THE STANDING SENATE COMMITTEE ON Social Affairs,
Science and Technology
EVIDENCE
VANCOUVER, Monday, June 6, 2005
The Standing Senate Committee on Social Affairs, Science and Technology, met this day at 1:36 p.m. to examine issues concerning mental health and mental illness.
Senator Michael Kirby (Chairman) in the chair.
[English]
The Chairman: Senators, we have a number of witnesses this afternoon. From the Coast Mental Health Foundation we have Darrell Burnham, executive director. We have Bev Gutray, who is the executive director of the Canadian Mental Health Association here, the province-wide organization. We have Susan Friday and Rob Carten from the Vancouver-Richmond Mental Health Network. We will ask everybody to make their brief opening statement and then go across the panel, as it were, and ask questions of everybody collectively, I think is the easiest way to do it.
Ms. Susan Friday, President, Vancouver-Richmond Mental Health Network: First, greetings to one and all. I am Susan Friday and I am here today representing Vancouver-Richmond Mental Health Network Society.
I certainly agree that we need a national action plan on mental health, mental illness and addiction, a plan that would mandate the federal government to devote a specific portion of its transfer payments toward mental illness and addiction.
In all fairness to my friends, I should briefly mention that although I find the term “mental illness” somewhat contentious, in order to maintain linguistic consistency across the board and to facilitate matters, I will use it.
Also, maybe we can learn something from Australia. I was looking at that and I did find it impressive. I believe that Canada needs a Mental Health Act, one that would include a charter of rights whereby a recovery orientation should drive service delivery.
I speak of recovery in a sufficiently wide context to include recognition of the social, psychological, biological, environmental and economic factors; and the holistic alternative pathways towards healing that represent freedom from an oppressive corporate drug culture, one that reinforces consumer/survivor dependency on the psychiatric status quo. The status quo is not an option.
As I think of specific populations across Canada and the three reports issued by the standing Senate committee, it is clear that we need to include gay, lesbian, bisexual and transgender populations within a national policy framework, and also a national information database, I might add. The statistics on rates of prevalence make this abundantly clear. The annual economic cost of mental illness and addictions resulting from homophobia, bi-phobia and trans-phobia cannot be ignored. For Canada to be a true leader in the international community I think it is obvious that we all belong; that we are essentially one family.
I also think that the issue of women-specific supports is important. As Phil Upshaw would say, “The time is now.” Yes. It is time for a women's mental health strategy in Canada. Women utilize mental health services more frequently than men, and the causal factors for this have been researched and must be recognized. Women are almost twice as likely as men to experience depression and anxiety.
A comprehensive national action plan must address the realities of violence, abuse, poverty, ethnicity and addictions.
In closing, I would like to add that one of the alternatives we very much need is more safe houses in Canada, places where women can obtain positive help in overcoming a crisis.
The Chairman: Ron, do you have anything to add?
Mr. Ron Carten, Coordinator, Vancouver-Richmond Mental Health Network: I will just say a little about myself. My presentation has been handed out to you. I apologize for not getting that to the committee earlier.
Briefly, my organization's core activity is running self-help groups for people diagnosed with mental illness. We have a dozen such groups. We also run a quarterly 16-page newsletter created by Consumers and Survivors of Psychiatry. We have a resource library and we stage events, workshops and so on throughout the year. Our organization has been in existence since about 1993. It became a non-profit society in 1999 and has a membership of approximately 200 people. Part of our mandate is to promote the interests and rights of mental health survivors/consumers; we use that term and I know that the committee is familiar with it. Part of our mandate is to promote alternative approaches to dealing with mental health crises — alternative therapies, alternatives from the mainstream, which is probably good for Canadian society as a whole, but I will not go into that.
My personal history, I am 43 years old. I have lived and worked across Canada in the cities and rural areas. I was hospitalized in the early 1990s and consider myself fortunate to have benefited from psychiatric intervention. However, that is not the case for all of my constituents, and because it is my job, I am here to represent their interests.
On page 6 of volume 3 of the committee's report, the committee asks:
Accordingly, how can a patient/client oriented system ensure an appropriate balance between the rights of individuals and the role of society in caring compassionately for them while protecting itself?
I would like to emphasize to the committee — and I hope its final report will reflect — the myth of the violent psychiatric patient. The committee has indicated as much already by stating on page 62 of the first volume:
First, it will be necessary to find ways of countering the attribution of an exaggerated propensity to violence to people living with serious mental illness.
Therefore, first and foremost, on behalf of my network, I would like to encourage the committee to do what it can, as other countries have, to advertise about mental illness and to underline the fact that people diagnosed as mentally ill are really no more dangerous than anyone else in society. I think this is a fundamental point. I do not have too much more to say, but I would like to go on a little longer.
I hear many stories from the people whom I work with and whom I serve, and I regret to say that some of them have grievances against the system. This is my focus. My focus is on the rights of individuals and caring compassionately. Let me stop there. In view of the stories of abuse I hear, frankly, reported stories, their reports and the grievances that a significant minority of the members of my organization have, if not a majority, I believe the committee should promote a stricter oversight of treatment within mental health facilities. Perhaps this may be achieved by creating an appeal body to the provincial mental health panels in B.C., similar to when the federal government got involved in welfare systems in the province. It created or required appeal tribunals for people on welfare. This would help address the inordinate power that psychiatrists have over mental patients who are confined under the Mental Health Act. I am sure the committee is aware that a psychiatrist or a mental hospital does have a significant amount of power over patients, and this does need to be addressed.
In addition to addressing this great power that psychiatrists have, their wide discretion to detain people and to treat them as they see fit, avenues for redress of grievances should also be made available in the provinces, and perhaps the federal government could, given its funding power, require that such avenues are put in place.
Another item that may assist in improving the care that psychiatrists provide to their patients is the possibility of holding psychiatrists liable if they do severe damage to their patients. I am almost finished, senator.
In B.C., and I think in some of the other provinces, a mental health patient does not have the right of informed consent. I think the committee is aware of that.
The Chairman: That is correct.
Mr. Carten: The committee has spoken about the impairment of decision-making capacities of people diagnosed with mental illness, and if this is an issue, I will not dispute it right now, but I will refer to the concept of advance directives. Particularly in B.C., the Representation Agreement Act provides for people to appoint representatives to make decisions on their behalf when they cannot, and this includes health treatment, but unfortunately, there is one exclusion in the Representation Agreement Act, people detained under the Mental Health Act. The network that I work for feels this is an incorrect position and we are putting out a position paper on that. We feel that advance directives are legitimate for people before they are diagnosed with a mental illness and after they are diagnosed with a mental illness.
