: I think they are heading in that direction. My understanding is that they are trying to make it more consumer-focused and driven, and less dependent on the professional sort of expertise. What it certainly is about is movement into the community and providing a service that the community is looking for.
The Chairman: And employment for consumers?
Mr. Chaulk: Exactly. I was the original consultant for A-Way Express when it was funded by the Ontario Government and that was 15 years ago. They were given half a million dollars to run the project or the program and the government was very nervous about entering into that domain at that time because it was sort of like moving into the private sector, the marketplace, et cetera, and here you have government money going in to support this program. We wondered if at some point the money could be — not removed fully but decreased over time. However, we found that that was not the case; that the infrastructure was still required to run the business. At any one point in time they would have a hundred couriers available to provide service and supplement their income.
May I make a couple of supplementary points to what has already been mentioned?
The Chairman: Sure.
Mr. Chaulk: The criminalization of the mentally ill is certainly one issue with which the CMHA has also been greatly concerned. In a province where there are fewer resources, sometimes very interesting things can happen. Over the past few months — and Ms. Greene was involved in the early discussions on this — the federal government has funded a lawyer to represent people who have serious mental illness and have had a Criminal Code offence. Part of our proposal to the federal government was also to have what we called "case advocates" or "peer advocates" to work with people through the court system. That aspect did not get funded, but the lawyer did. That put us in a bit of an awkward position. CMHA was a party to that proposal, and we saw the statistics. Our folks are ending up in the wrong place, in the worst place possible if you are psychotic or ill, and having to contend with a prison environment. However, with people talking to people, some synergy starts to happen. You get a meeting with the chief judge of the Provincial Court, and you start to talk with some of his staff. He calls a larger meeting of health care providers, Ms. Greene's group, et cetera, and what we end up with is a pilot mental health court wherein the Health Care Corporation seconded out, in an administrative capacity to CMHA, two very senior staff who are very qualified in terms of this work, the criminalization of the mentally ill. What that offers is an opportunity for the person who appears before the court. If the Crown agrees that this incident that the person committed was really related to illness, the social worker and the licensed practical nurse who have been seconded to us do an assessment, have a look at what could be better provided in the community, and then get the person out of the court system, so he does not end up at the local HMP, where he should not be in any case if he has been sick.
The Chairman: Right.
Mr. Chaulk: The other issue is in relation to home support services in the province. This is a long-standing problem and issue which begs questions around discrimination in terms of a group of people with a disability who are not included in a provincial program. However, the province has come a long way, considering, over the past year, as Ms. Greene assuredly knows, and has allocated funds to start a pilot project so that consumers of mental health services can avail themselves of in-home support. We are now in the process of training the in-home support workers, using the project that I mentioned in my brief, the Changing Minds projects. We have now been to the four regions in the province, training the in-home support workers who, through the pilot, will go in to work with mental health consumers in their home environment. Thus, even though it is still in the pilot stage, some important progress has been made.
Senator Trenholme Counsell: You have presented us with so much information and we have asked such good questions that it is hard to know what else to ask. We are obviously here with the support of the federal government. We are a Senate committee but we represent, in a way, the Government of Canada. I know how much conflict there is between the provincial and the federal levels so I want to just raise a topic which perhaps one or all of you can address.
In your paper, Ms. Greene, you say, "Presently, federal programs and funding are not integrated with provincial initiatives." I am wondering how those initiatives are delivered and how they happen, since health care and the whole health and social transfer functions through the federal government. I know that the federal government can intervene and have certain projects or certain initiatives, and I know, of course, that the corrections system is a different matter. You are asking us to recommend that we adopt a national action plan, but then you say very clearly that the federal government should get out of the way. I thought perhaps you might elaborate a little bit on this issue of a federal-provincial split, in relation to what we are doing here today and across the country.
Ms. Greene: I wish I had all the answers to that one. I will just give you an example of what we are talking about. Recently, the Canada Mortgage and Housing Corporation sponsored an experts consultation around housing and support services. They went across the country supposedly looking at a national framework for housing similar to a national action plan. They had consultations in each major city and there were five experts consultations. I was invited to the one in Halifax. Remember that this consultation is on housing and support services, and support services, as in mental health services, are funded right now by the provincial governments. Then here is this huge consultation; they gather people from all over the country, and nobody is there from the provinces. I raised the question, "Why are we talking about this subject without our provincial counterparts?" The B.C. provincial housing had sneaked in their minister. He was very glad I had asked the question. However, I was actually told that I was not supposed to be asking this question. They apparently had had an expert's consultation in Vancouver on "horizontality" — which is apparently the new term in the housing field for federal/provincial interchange — but the provincial people who were invited to that session did not even know what it was about.