I do not have much more to say. I will just conclude with the last couple of lines of my written submission.
The focus of my presentation has not been on access to care. There is access to care. Access could be improved. My presentation has been on human dignity. Without civil rights, without freedom, when help is imposed on people rather than offered, there is a threat to the dignity of the individual. I hope the committee will recall in their deliberations some of the suggestions I have made and that they may help the committee produce a national mental health strategy that can improve upon the system we have. That is all. Thank you.
Ms. Bev Gutray, Executive Director, Canadian Mental Health Association, British Columbia Division: Thank you for the opportunity to appear before you today.
B.C. division would like to extend our thanks to you, your colleagues and your staff for the attention that you have brought to mental health issues in Canada and for your initial series of reports.
The Canadian Mental Health Association is the only voluntary charitable organization that addresses the full spectrum of mental health and mental illness and whose mission is to promote the mental health of all Canadians. The Canadian Mental Health Association, B.C. Division carries out its mission through education, research, community development and advocacy. One of our core objectives is to promote and create innovative programs that contribute to the recovery, secondary prevention, empowerment and community integration of persons with a mental illness. There are currently 20 CMHA branch offices across the province of B.C. that provide a range of services in their communities, from rehab to housing, to employment, to education services, to mental health promotion services.
As part of our presentation we want to be clear that we definitely support the work at the national level for the development and implementation of a pan-Canadian strategy on mental illness and mental health and believe that this is pivotal to overall change in our country in the way people who have mental health problems are supported. The incorporation within the pan-Canadian strategy of housing and income is well detailed in your reports, certainly on the income side. These are two critical determinants of health and mental health, and thereby we recognize that that has to be where strong effort is put forward.
B.C. division recommends that any pan-Canadian strategy explicitly adopt a focus on mental health and addiction services and systems within the context of people's lived experience, recognizing the importance of, and addressing the deficiencies in, key determinants of health.
Rather than focus on the need per se, which has been clearly articulated in your first series of reports, or on large policy issues, B.C. division has chosen to focus on key issues within the Issues and Options paper and highlight some innovative strategies and programs that have been developed through the work of B.C. division and B.C. branches as potential models for other jurisdictions.
In the area of system coordination and integration, while there is no doubt that there is significant duplication and overlap among the NGO sector delivering mental health services and supports at a local level, it is also critical to recognize that a diversity of organizations can in fact be an asset rather than a mere problem, allowing for real and meaningful choice on the part of people with a mental illness. In particular, when we talk about the fact that a large group of Canadians do not find that mental health service, it is not about accessibility. It is about acceptability. We think this diversity in the non-profit sector can contribute to that acceptability.
I would like to point out that in the community of Williams Lake there is an example of a co-op of non-profit organizations called the Central Interior Community Services Co-op. Our branch office is part of that co-op, along with the Boys and Girls Club, the Child Development Centre, the Association for Community Living. Numerous organizations that were feeling threatened got together and formed a co-op whereby they could build expertise within their staff. They can deliver more effective services. They have a better presence and administrative efficiencies in their organization. I will try to hurry along, senator.
Just touching on the area of early detection and intervention and the importance of us being able to focus on that, we would like to point out that there is also another aspect of early intervention that we do not think gets very much attention. That is the issue of parental mental illness, recognizing that there are people with a mental illness who have children and that unique services and supports need to be put in place for that group. We know that the children are a risk group. We believe that some of the things that have been done in B.C. could be built on to ensure that the parents are supported, that they have good mental health and their children have good mental health, and that they can reach out for services without fearing that their children will be taken away from them.
On the issue of enhancing access to services, as I tried to point out earlier, 76 per cent, over 173,000 people, do not find services acceptable and that is their barrier to getting help. We believe that we need to expand our concept of access to explicitly include the concept of acceptability, because so often we only think as providers and planners on the access dimension. We need to conduct focused, community-based research with people with mental illness and mental health needs to more clearly define the elements of acceptable services and supports. This is the only way that we can begin to see those kinds of numbers decrease in the future.
Child and adolescent mental health services: In B.C. we believe we have one of the best child and youth mental health plans in the country. It has all of the right elements. It has a central leadership role. It has a focus on treatment and support, risk reduction, community and family capacity and improving performance. In fact, what is unique about our child and youth mental health plan is it also brings to the table non-profit groups, family members, et cetera, in planning new services, understanding the latest evidence and rolling out new programs. We think this is a very good plan, with elements that should maybe be repeated in other jurisdictions.
As well, CMHA, B.C. Division is being funded through the Public Health Agency of Canada to work with five communities across B.C. on ensuring that family and youth voices are included in decision making and in the planning and delivery of services.
Two more points I would like to focus on. One is employers. Much of your third report concentrates on the issues of mental health and the workplace. We would like to say that in B.C. we will be soon starting the Mental Health Works program, an award-winning program out of Ontario division; that a lot of time and effort has been spent on the research and development of that service. We believe that through that program we can help those people who supervise, hire and support people with mental illness in the workplace by providing them with the latest knowledge and specific skills to intervene, hopefully before people access long-term disability or short-term disability programs. We would like to recommend that you consider looking at the expansion nationally of the Mental Health Works program.
On the issue of combating stigma and discrimination, I heard that somebody commented this morning on an ad that B.C. division had done with a baby. We call it the baby ad. We were funded by the B.C. broadcasters for a one-year media campaign. It shows a man holding a young baby, and you can see that this father was very content with his child and his child was content with him, but the camera cut away from him and a voice said: “Do you know what? This man has a mental illness.” Then it went back to the man playing with the baby. Then it said: “But you know what is sick? It is how your attitude towards him just changed.” Now, that caused lots of controversy and lots of feedback. However, the sad thing, and I think it is in all of your reports as well, is we do not have a sustained effort. Whether it is that campaign or somebody else's campaign, we have to be able to roll out those campaigns over a two- to three-year period to ensure that we have some real impact.
The other issue around discrimination is that we know that many other service providers do not have a lot of knowledge about mental illness or mental health. It could be people who work in the disability income offices. It could be people who are working in regular housing programs, landlords, et cetera. The Vancouver-Burnaby Branch of the Canadian Mental Health Association has taken the model of the first aid course and developed a mental illness first aid course that mirrors the physical one and is delivered to those kinds of key constituents, key groups who actually work with people who have a mental illness but are not in the mental health system. For example, knowledge about mental illness of people who work in the income security program before taking the course was 30 per cent. After taking it, it was 90 per cent. This two-day program is led by a professional as well as a consumer.