Those are some of the things that, quite honestly, are totally frustrating. As I said to Senator Kirby, I have read your reports and I can appreciate your very thoughtful analysis of what is happening to date, but part of me says, "Okay, what can you guys do?" I am dealing with a provincial government that is funding us, and they have limited funding; indeed, they have lost funding. Therefore, in some ways part of what I am saying is, yes, set the standards. To me, that is what a national government needs to do.
Senator Trenholme Counsell: Yes.
Ms. Greene: They need to set the standards, increase the funding levels, ensure that it is designated for things such as home care and drug problems. However, I am telling you that the federal government's track record on delivery of systems, certainly within the housing field around CMHC, has been poor. We do not need to spend a ton of money or waste a lot of resources if health care is under provincial jurisdiction, which it is. If the federal government's responsibility is to establish the kinds of things that Mr. Chaulk alluded to, such as equity across the country so that I can come here from Ontario and expect that I can get supported housing and supported employment program, then please do establish that and put some teeth into it, but do not add all these cumbersome layers. I hesitate to say this but sometimes effective pilots get us out of the gate. You know what I mean?
Senator Trenholme Counsell: Yes.
Ms. Greene: I would like to see you say, "Okay, we are going to establish some mechanisms whereby we get the money out and see if it is effective and then push the envelope." That is kind of where I am coming from in that regard.
Senator Trenholme Counsell: I know we have had a lot of comments regarding pilots versus programs. Pilot projects, in my opinion, are often very good and necessary as a first step in deciding whether something will be funded and whether something works. One of the things that we talk quite a bit about is a national anti-stigma program or strategy to lessen stigma with regard to mental health. Mr. Chaulk, having read your biography I would like to ask you, how would we do that? Do you have advice for us?
Mr. Chaulk: My national organization, as you know, has been advocating for a pan-Canadian mental health strategy. I agree with some of Ms. Greene's points. In terms of the nuts and bolts of the programs and projects at the local level, I would say leave us alone and let us work out what our local needs are, and make access to funds, equitable funding, as user-friendly as possible. As an NGO with only four staff, it gets wearisome to have to do a third iteration of a project request for $40,000 to supplement something that you are attempting to do.
However, in answer to your question, in terms of an anti-stigma campaign, I think that is where the federal government can take a lead and —
Senator Trenholme Counsell: We want your advice.
Mr. Chaulk: — and you want my advice. I think one of the things that you need in terms of anti-stigma is champions, especially champions within the federal bureaucracy at the ministerial level. If you look at the statistics regarding where the disability insurance system is going, and the costs that are being incurred in relation to people missing time in relation to depression alone, and if we do not start to pay some attention to that, then the World Health Organization has signalled to us, "Look out in 2020, if you do not start to plan in advance."
I think we you need champions at the ministerial level if we are serious about a national action strategy in relation to mental health, mental illness and addiction. You have an assistant deputy minister, for example, who champions that within the bureaucracy. As we have been seeing in the media, I think we must look for some opening up taking place, where high-profile people are coming forward to talk about their experience with illness, in the same way as recently I have talked about my 20-year history of periodic treatment for depression. There was a time in my life and in my career, working in a psychiatric hospital, working with the Ministry of Health, where I would not have acknowledged that, and I might even have denied it, if that was an issue, because I had seen situations where people were by-passed for some of the plum projects. When you are well, you are able to deal with the plum projects, so you do not want to miss out on opportunities in relation to your own career.
To answer your question, I think that champions, people who can bring forward the fact that this is an illness like any other illness, would be helpful. It should, however, be part of building from the ground up. You could start with school-age kids in an age appropriate way in terms of their developmental level, and come at it from a media perspective so that you are educating the public as you go, like the one in five who will experience mental illness in his or her lifetime. In my opinion, however, without champions, you are hampered. I think you need people who can grab the attention of the public in relation to their own experience with mental illness.
Senator Trenholme Counsell: Champions are people, but are there any existing materials that you can think of that would be helpful? We have talked about having signs on buses or on subway trains, et cetera. The champion issue, do you see it fitting under Public Health? There is no question that Carolyn Bennett is a champion, in my mind, with regard to the public, and Ken Dryden is a champion on early childhood development.
Mr. Chaulk: Yes. They have been here for consultation, as you probably know, and we have talked about the need for mental health promotion and stigma reduction.
Senator Trenholme Counsell: Do you see that as happening under public health?