The other point we want to bring to your attention — and we know you have highlighted some of our work in your report — is the B.C. Partners for Mental Health and Addictions Information. We believe that this is unique, that provincial organizations that are focused on mental health and addictions have come together with a very broad mandate focusing on the mental health literacy skills of the population. What we mean by that is everybody needs some knowledge about mental health, and that is how we will protect and promote our mental health.
My final comment has to do with research. Community-based mental health research that uses participatory approaches to systematically gather information with and from people with mental illness directly is a tool that CMHA, nationally, provincially and locally, has used to identify issues and solutions from the perspective of people with a mental illness and to increase their voice in decision making. One example is a report that we released on navigating workplace disability insurance that actually detailed people's experience with workplace insurance programs; it is storytelling.
To date, there is little or no infrastructure to support the development of a national and provincial community-based research agenda or to effectively integrate findings from this form of research into the larger mental health agenda.
At a national level, providing research funding and support to build the experiential literature, thereby equipping people with mental illness with evidence when they are involved in decision-making activities at local, national or provincial tables, is one concrete strategy for increasing effective participation. That does remove it from the anecdotal comments that are often seen as the literature we are talking about.
In closing, from the Canadian Mental Health Association, B.C. Division's perspective, intentionally and systematically involving people with direct experience in training, research, education, planning and evaluation of activities can and will have a profound impact on how our local and provincial mental health systems function in the future. We urge you to recommend that this intentional and systematic involvement be embedded in all aspects of a national strategy on mental health.
I would like to thank you for the opportunity to present to you today.
Mr. Darrell Burnham, Executive Director, Coast Foundation Society/Coast Mental Health Foundation: Thank you for having me here today. I just want to compliment you on your work. I think it is provocative and makes us think as Canadians about how we serve people with mental illness and promote mental health across Canada. Our job is challenging. Your job is challenging. The situation we are all facing is far more complex today than it was 10 or 15 years ago.
Coast Foundation has been around for over 30 years and provides an array of services for people with mental illness. I do have a briefing package here. I will try to hit the highlights and keep within the time.
We provide an array of community-based services for people with schizophrenia, bipolar disorder, schizoaffective disorder and other disorders. However, more and more, the people we are serving suffer from concurrent disorders, serious addictions as well as physical illnesses that complicate and frustrate recovery. Therefore our job is a little more difficult today than it was. As well, the vast majority of our clients not only must deal with the symptoms and treatments of their illnesses, but they also live in severe poverty in one of the most expensive cities in North America. A lot of what we do in the system is really trying to alleviate poverty. It is a huge part of the mental health system.
We serve well over 2,000 people. I want to highlight two categories of services. One is that we provide an array of supported housing. Indeed, we pioneered supported housing for people with mental illness in 1974 and now serve over 544 people in many different forms of housing throughout the Lower Mainland in decent neighbourhoods in the community. We have found that it is not only a cost-effective means, in that it keeps people healthy and out of hospital, but also they blend well into the communities. They are not places that stand out and cause any concern in the neighbourhoods, so supported housing works.
We also have a centre not far from here in Vancouver's downtown core that is reaching out to people who are homeless or at risk of becoming homeless and providing an opportunity to stabilize their lives and get back on the road to recovery. We have had a 400 per cent increase in use of that centre at Seymour and Davie since it opened in August, 2000. It has over 2,000 members and 500 people use it on a regular basis.
My first message to the committee is that in Canada there is much expertise and proven best practices already out there to support the recovery of people with mental illness. The problem is we are overwhelmed. In Vancouver many parts of the system are in crisis. Right now 60 per cent of people in the emergency ward at St. Paul's are there because of a psychiatric disability, not because of broken bones and other types of trauma. It has just overwhelmed this community.
Third, the funding for new community initiatives has either declined, as in the case of supported housing, or has been flat in the last 10 years of both federal and provincial restraint. It is only in the last year or so that we have seen some snippets of new money in the field to help feed the system, so it is no surprise the system is more challenged today than it was 10 years ago.
Finally, it is far easier to prevent homelessness, the most severe symptom of a system failure, in my opinion, than it is to provide solutions for it. It is far harder to get someone who is currently homeless back into the community as a fully functioning citizen than to try to prevent that person from falling that far through the service system and ending up on the street.
In reviewing your report, there are several areas I would like to comment on. One is the recovery oriented client-centred system. The second is system coordination and integration. The third is the role of the third sector in mental health service delivery. The fourth is dealing with individuals with complex needs, a homelessness area. The fifth is the supply of mental health human resources. I would like to add to the mix the use of your term, “supporting caregivers.” Finally, what the role of the Canadian government is in leadership of the system through the next few years.
We agree that a recovery oriented client-centred system is a fundamental part of, and indeed a change in philosophy in many cases, the care and support of people with mental illness. The path to recovery is not clearly drawn on a map. We see it as a very person-centred approach; that people will have their own way back into society. The system needs to foster and facilitate that rather than deliver a specific program that may prejudge that path.
One of the components is the field of psychosocial rehabilitation, PSR. Certainly it is a major part of the mental health field, but I did not see mention of it in the report. I was in Nova Scotia last week for the national conference of Psychosocial Rehabilitation Canada, which represents eight provinces. It just opened a Maritimes chapter. It is leading that approach to the field. It involves people in health authorities and non-profits, consumers and family members and delivers a philosophy of care consistent with this principle. My recommendation is that philosophy should be fostered through the work of this committee.
On system coordination and integration, Vancouver used to be seen in the early 90s as one of the best places in the world for community mental health. People used to come from all over the world to Vancouver to see what was working. It had innovative programs and best practices. I met a fellow from Japan last summer who said, “What happened? Where did it all go? Where is that sense of purpose and the framework?” Some of it is money, but I also think that with the regionalization phenomenon, leadership in mental health has been buried within the regional fabric. A maintained and protected mental health system needs to be pulled out and supported because it gets lost in the competition for scarce health care dollars and the very difficult challenges that face health authorities in delivering health care services.
My recommendation is to look at regional brokerage services that manage a clear budget for mental health for the regions rather than deliver it. I will speak later about how sometimes regions do not necessarily deliver cost-effective services, and there are probably other ways to deliver the same services, either through consumer-run initiatives or the not-for-profit sector.