Mr. Chaulk: I do not know exactly where it would sit, to be honest. In terms of public health, it might depend on where you would get the best bang for your buck, and which ministry might have the ability to take it the furthest at this point in time. The Ministry of Health is undoubtedly coping with many and varied things. The question did come up during the consultations with Carolyn Bennett, but it did not get a lot of air time. There are so many other things in terms of public health that can get in the way, so I am not sure that I can answer beyond that.
Senator Trenholme Counsell: May I just take a minute and say to you that I think the frustration you are feeling with regard to applications and reporting, and so, on is a sign that there has been a change in the federal government because of recent events in the last few years with regard to money that is not being properly accounted for, and the fact that there are not enough rules.
Mr. Chaulk: Yes.
Senator Trenholme Counsell: I work closely with people in literacy and they have said exactly the same thing, that now there are more forms to be filled in and that they need to report more often, and that this has all increased. I do not think that is going to change for a while and perhaps there will be modifications with time.
Mr. Chaulk: Yes.
Senator Trenholme Counsell: It is the desire and the determination of the people in all departments of the federal government that there be a heightened level of accountability for funding.
Mr. Chaulk: Yes.
Senator Trenholme Counsell: You are expressing that frustration. I could go on, but thank you.
Ms. Greene: I want to make a comment on how you attack stigma. While recognizing the monies that went out to sponsorship and the implications, I do not think it should go to Public Health. I actually think you need to go to the private sector, to marketing specialists. I say that, knowing the climate we are in. However, we managed to do the seat belt campaign and the drunk driving campaign, both of which have worked in our lifetimes, in our generation. I can remember when I started university, everyone drank and drove. Nobody wore seat belts. We have run a successful campaign such that my kids do not think twice about those things. I think that we can do the same thing with mental health, but it takes that kind of campaign, and personally I do not think there is a department of the federal government to which you should give that campaign. I think you should be looking elsewhere.
Senator Trenholme Counsell: There is certainly legislation involved in both those examples.
Ms. Greene: Yes.
Senator Trenholme Counsell: What I mean is, you have seat belt legislation and you have more strict rules with regard to drinking and driving, —
Ms. Greene: Yes.
Senator Trenholme Counsell: — so they are not necessarily in the same category. I had the feeling that community development was increasing across Canada, and you used these words, Ms. Greene: "...absolute lack of community development." I go back a long ways with government. Thirty, forty or fifty years ago there was a lot of emphasis on community, and then there was a time when it was relegated to an issue of lesser importance. I had thought in the last 10 years that it was coming back, that community programming, bringing people together in communities, community development, all the phrases and terms we might use, were finding their place again and being valued, recognized and elevated in terms of making things happen.
Ms. Greene: I think it has come back as a concept, but with a difference. Those of you who can remember the Linsky days and those kinds of things, community development then was a process as well as a concept, and the process requires very much working with people and helping people build their own capacity.
I sat on the Premier's Council as one of the first members, and we started with these wonderful principles that said, "place-based solutions," and "helping people to be part of the solution," and we funded one person in each region.
Mainly what is involved is bringing together committees, such as bringing together the health care boards and the educational boards and perhaps representatives and NGOs. That is different from what I call community development, which is really working with groups to help them find their own voice. Certainly, CHANNAL, which Mr. Chaulk and CMHA have been critical in fostering and supporting, is an example of that. What I am saying is that we are not training people in true principles, in my opinion, of what community development is, which is really allowing people and groups to engage in a very meaningful way and facilitating and fostering that.
I think you are right when you say that it has come back into vogue, but the foundations are not yet in place. Nursing has come on to a degree, but their whole training is different. In terms of social work, which is my field, I feel we have left our roots and became "wannabe" psychologists many years ago, and I keep saying, "Let us go back to what I think made us distinct and important in the continuum." There is a place for everybody. Consequently, I think we are only paying lip service to community development.
Dr. Callanan: I had one very brief comment that I wanted to offer with respect to the stigma of mental illness. I do not know what might be the best way to market or situate the program, but education is clearly the key. When we talk about the scope of mental illness, we are talking about 20 per cent of the population who have periods of time when they are clearly symptomatic. However, I think that issues related to the concerns that give rise to stigma do actually reflect on the behaviours of a very small subset. Given the sorts of cases that Ms. Greene was talking about earlier, mental illness can be both a situation wherein the individual is disturbed and where the individual is disturbing others. I think it is the set where their illness leads them to be disturbing of others that becomes associated with the issue of stigma, and stigma, again, relates very much to some of those things that people know that are not true in terms of rates of criminality and rates of violent behaviours.
Senator Gill: I saw in one report, possibly Mr. Chaulk's, that you support the recommendation by this committee that it is a good idea to help the Aboriginal people organize their own programs. I know that some years ago the people at Indian Affairs were transferring money to the provincial government here to give services to the Aboriginal people, and I think it included services for mental health. I know that the Aboriginal people have special circumstances. Are services for mental health and other services related to health given to the Aboriginal people here?
Mr. Chaulk: Do you mean in general?
Senator Gill: In terms of services such as treatments, if they are needed.
Mr. Chaulk: Yes, that is my understanding, but I do not know a lot about the area.
Dr. Callanan: Some services are provided. There are some dedicated services provided, but they are probably minimal with respect to global demand and need. I think the best vehicle of service delivery to our Aboriginal population, to our native peoples, is community development.
Senator Gill: Yes.
Dr. Callanan: This is one area where we are now beginning to recognize that what we can bring in, we bring in from a perspective of western medicine, and psychiatry being a medical specialty, if I can speak from that perspective, I think we need to have a much greater understanding of community, and some of the ways in which we can best do that. Of course, some specialized interventions will be required but it is a question of how the community can be helped to make its own response.
Senator Gill: Those services that are local, are they actually under the provincial government? Do you know if they are offered through the provincial government?
Ms. Greene: There is a range of services. For example, at Emmanuel House, which is one of the only alternative treatment programs for mental health in this province, we would oftentimes have Aboriginal people, people from the coast of Labrador, and I actually worked in Sheshatshiu and in Goose Bay. Certainly, there are services provided by the Labrador Inuit Association. I echo Dr. Callanan's comments that there is a need for a more systemic response. I was recently at a social worker conference, and one of the social workers who spoke is married to an Inuit man. She talked about the impact of going back to the country and those kinds of things. While there is a recognition of the catastrophic problems existing in coastal Labrador, they still exist. I mean, you would need to speak to local people, but we certainly have a long way to go in resolving mental health and addictions problems for our Aboriginal peoples.
Senator Cordy: Mr. Chaulk, you spoke about the challenge of seniors caring for adult children. I worked on a Prime Minister's Task Force for Seniors a couple of years ago, and this was one of the issues raised by people who were in their seventies and eighties, dealing with adult children who were dependent on them.
I know you cannot look at mental illness in isolation, and you all spoke about the contributing factors — poverty, abuse, housing, discrimination, all of those things. However, are there programs for which seniors caring for adult children are not eligible because they have an adult child with them? One example would be seniors' housing programs. If you have an adult child living with you, does that mean that you are ineligible for many of the community programs that are out there?
Mr. Chaulk: If you are in a seniors' program, do you mean?
Senator Cordy: I mean if you are a senior and you are caring for an adult child, are you eligible for seniors' housing? Municipalities have seniors' housing, apartments for seniors.
Mr. Chaulk: Right.
Senator Cordy: Does that disqualify you for housing if, in fact, you are caring for an adult child?
Mr. Chaulk: I am not exactly sure. I think in some jurisdictions there are limitations in relation to who can occupy a unit. My point in the brief was that there is the need for options for the adult child with a serious illness in order for that person to move into the community, like any other adult wants to do, and not necessarily to be living at the age of 45 with his or her parents.
I think one of the challenges for us here is the level of income that you can receive if you are a single person and you want to live on your own, which is about $630 a month to pay for your rent, your heat, your food, for everything. If you have been living at home and your parents have been helping to run your life, then you will need some support in order to start to run your own life, such as in-home support, which we have been previously not eligible for, but now the door is opening. It is really an issue of the availability of, and accessibility to, community-based supports that can take the responsibility off the aging parent and work with the adult child, who can then live in the community with the right supports. That is the belief these days, that in the case of most people with severe and persistent mental illness, with the right supports, they can be living in the community.
Senator Cordy: Which is win-win for the adult child and for the parent, that they would become independent.
Mr. Chaulk: That is right. I think part of what I mentioned in my brief is some small amounts of money that we have received from government and from health care foundations to do some further work with families, because families are often the forgotten caregivers, right? We get calls at our office from the aging mum to say, "I am 80 and he is 58, and he is still living here. What can be arranged? What can be provided?" I think, for some of those aging parents and for families in general, there need to be support outlets to go and talk about some of these things. Also, when you talk to some of these folks, There is guilt about the fact that their child will only be eligible for a certain amount of money, and he will only be able to afford a halfway rundown bed-sitter in the wrong part of the city, right? It is a real tussle in terms of what to do. I know there is not a bottomless pit of money but for our sector in health care, in terms of prevalence and rate of disability, we have never really received funding commensurate to what is required at the community level.