That segues into the role of the third sector. I was quite disturbed by the report that spoke to the need to control the sector. In terms of Bev’s comments about the conflict between elements in the sector, we may have some similar programs, but it does offer choice to individuals. I would suggest that many of the major breakthroughs in the way services are delivered to people with mental illness have come from the non-government sector. We have the ability in the non-government sector to do things that the formal sector often cannot because of bureaucratic rules. Many programs in terms of case management were first fostered by the non-profits — the clubhouse model; transitional employment; in Vancouver, the Car 87 model; the Portland Hotel Society, which is an innovative program for reaching out to hard-to-house individuals; and, of course, Coast Foundation supported housing programs. Now these services have been adopted by the formal system, so I do think that you have to look at the non-profits as a potential partner for government in delivering services. One, it can be very cost effective. We bring the community into our organizations. We have volunteer boards of directors. We go out and raise money. When you raise money, you raise support for the cause, an understanding of the cause, and that is important. In B.C. the non-profit sector is smaller today than it was 10 years ago, and I think that is a problem. I am not sure if it is the same across Canada.
The other important aspect in a client-driven system is that clients and families often have a strong voice, often sit on boards. One-third of Coast's board members are clients of the organization. Family members sitting on a board give direction on what are the priorities. Those are all significant elements that should be fostered in a new system of support for people with mental illness.
I mentioned cost-effective services. We often use non-professionals to perform roles where the health authorities will use professionals. It does not mean that we perform roles less capably than the formal system, but we use different staff with different skills and capacities. We often use peer counsellors. We can often deliver a quality service at a far lesser price than trying to find a very scarce RN to provide it.
Speaking of individuals with complex needs, homelessness in Vancouver has doubled in the last two years. These are Lower Mainland statistics. The numbers of people on the streets or in shelters has doubled in only two years. Something is responsible for that failure. When you cut off the housing supply for 10 years, it is no surprise that there are people living on the streets. That is part of it. However, I also think that those people have more complex problems: issues of addiction, of complex, unmet health needs, of TB, of HIV/AIDS, hepatitis C, just the poor lifestyle of people living on the streets. To be honest, people develop an adaptive way of living a tough, rough life. However, it does not help when they want to enter hotels or work in the business community and get back into society. The path back from homelessness is very difficult.
Rather than reinvent the wheel, there is an excellent report that talks about all the elements of homelessness developed by the Substance Abuse and Mental Health Administration in the United States. It contains a comprehensive listing on pages 7 and 8 that speaks to the elements of a system to help people come back from homelessness. I have spoken of many of them. It is certainly addressed in your report. There will not be one fix. Frankly, if it has taken 10 years for it to get this bad, it will take 10 years or longer to fix it. It is something that we have to be ready to pursue for a long time.
I would like to speak to the human resource issues. There are issues of scarce professionals and certainly all the major professions in B.C. that I know of, nursing, social work, occupational therapy, psychiatrists, are in severe shortage, and that will only get worse. All they are trying to do is stem the tide of a situation that is getting worse. Part of the problem is that half the nurses are over 50, so in the next five to ten years in B.C., that huge number of expert people in the care system will be gone. I think it is wrong to design a mental health system that relies extensively on the skills of those scarce professionals. The system needs to be looking at using those people in leadership and case management roles that oversee skilled rehab professionals. There are accrediting bodies and other ways of making sure that the quality is maintained, but you can find a supply of capable people who are either consumers or staff from the college system to fill important roles as long as they are supervised, where necessary, by the appropriate professionals and probably reduce the need for that level of professional in the PSR or the rehabilitation facilities by a 5:1ratio.
Finally, to the role of the Government of Canada: First, I think the primary role is to provide leadership, and what you are doing today and have done in your reports does that. You set the stage. You start the conversations rolling. However, I think it needs more than that. I agree with the recommendation for a comprehensive national action plan. I think it needs to be a multi-year plan. It needs to be longer term because these are not simple, one-off questions. Unfortunately, as governments come and go and people change, momentum is lost. In B.C. in the last 15 years we have had two mental health plans and a couple of sub-plans. All started with great fanfare and are now gone. They lost momentum right away. There has to be a way of maintaining that focus and momentum among the Canadian public to move it forward, otherwise it will fail. Frankly, it will fail.
One of the things you can do is provide resources, specific funding, for innovative solutions. You can fund research, particularly transformational research, the practical research that put services on the ground and makes a difference in the lives of people with mental illness. There is a lot of research into brain and biochemical activities. The drug companies are doing a lot of that because that is their bread and butter. However, there is not as much happening to transform good theory into practice and make sure that with whatever scarce dollars we have, we are using the best practices possible.
I think you can do a lot by reviewing what programs you currently deliver that affect people with mental illness and make them more rational and less in conflict with other parts of the system. I know, for example, CPP disability is a difficult issue. Right now in B.C., people on disability benefits must apply for CPP disability and so the payments are shared. It ends up being very difficult for the person with the disability to figure out. They have to handle the federal masters as well as the provincial masters and it becomes very complex.
As well, I think you need to raise the issue of homelessness and housing and put forward a separate initiative to target that specifically. If you monitor the status of mental health among Canadians, add many more measures of it, as you posit in your report, look at symptoms, indicators of health — that will be homelessness and others — and set targets, as we all must, we can move forward. Thank you for the time and good luck.
The Chairman: Darrell, since yours was the last presentation, I have it right in front of me. I will ask you a couple of questions on it. Intuitively, I agree with your statement that it is far easier to prevent homelessness than to provide solutions to it. Has anybody ever done any data analysis on that? A fellow who was here earlier this morning said that a nine-year longitudinal study had been done, I believe he said in New York City, which showed the cost of homelessness. It was substantially more expensive than dealing with supported housing and that kind of program. Have there been any Canadian data collected at all?
Mr. Burnham: There is very little research in the community on homelessness.
Mr. Carten: I think the Mental Patients Association of Vancouver did a study showing that the housing they provided prevented the hospitalization of people, and therefore reduced overall costs in the health care system. Mental Patients Association of Vancouver has been in existence for about 30 years.
The Chairman: If by any chance any of you can find that report, could you send it to us?
Mr. Burnham: There are examples of that. There is the MPA report and the Vancouver Mental Health has done another one on civil housing, supported independent-living housing.
The Chairman: However, the bean counters do not like intuition, so to the extent that you can give me hard data, it helps.
Mr. Burnham: Sure.
The Chairman: You talked about psychosocial rehabilitation. Frankly, I did not even know there was such an association. You talk about their philosophy and so on. You do not need to give it to us right now, but can you give us a reference?
Mr. Burnham: There is a website. Psrrpscanada.ca, I think is the reference for the Canadian association. There is an organization in the United States called the USPRA — uspra.org — United States Psychiatric Rehabilitation Association. Then there is also the World Association of Psychosocial Rehabilitation. Those three are very important organizations. It is a philosophy that is known in the field, but I do not think it is as well known to the formal health authorities. They practise bits of it but do not know it.
The Chairman: You are the first person to mention it to us. That tells you something.
I want to make sure I understand your concept of “brokered,” because I think we have used a different term. You mean that there ought to be within a regional health authority a subunit of some kind, a division, whatever you want to call it, whose job it is to purchase but not deliver health services; correct?
Mr. Burnham: I think they are actually in a conflict of interest when they deliver them through their own mechanisms. Even if they just purchase services from other departments of the health authority, it is better that way and they will make some choices. They can have performance standards and can look at where they want to go.
The Chairman: We have used a different word and have been pilloried for it, but that does not matter. That is precisely the model that we advocated for regional health authorities purchasing services. When we first proposed it, we talked about cataract removal, hip replacements and that kind of thing. That is what I thought you meant by “brokered.”
Mr. Burnham: If I could just follow up on that, sometimes people see contracting with a non-profit as privatization and it raises all kinds of alarms.
The Chairman: Some of us would have loved to have you following us around when we were being attacked by the left. The committee, in our report of two years ago, was 100 per cent behind what you just said.
Ron, I know you said you have a draft position paper on discrimination against the mentally ill in the Representation Agreement Act of B.C.
Mr. Carten: That is correct.
The Chairman: Is there any chance you could send that to us? I understand it is a draft and we are not holding you to it. However, it would give us a flavour of what the problems are.
Mr. Carten: Okay.
The Chairman: Bev, you talked about how you got organizations in the northern interior to form a co-op. In the previous paragraph you talked about incentives. What were the incentives you used to get these various NGOs to work together, or is it just that you had the right personalities? There are so many interesting initiatives going on in the mental health field across this country, and when you probe, it turns out that a huge part of it depends on the personalities of the individuals who happen to be there. I am trying to find out whether we can learn something systemic from you or whether it was once again a unique person.
Ms. Gutray: I think the systemic response was the fact that all of the non-profits were subject to their contracts being changed by the funder. A majority of the organizations I am talking about received substantial funding from our provincial ministry of health or its counterparts.
The Chairman: Funding to deliver services.
Ms. Gutray: To deliver services — or through the Ministry of Child and Family Development. There were some major changes going on about “We want to collapse contracts. We are not sure we want to contract with agency A. Maybe we will take agency A, B and C services and give them to agency D.” I think this is where personality does come into play. There was certainly one leader within that group who wanted to take control of the response. The way of taking control was to say “We can get you administrative efficiencies and we can deliver high-quality services.”
The Chairman: So the incentive was fear of being beaten up by government?
Ms. Gutray: Yes.
The Chairman: It may be a negative incentive, but it certainly is an incentive.
Ms. Gutray: However, I just want to speak about other positive aspects, because that experience has been so positive now they are working together in Williams Lake. It looks as if Williams Lake will be the co-op city of B.C. They are now working in the area of housing. There are several independent housing agencies, and they are coming together on purchasing services, whether that is for elevators or lawns, et cetera. From that people begin to understand where their relative expertise is versus having to be an expert in everything. I think that is the huge benefit.
Senator Cordy: How did you get that cooperative grouping and everybody working together, which is a wonderful model? How did people let go of the ownership of their own organization? Everybody's goal is the same, but human nature being what it is, people tend not to want to let go of the ownership of their particular organization.
Ms. Gutray: No. We are all the same in the end. I want to just say this is not a credit to me. It is a credit to the leaders of our association in Williams Lake, who actually made that happen. When I look at it as an outsider, what makes this model so attractive is there is no inherent competition amongst the organizations. They have a no competition clause. When a government contract becomes available, let us say, to deliver employment services, they decide as a group who has the expertise to respond to that RFP. One agency will be the lead and maybe will subcontract with another, but they have a management table at which they decide those things. Also, they are not all from the same sector. In mental health it might be much more complicated, but when I am talking about Williams Lake, I am talking about the Association for Community Living, the Child Development Centre, the Boys and Girls Club, the Canadian Mental Health Association and maybe two others that I cannot quite recall at this moment. That is the strength. There is diversity in the organizations that adds to that team building, versus “If agency A gets the contract, that will take away from me.” I think that is why they have had such success. People are knocking on their door. They are doing community-based research. They have staff exchanges. If a position becomes available in one agency, they can pull staff in from another agency. I think it is an extremely promising model and it does not mean losing your organizational identity. I am very excited by it.
The Chairman: Tell me is there an incentive other than fear of government? I do not mind using fear of government as an incentive. I would like to find a nicer one, but I am not averse to it.
Ms. Gutray: To be clear, it started as controlling your destiny. I would say that for the non-profit sector it is controlling your agenda. However, the success of the group is so profound that it keeps people motivated. Success was being able to serve a variety of people who come in the front door, knowing that there is a multitude of agencies. We all know this from mental health facts. We do not often come asking for help and only need one door. Sometimes we need two or three doors. That has worked very well. Now it is pride in the success of what they are doing that is the motivation.
Senator Callbeck: Do all the local NGOs belong to this co-op?
Ms. Gutray: It is those that wanted to come together.
Senator Callbeck: Right, but some have chosen to stay outside.
Ms. Gutray: It was an initial group of five or six non-profits. I am not sure how the co-op will address issues of other agencies wanting to join or agencies wanting to leave. At this point, they are in a very healthy development phase.
Senator Callbeck: When did this start?
MS. Gutray: I may not be correct, but I think it is two years old.
The Chairman: If it is working so well, is it being copied elsewhere?
Ms. Gutray: I hope that we can copy it elsewhere. We certainly promote it. At B.C. division we promote it as a model to other branches, other communities. Our own model at a provincial level is the work that we have done through B.C. Partners for Mental Health and Addictions Information.