Senator Cordy: You mentioned the family support group that is starting this fall. What exactly will that be? Will that be a peer support type of thing or could you explain what might be?
Mr. Chaulk: What I know about is that it is a model that was developed actually in the United States through the National Alliance for the Mentally Ill, and it has been adopted by groups here in Canada. Facilitators of the group need to go for training in order to run the model, and you go through a screening process for family members to assess suitability for the program. It is very much a psycho-educational support approach and I think it runs for 13 weeks. We got money to launch it once and, depending on how it goes and how it is received, we would like to try to continue with it.
Senator Cordy: You also referred to a seamless delivery of services.
Mr. Chaulk: Yes, right.
Senator Cordy: In fact, you said that perhaps we should not even be referring to it as a "system" because it is all so disjointed.
Mr. Chaulk: Yes.
Senator Cordy: I remember that, in Ottawa, someone appeared before us and presented a diagram with all of the services that were available: federal, provincial, NGOs. For me, looking at it, I would not know where to refer a person. Where do you start? What is the starting point? Who can that individual turn to when they want to know how to open the door and get started with some help?
Mr. Chaulk: I think, right now, they start at various points. In fact, they often start at the family doctor's office, and their referral may be related to what the family doctor may or may not know in relation to resources in the community. As I mentioned, we get about 120 calls or drop-ins per month from people that are just looking for information and/or referrals to services. The restructured regional boards may be able to help with that in terms of access but it is still a problem. There are still a number of doors that consumers are required to knock on, which means that you are telling your story, as painful and personal as it might be, over and over again to several different potential service providers before you find the correct one.
Senator Cordy: Or you are calling and, "If you want this service, press one; if you want this service, press two; if you want this service, press three", and there is no real person at the end of it.
Mr. Chaulk: Yes.
Dr. Callanan: You are exactly right, and that is a complaint that we frequently hear: There is no portal of entry, and at the end of the day I hope a fair number of individuals are pleased with the service with which they finally come in contact, but they say, "Do you know, you are the ninth person I have called before I got to this door, and none of the previous eight actually sent me here?"
Mr. Chaulk: Yes.
Senator Cordy: Ms. Greene, you have referred to the bureaucracy you face in trying to get things done. How much of your time do you have to spend filling out forms? Do you have it down to a percentage? It just seems as if it is so cumbersome.
Ms. Greene: There is no question that it actually takes a considerable amount of time and, quite honestly, outside of filling out forms, an incredible amount of time goes into consultations such as this. As I said to Senator Kirby yesterday, I have not started the revolution yet, so I am still needing to infiltrate and conquer. You feel as though you must take every opportunity to do that, but this must be done between dealing with housing, homelessness, income support, employment issues, and so on. It is one of things that I would like to highlight.
I am not sure what the simplest way of doing this is, if you asked me to come up with an idea. That is the real gap for agencies, and I know that Mr. Chaulk feels the same way. We give a tremendous amount of time and energy to consultations and travelling and things like that because we do know that if you ask us and engage with us, then we must give it back. However, resources are limited, especially now with the middle management cutbacks. Opportunities to step back and reflect, opportunities to write about what is working, those kinds of things have been going out the window, but I keep saying that we must find some funds and resources.
If I may mention here, there is a really neat housing project in New York. They actually took some old, rundown Times Square hotel and turned it into a fabulous housing project. They received funding through some of their tax credits. I am not trying to suggest that we follow a United States model, but in that case they have a replication unit, meaning that they have people whose job it is to do just that.
You ask us, why are we not sharing this experience? The answer is that those things need to be funded, and funders do not tend to provide resources for executive assistants, administrators, comptrollers. It involves a considerable outlay of resources, and what happens is that we have people who are just multitasked to death; people who are doing far too much because we try to meet those demands.
Certainly, in terms of the application processes, we have really seen a difference since the sponsorship scandal. While I recognize the need for and commitment to accountability and the establishment of standards, that takes resources. What I mean is, making sure you have proper orientation manuals for all your staff and codes of conduct and everything outlined; it is a huge output. Somewhere in here, if you want that, that has to be recognized as a legitimate resource. I know there is a voluntary sector initiative and I hesitate to say, "Put it there" because it seems that that is a whole other layer, but some kind of resources are needed to which groups can apply to for that kind of infrastructure, especially those who are doing much of the work of government in partnership.
Senator Cordy: We frequently get calls in our office from people working through the myriad of layers within the system, and part of the difficulty now, as you can imagine, is that when an MP phones bureaucrats, they are being told, "How dare you phone!" so I agree with you. I think it is a major issue and that we could save substantial amounts of time and avoid burnout.
I used to be on the board of Phoenix House in Halifax, and our executive director spent tremendous amounts of time doing what we call "PR" work, but nonetheless important. When you are doing good things, people from other jurisdictions are calling, looking for information, and people like us want to hear about your programs, so it is a challenge.
I was interested also when you talked about champions. When we were in Vancouver, we had Svend Robinson, Bill MacPhee and Rafe Mair all appear before our committee. I agree with you that when you put a human face on mental illness, it seems to reduce the stigma, but it is almost a catch-22 situation: While the stigma is still there, people do not want to come out.
Mr. Chaulk, you spoke about your fears about speaking out on your job, that you were afraid that you may not get your promotion or any number of other things. Michael Wilson is doing a lot of good work in that area, and has actually been hired by the government to do some work in that area.
Mr. Chaulk: I heard about his appointment recently and I was really quite pleased because I had worked with him on the Toronto-Peel Mental Health Implementation Task Force. From his own personal life, he has a real sense in terms of the toll that mental illness can take. It is a tough one, and I think a multifaceted approach needs to be taken. I was not meaning earlier to suggest that a federal ministry or department should take it on because I do not think, from my experience within government, that the expertise lies there. I think you need to go to where the communications experts are to put together that kind of anti-stigma strategy, and it takes time to be effective.
As I now understand it, after 20 years of having to use mental health services, maybe as things change it is easier for people to "come out", per se. I think for those of us who are at a certain age and who have achieved a certain stability in our careers, we must take that leap. I wish I had taken it myself some years ago because I have found it actually quite liberating. It also paves the way for people to share their experiences when they hear about your story, "Well, you know, my sister also..." In the education sessions that I conduct, I talk about my own experience. It is almost like an automatic ice breaker because, as the statistics say, it is one in five as well as everyone around that person who is affected. There is a certain amount of individual responsibility for eroding the stigma and putting your own face out there.
The Chairman: Sometime last week, Sven Robinson testified before us in Vancouver, and he referred to his coming out on mental illness as his second coming out. He said it was infinitely more difficult for him than the first one. That is the first comment.
The second one is that you commented on the ice breaker. I may have mentioned this to Ms. Greene yesterday that, as we go around the country or give speeches and so on, the vast majority of members of this committee have a member of their family who has had a significant mental illness. Any time I am giving a speech, I mention that at the very beginning. The ice breaker comment is absolutely right. Suddenly, we move from being abstract policy makers to being one of them, and the impact of that is absolutely extraordinary.
Mr. Chaulk: Yes. Just to give you some feedback, I agree with Svend. I have had, too, the same two coming out processes, and the first one as a gay man was so much easier because you had an identifiable community to which you could go and that you would be part of and not be seen as any different. But for me, that was 20 years ago.
The Chairman: The same for Svend, too, actually.
Mr. Chaulk: It is really interesting that that would be an easier process for me, even working within the system, than being willing to take the risk to say, "Yes, I am back on medication and I am not actually on a two-week vacation. I am waiting for this new medication to bring me to a point where I can come back to work and work a little more comfortably."
What I think is really instrumental and significant now is the work done by CHANNAL, the group that you heard from yesterday, in terms of providing safe places for people to go to in order to commence that coming out process.
Senator Cook: Thank you all for your very compelling presentations. If we look at the person at the centre, I think the strength is in the stories that we tell each other because, right now, I do not have a clue as to how to find the person that is at the centre because there are so many layers and so many bits and so many pieces that we need to look at in a holistic manner.
When you talk about education — yes, Mr. Chaulk, this will be my first story. On Saturday night, I went to a national dinner meeting of the Girl Guides of Canada that has been held here for many years. Part of the entertainment was a group of about 120 school kids from an elementary school in Paradise, and they did an anti-stigma presentation. That is the only way I can describe it. It was song, it was dialogue, it was action, it was recitation, but there was a common theme. When they would do a piece, they would say, "It is up to you and it is up to me. Together we make one, big happy family." I do not know where it came from, but it was incredible. I think the education is out there.
Mr. Chaulk: Yes.
Senator Cook: It is in one school because they would come to the microphone and say, "It is wrong to be rude to your friend. It is wrong to steal from your neighbour." It had all of the elements of that piece, and I was encouraged by that.
When we talk about a seamless delivery of services, then it becomes more complex because there are a great many needs that the one person has. My understanding of why I am sitting here this morning is that we hope that if we listen to your stories and all of your expertise, that we can offer to the federal government a national plan for this country, a national mental health strategy. We will do it because we have listened to people and heard your stories.