The Chairman: However, from what you said earlier, it seems to me that if it is to work in Victoria, in Kelowna, wherever, you will have to have the right person on the ground to pull it off.
Ms. Gutray: That is true of everything, right? It is true in business. It is true in the non-profit sector. Somebody has to have the vision and be able to communicate it for the benefit of all, and I think we certainly have those elements.
The Chairman: That is exactly what has made this study so tough for all of us, because unfortunately, we cannot figure out how to legislate that.
Senator Cook: Just to continue with the current topic, change is inevitable and in this society we have to work by consensus, but I feel a certain amount of vulnerability here. I am part of a little group that looks after a social centre. We resisted the clubhouse concept for the same reason. We felt that if we gathered a group of us — and money is essential to everything that we do — that government would see it as opting out and our funding would be cut. Five or six agencies get A, B and C funding. If you come together as a group, you are in danger of jeopardizing that. Is that a reality? You have the vision, the drive and the concern, whereas, dare I say, government can be impersonal and look after budgets and balance sheets. Do you see that as a dark side?
Ms. Gutray: What I can report to date is that is not how it has been working. Any savings on the administrative side are from coming together and they have been able to convince their funders to invest in responding to new needs in their community. It may be too early to be sure, but there is no dissatisfaction reported at this time. That may be because it is very early in its development.
Senator Cook: Well, it is certainly a good news story, and if we are to embrace change that is the way to go, because as in everything, there is strength in numbers, and if the core group is together, then you are a formidable force.
Ms. Gutray: That is right.
Senator Cook: Susan, you talk about the need for a national action plan, and along with that you call for a women's mental health strategy. I am just wondering if it is not possible to develop a national mental health strategy that would be inclusive of the communities that you mention here other than women, because I believe that at the end of the day unless we can say “There is a place for you,” we will have failed. I look for you to think about the populations that we are looking at, whether it is possible to write a comprehensive plan that will address the needs of everyone, and maybe women's mental health would be included in it.
Ms. Friday: I remember back in late December when I had my first opportunity to study the report issued in November 2004. I was going through Chapter 5 that deals with prevalence and costs. In looking at specific population groups across the country, I noticed that there was mention of Aboriginal groups and some others. For example, I believe that seniors, veterans and inmates were mentioned. However, I noticed that there was no specific mention of gay, lesbian, bisexual and transgender communities, although the reality is that these groups suffer from higher rates of prevalence of disorders and substance abuse than the general population. That observation led me, in part, to formulate my presentation down the road.
Looking at a national action plan, I believe it is necessary, in conjunction with forming a national policy framework, to have a national database on rates of prevalence, in that if I understand correctly, the current economic burden on Canada is enormous. What is it, some $15 billion per year? That is a lot of money. That is a huge cost. I would say, quite simply, spending more money on promotion and prevention and perhaps not so much on the drug culture, the pharmaceuticals, would be a healthier way to go in the long term. I hope I have answered your question sufficiently. If not, please do not hesitate to let me know.
Senator Cook: I want to thank you for flagging that. You are obviously responding to something that we already have out there for consultation purposes and we just make sure there are no gaps left in the system.
Ms. Friday: Thank you.
Senator Cook: You have all mentioned in some way a mental health charter of rights. Well, I am a very simple person. At the moment we have the Charter of Rights and Freedoms. Depending on what province you live in, you have mental health legislation of some kind. Today we are out trying to put together, with the patience of Job and the Wisdom of Solomon, a national mental health strategy. Is it not possible to bring those elements contained in those other areas together so that it is practical, so that we can understand it, so there are no grey areas? I think that is the goal, and that is the information that we are looking for to put that together so we do not have to go to three or four places; you can say there is a place for you. The challenge is how to do that for 10 provinces and 3 territories. Do you see this as a realistic goal and can you help us get there?
Mr. Burnham: It was not my recommendation, but I will respond. I do not know if that means anything. There are some equivalents in the United States, the Americans with Disabilities Act and the Fair Housing Act. Both are important pieces of legislation that enshrine special rights for persons with disabilities to allow them to fully participate as citizens. The Fair Housing Act, for example, prohibits Nimbyism in terms of housing development; it is a sword that organizations can use to fend off NIMBY responses to housing activity. The Americans with Disabilities Act is a bit like our Human Rights Code and provides for accommodation for persons with disabilities and a lot of other elements.
Senator Cook: Did you want to respond too, Ron?
Mr. Carten: You mentioned bringing services of a type under one roof?
Senator Cook: No. I am saying that at the moment we have the Charter of Rights to give you your rights. Then you have provincial mental health legislation that takes care of you and gives you a certain piece of your rights. You are asking for a mental health charter of rights and we are advocating a national mental health strategy. I am just wondering if it is not possible to make it more seamless, if you like, so that we can have one aspect that takes care of the rights, because on the other end you have all the other parts to give it balance, like hospitals, counselling, medication, housing, poverty issues that seem to be converging on that one individual who wants to be a responsible member of society. That is my question.
Mr. Carten: I think the issue of a charter of rights might have been brought up because it was in the committee report as something the committee was interested in and you were wondering whether or not we were interested in promoting it. I think the charter of rights in that report was referring to rights to access. You have raised a large question, but the rights that I think of are to choice and personal autonomy. We can talk about a charter of rights for access to care, yes. In terms of protecting personal autonomy, it is actually the right to refuse to be cared for. The mental health legislation you mentioned accords rights and deals with caring for people. It actually more generally accords rights to the state or to psychiatrists in terms of what they can do to people. It does provide for an appeal tribunal, for example, for mental patients, and I have suggested there might be another appellate body beyond it.
One of the questions is who are the rights for? There are rights for the state over the person diagnosed with a mental illness, and there are rights that I am advocating people diagnosed with mental illness should have. Our Charter of Rights and Freedoms is the supreme law. It is good to have it there. It will always be there. It governs everything. It governs legislation. You say that you are talking about a national strategy and how these things fit into it. It is a difficult question, but I think one thing we can do is bring our mental health legislation, which purports to care for people and allots rights to the state and the patient, into line with the Constitution. As it stands now, psychiatrists are given a very wide discretion in interpreting criteria for detaining people, and it is a very difficult thing to deal with. You did not say you were talking about bringing all the elements under one roof, but I do not think that a strategy that will govern everything is actually necessary. I think that rights should be uniform across the country. For example, I am interested in patient rights, so I am interested in having tribunals, mental health panels across the country. I am interested in having an appellate body outside the hospitals across the country.
Senator Cook: So you would see that embodied in the strategy?
Mr. Carten: I would, yes. I think the federal government can play the same role it played in the welfare system in the provinces, in that in funding those systems, it has a say in how they are governed. I also think uniform standards would be fairer.
Senator Cook: You just led my thought processes into another area, and that is medicare, which we all say is universal. Well, I am sorry but it is not, because the formularies vary from province to province. Do you see us tackling that one so that at least people can have the right of access across the board? There is one drug for schizophrenia that is available in B.C. but not in my province. There are inadequacies in the delivery of care and the continuum of care.
Mr. Carten: I think the marketplace plays a role in making drugs available to people. I do not feel that the state has a role in regulating what options are available for people to choose from. However, with mental patients it is a little different. We do not choose. We have medications imposed on us, so access to the wide variety of medications that may be available, some of them in Ontario and some of them not in Quebec or Alberta, I find does not get to the root of the issues that I am addressing. I will leave it to my colleagues to respond to the rest of the question.
Ms. Friday: In regard to your comment about, for example, a drug for schizophrenia being available in British Columbia and not in another province, while I can relate to that to some degree — having access to a drug treatment plan can be beneficial — there has been over the years a countervailing argument against neuroleptic drugs. The standard argument is that neuroleptic medication is psychiatry's most powerful weapon against mental illness, but the essential problem, as I understand from the literature, is that it seems likely to cause long-term brain damage in individuals. It seems to cause long-term modification of dopamine neurotransmitters. That strikes me as a serious side-effect problem of neuroleptic medication. For example, let us say if a drug like loxapine is available in British Columbia but not in Nova Scotia, as a patient, I might be happy to be in Nova Scotia just the same.
Senator Cook: Far be it from me to speak about the value of treatment from a medical perspective. I am just looking for some uniformity here.
Ms. Gutray: I think the issue is finding the best evidence-based treatment, whether we are talking about medications or forms of talk therapy. We should think about them all in the same box and should they all be available from one province to the other. Obviously that would be a good thing. The other part of the equation is it is my understanding that the provinces have already started to work with the federal government in the area of what medications are coming on stream. That is my understanding. I may not be correct.
Senator Cook: Yes. It is a formulary that not only applies to drugs for mental illness.
Ms. Gutray: For everything.
Senator Pépin: I will pose my question to Ms. Gutray and Mr. Burnham and the others can answer if they feel comfortable doing so. After listening to you, I agree that you have a very positive approach to mental health, but we have heard about one problem. It has to do with the confidentiality regarding patients. I would like you to elaborate on it, because if you have a child or an adolescent or you are responsible for a parent who is mentally ill, it seems it is very difficult to get information from the doctor or from the health services regarding that person. As a parent, I would be really upset and perhaps even furious if a doctor did not want to tell me because of the confidentiality. I agree with confidentiality. I am a former nurse. I know what it is. However, I do not understand why, if you have someone in your family who is mentally ill, you cannot get information because of confidentiality. Could you explain to me how it works and how maybe it could be better adjusted or amended?
Mr. Carten: I can chime in if you like. Regarding children, I do not think confidentiality should be extended to exclude parents. Parents need to know about their children and have a right to know about their children. Regarding adults, I think we have to treat the mental patient, regardless of his relationship to his family, as an individual with rights and dignity, and therefore, notwithstanding the family's interests in their family member, confidentiality should stand.
Senator Pépin: Then who will help them to make a decision?
Mr. Carten: Well, you are questioning whether or not the person who is diagnosed with the mental illness can make a decision. There are such things as advance directives. The Representation Agreement Act of British Columbia provides for those, but explicitly excludes people with mental illness. If that right were granted to people with mental illness, they could appoint someone ahead of time to make decisions for them when they are not capable of doing so.
Senator Pépin: However, we heard about a doctor not wanting to give any information about a child of 15. Do you have something to say about it?
Ms. Gutray: I cannot comment on the situation with the child. I would support what Ron has said on the adult issue. When people with a mental illness are well, they are quite capable of naming someone to make decisions on their behalf when things do not go well.
Senator Pépin: However, for the younger ones?
Ms. Gutray: For the younger ones, no. I would not comment on that.
Senator Pépin: It seems that it is a reality in this part of the country.
Ms. Gutray: It just does not make sense to me that parents would not be involved in the care of their child.
Senator Pépin: Do you have anything to say?
Mr. Burnham: I do not think I have anything useful to say. I know it is a dilemma. I know they want to protect the rights of young people to make their own decisions. I find confidentiality is used far too often as a shield rather than to respect someone's rights, and we have not found the right balance. Frankly, I think with the new legislation and the national privacy legislation, it will probably get worse as people try to figure out what the new law means. I expect we will see confidentiality used more protectively than necessary, and as a result continuity of care will suffer and communication among people who should know, who have a right to know and need to know, will be compromised.
The Chairman: Darrell, by the “new legislation” you mean the federal legislation?
Mr. Burnham: Federal legislation as well as provincial.
Senator Cook: If I may, Mr. Chair, I guess when it comes down to it, you cannot legislate common sense, because I have had that experience. After my husband died, my daughter became very anorexic. It was a three-year journey. I just wanted to probe too much. She said, “Look here, Mom. Olga — her psychologist — says I do not need to tell you anything.” I said, “You go back to Olga and tell her that your mother, who brought you into the world, has some rights and ask her to reflect on it. By the way, does Olga have any children?” “No, Mom.” It took a while and I was patient, but one day I got a call asking if Olga could be part of Jane's therapy and I met Olga. It is difficult, but you have to be patient. At some point you have to assert your right as a parent, and I suggest that has to be done case by case.
Senator Pépin: Depending on the doctor, too.
Senator Cook: Well, whomever.
Mr. Carten: I would tend to agree on a case-by-case basis, but I think the rights to autonomy that have been gained in Western society are hard-won. Adults have a right to determine how they should be treated and what they plan to do with their lives irrespective of family wishes. An adult has those rights and they are hard-won rights.