The one thing that you can help me with in terms of that, Dr. Callanan, is the cost of delivering services. I mean, you are the expert. Your vision is great and you have all your material, but it comes down to dollars eventually when you are dealing with government. What will be the cost of delivering a functional telehealth, telemedicine system? I will only use my own island as an example because that is where I come from, and then we can be a model for other parts of Canada, because rural Ontario is no different from rural Newfoundland, and probably not as sparsely populated.
Dr. Callanan: Yes.
Senator Cook: Ms. Greene, I have known you for so long and you are still that visionary that I always knew, and you have come miles in your life's journey. I hear you asking how can we peel away the layers for you to achieve the optimum, which is to care for that person who is at the centre of this whole issue. The only question I have for you is, if the first layer is the federal bureaucracy here in this city, in this province, where are the barriers? What stones do we need to roll away and how can we help you to do that because, clearly, from your presentation, these barriers exist. Those, then, are my questions for you. How can we help? Your clarity of purpose is reflected in your presentation, as it is in the presentations of all of the people from whom we have heard across the country, and your responses are the same and your needs mirror those of the other parts of Canada.
Mr. Chaulk, do you have a wish?
Mr. Chaulk: Are you referring now to telehealth?
Senator Cook: No, I will leave that to Dr. Callanan. You were talking about education and the seamless delivery of services. Where do we begin, because for me it is not stigma; it is discrimination. Let us call it what it is.
Mr. Chaulk: Yes.
Senator Cook: Should we take the first step into the school system, into the curriculum?
Mr. Chaulk: Yes.
Senator Cook: Should we, as Ms. Greene suggests, give it to a marketing agency and let them get on with it? Let us do something about it.
Mr. Chaulk: Yes.
Senator Cook: If you had a wish this morning, where would you begin?
Mr. Chaulk: It would need to be multifaceted. I think we need to rely on media and technology to be presenting information and images to the public that correct some of the myths and the stereotypes, and I think you do start with the young. As I said in my brief, our previous education coordinator — who, regrettably, died suddenly about a month and a half ago — had the ability to go in and talk to grade 6 students. He was a man who lived with schizophrenia, accomplished a lot in his life, had a university degree and was working part-time.
It all comes down to the material that you develop, the approach that you take, and I do believe that as part of the learning for children and adolescents — and adolescents in particular because of their susceptibility — that you start in the school system, and that is part of where we have tried to go.
However, that is not the only place where you can be meeting young people. You also need to go to places that they call their own, and that they claim as their own where you might be able to have a different level of interaction with them. However, I do think that education in the school system is the starting point.
Senator Cook: The concept of telehealth and telemedicine is very much a part of me, but is there a big cost of setting that up and maintaining it?
Dr. Callanan: Interestingly, in Newfoundland, of course, we have Canada's largest and longest-running telehealth network, through which we have access to some 70 communities throughout Newfoundland and Labrador. Last spring, we had the twenty-fifth anniversary conference of TETRA here in this hotel. The issue is, again, that we are not using it in the way that we should. In terms of cost, the largest study that has been done on that was done by Richard O'Reilly in London, Ontario and he has worked with a group of over 200 patients who volunteered to participate in this study, which was a randomized controlled trial; that is to say, the research protocol identified where the individuals were to be seen via telepsychiatry versus Dr. O'Reilly flying down and seeing them in Thunder Bay. At the end of his one-year study, and even taking into account all of the data has not been received yet, the saving was about 20 per cent for telepsychiatry. That comparison included a study of the cost of buying the equipment and doing the set-up for that study.
In Newfoundland, the equipment and the set-up is here. One of the problems with it is that some of the areas have their own regional networks, and throughout Atlantic Canada there is a group called Tele-Mental Health Working Group, and we do not have the same capacities to interconnect between and among various communities, say, between Newfoundland and New Brunswick. We have had difficulties holding some of our meetings because we do not all have the same type of equipment. I do not have the technical expertise to point out the differences, but there is a difference between whether you have a satellite link, which is a medium I am familiar with, versus an Internet protocol, or wide-band versus some telephone line that is shorter than wide-band.
The Chairman: That is the modern version of the narrow gauge railways.
Dr. Callanan: Except this time the problem is not unique to Newfoundland and Labrador. It stretches across the country from sea to sea.
The Chairman: Right.
Dr. Callanan: I have an anecdotal example. We have this network throughout Newfoundland. We saw somebody through a clinic where I work. The individual was a professional going to take up a position in a small community, and we offered to provide a telehealth follow-up rather than trying to orchestrate a visit back to St. John's. Because of stigma, the individual would not take a booking at the local telehealth centre to talk to a psychiatrist in St. John's. However, since the follow-up was being provided by one of our students, who tried to go ahead and make the booking and to say, "An appointment is available at this date and this time," we discovered that the cost for the link-up would be about $240, and nobody was available to pay that bill. The cost is usually about $95 to do the link-up and then about $60 an hour to continue the consultation.
However, work is being done in this area. It has been piloted here in Newfoundland and has now gone beyond the pilot stage and will soon be, as I say, rolled out across the country.
Veterans' Affairs Canada has a peer support program and a treatment program for individuals who have been in military service and are suffering from post-traumatic stress disorders or other conditions related to the service, where they can, as an option, choose to come to St. John's, where most of the services are located. There are some in Corner Brook also. However, they can now also access their counsellors via telehealth technology and that is actually proving to be fairly popular. They have worked out some ways around identifying why the different individuals would be coming to the telehealth centre in the small towns, and that is moving now into Nova Scotia and going across the country, not as a replacement but as another means of veterans accessing service.
Senator Cook: Ms. Greene, as I said, I am trying to seek knowledge so that we can all move forward together. You mentioned Harbour Breton, which is 20 miles down the road from where I was born and brought up. Yesterday, a young woman from Grole sat there before us. She had been resettled in the 1980s to Harbour Breton. You talk about a continuum. I know since January or February there have been delegations coming to Ottawa from that community, seeking a way to continue to live where they want to live in the best possible way. I realize my inadequacy. I am not a community worker. We can only take forward what they are saying to us and I feel for the communities around my province, but that is one of the challenges of living where we live, I guess. However, I think we would be remiss as leaders, whether we are NGOs, whether we are not-for-profit, whether we are professionals or whether we are so-called politicians, if we did not move forward together and try to understand each other's needs and work within the realm of what is possible and what the reality is.
I will go back to my question: How can we help you?
Ms. Greene: I have a couple of thoughts on that. One of the things has got to be that if what we are delivering is provincial services, there has to be increased money. I know that there has been significantly more monies put back into health, but what I would like to see is perhaps some strings attached to the money coming in, requiring the province to actually look at some joint submissions. We talk about integration of services and, certainly, CMHA's model is one that we hope that we are putting into effect, which is integrating employment, community, health and housing. If some funds were made available to the province, the federal government should stipulate that, "This money is there if you can actually show that you are breaking down silos and you are taking some integrated approach that is not related to just one response." I think it all revolves around setting the guidelines but, quite honestly, as for the federal government delivering provincial services, I think you will have to find a way to make that collaboration work. I know you have met with our Minister of Health. There needs to be some opportunities to collaborate. I know I would like to get people in a room for five days and do an organizational transformation workshop with critical policy makers to ask, and perhaps answer, the question: How can we do things differently? Something along those lines, in any event.
We talked about cost benefit analysis. You talked about the cost of things. I think you need to find out ways to show the kinds of monies that are being spent now. I mean, $60 an hour or $95 an hour is not a lot of money when you consider the impact on people's lives and the cost of institutions. I heard that we have the reverse situation here. We have 80 per cent of our patients spending time in a psychiatric facility versus a general hospital. A lot of money is being spent on expensive systems, and I think we need to do some research on that whole premise.
Having said that, we were asked by CIHR and the National Homelessness Secretariat to do some research pertaining to housing and health. When it came to the call for proposals, we said, "Please make it relevant to us. Do not waste our money on counting the homeless or whatever." The call for proposals turned out to be entirely too academic. Talk about having resources to do something! We had Bruce Pearce and he could not walk us through that. We just said, "We cannot do it. We cannot actually look for this money." Thus, the money is still going out to academics. I am not saying that all academics are not connected to the communities. There are some very good people in academia across the country. But I think that we need to do some cost benefit analyses that looks at the value of community-based responses in a way that is user-friendly.
Senator Cook: If I may say so, Mr. Chairman, you will remember the Heart Health Program that was federally funded and provincially delivered. However, once that project was over, it was over. I suppose there were some benefits to the people who participated in the program, but when you looked at the population in general and the increased capacity that came with that building, it did not happen. Thus I see here one of the stones that we need to roll away. We need to move from projects to programs.
Mr. Chaulk: Absolutely.
Senator Cook: I hope we can achieve that. I want to thank you all for your vision and your expertise and everything else. Just tell us how we can help you.
The Chairman: I thank all of you for appearing before us today.
The committee adjourned.