The Chairman: The dilemma we do not need to debate. Generally I do not have any difficulty with your statement. The problem is what do you do when the principal caregiver is a member of the family, which is presumably a decision that the patient has made? I am just saying if that is a decision that the patient has made, it seems to me there goes along with that some responsibility for ensuring that the caregiver is in fact able to provide the appropriate level of care. If the patient does not want the family member to know, then the patient has every right to decide to say — there is a quid pro quo here — “I am fine. I just will not use the family member as the major caregiver.” That is the dilemma, because you are absolutely right. Forget about it being a family member for a minute. It is very hard to be the principal caregiver if you do not understand the nature of the problem and, therefore, the nature of the treatment. Yet the privacy laws, unfortunately, do not recognize that dilemma. First, they were never drafted with this situation in mind. This committee delayed their application to the health care sector for two years because they were never designed for that sector. That is problem one, but that is past history. Had they been designed for the health care sector, inevitably they would have been thought of in the context of the physical care, the hospital/doctor system, in which case information going to the caregiver is going to a doctor, a nurse, for whom it is quite legitimate to exchange information. The problem is the vast majority of mental health care is not given by hospitals or doctors. None of the privacy acts ever contemplated that a “health care service” would not be given by a “health care professional.” That is the dilemma. That is the root cause of the problem. It is that problem that we are juggling with, just to give you the background, which is not to disagree with anything you said.
Mr. Carten: Access to care is important in that situation. We need to make mental health care more readily available to people and make them less afraid to reach out for it.
Senator Gill: In those cases, maybe people should have alternatives in terms of who will represent them. I think there should be alternatives to make sure that people are being responsible for their own treatment. This is the freedom we should have. Maybe this is the alternative.
Mr. Carten: I think one of the issues is advance directives are generally dealt with in provincial legislation. I think the committee is quite correct in saying we need a public relations campaign, as in Australia, for example, but we also need to make people aware that a legal alternative such as that is available to them.
Senator Trenholme Counsell: It is my understanding that most of the initial crises in bipolar disease and schizophrenia manifest themselves in the late teens or early twenties. Now, do you think it is reasonable to expect that somebody at 16 or 17 or 18 will make this decision about an advance directive? It is very different as we go on in life and face becoming old. However, I cannot see the practicality of what you are suggesting, because once this crisis hits, it usually involves certain elements that require intervention that maybe some might describe as force, but where there is a loss of insight on the part of the patient. How can what you are suggesting be applicable to these first, sudden crises in severe mental illness?
Mr. Carten: When you refer to people of age 16 or 17, they are under their parents' care at that point and their parents can direct their health care. Am I not correct in that?
Senator Trenholme Counsell: In New Brunswick and some other provinces, not after the age of 16. I do not know what it is in B.C.
Mr. Carten: Well, I would say the law is the law and imposing something like detention on someone is controversial. It is a problem.
Senator Trenholme Counsell: However, if we were to follow through on your suggestion that people should have the right to designate who will speak for them if they cannot speak for themselves, I am just looking at the practicality of that, how it could happen. If young people have a bipolar manic crisis at age 19 or 21 or 22, do you think that in practice, they would have thought this through?
Mr. Carten: I see what you are saying. When a person is in a crisis, it is questionable whether they can make an advance directive; but if these issues are sufficiently publicized, people will realize or should realize that their health care is very important when they are in a position where they cannot make decisions for themselves. Parents should even encourage their children to get an advance directive for such situations as mental health care, a car accident, skiing accident or whatever.
Senator Trenholme Counsell: Your point is well phrased. That is something that society needs to advance. I wanted to ask about this psychosocial rehabilitation. How does that differ from being a psychiatric social worker?
Mr. Burnham: Well, it is interesting. There is very little training in PSR for psychiatric social workers, or even in psychiatric nursing. I heard the other day that it was only a few days of training in both of those fields, at least in B.C. Psychosocial rehabilitation is a field of study. It is a way of approaching and providing services and support for people with mental illness. Psychiatric social workers are professionals who work in psychiatry as a social worker. They are using the practice of social work in the field of psychiatry.
Senator Trenholme Counsell: I have been trying to understand this. The model is that you have mental health clinics in which there are psychiatrists, psychologists, mental health social workers, et cetera, and that these become the first point of service, and then community agencies and so on may certainly be involved. Are you suggesting that the model you recommend should replace that?
Mr. Burnham: No. Clinics can operate with a PSR model, a wave approach and philosophies and principles, and even a staff team who promote that. Actually, the mental health clinics run by the Vancouver Coastal Health Authority often use PSR models as a way of supporting people. They also use other models.
Senator Trenholme Counsell: You mean the psychosocial?
Mr. Burnham: Psychosocial rehabilitation.
Senator Trenholme Counsell: No. I am not talking about that. That is a school of thought unto itself. I am just talking about in the case of B.C. and your Coast Foundation Society; do you get funding from government?
Mr. Burnham: Yes.
Senator Trenholme Counsell: What percentage?
Mr. Burnham: About 60, 65 per cent.
Senator Trenholme Counsell: Do you complement the mental health clinic?
Mr. Burnham: Yes, we do. We wrap around the clients. We provide services. People live in our housing, but they seek clinical services through the local care teams, private physicians, private psychiatrists, or through their own methods.
Senator Trenholme Counsell: However, they can go back to the mental health clinic, to the psychiatrists they had in the beginning or whatever.
Mr. Burnham: It is an adjunct to the formal clinical system.
Senator Trenholme Counsell: Some members of this committee are in favour of buying the services. I am not, so that is another thing we talk about in the committee. Ron, you said mental patients do not choose their medications. Do you feel you are singled out in that case? Because I would say that a patient with heart failure does not choose his or her medications.
Mr. Carten: Actually, I have been a mental patient and I do choose my medication.
Senator Trenholme Counsell: However, do you feel that there should be different arrangements in terms of how medication is decided upon? Do you think it has to be different for mental patients, cardiac patients, cancer patients, diabetics, et cetera?
Mr. Carten: Who is doing the deciding in that case?
Senator Trenholme Counsell: Well, I am asking you. Should it be different?
Mr. Carten: Well, I think it is a very difficult situation. In the long term, mental patients should be made aware of the benefits and risks involved in the medication or treatment with which they are being provided.
Senator Trenholme Counsell: Yes, but so should a woman who is intending to take estrogen or somebody who is intending to take a pill for cholesterol or Accutane for severe acne or whatever it is, an entire list of things. I think that is the responsibility, to know the pros, the cons, what could be expected, the side effects.
Mr. Carten: That is informed consent.
Senator Trenholme Counsell: It is not really informed consent. That is when you go to a dentist and you are told you might get a paralysis of your nerves. You sign a paper or whatever. That is really consent. I mean I do not think it goes that route in an ordinary clinical setting; you do not actually write your consent to have a medication prescribed for you. I think informed consent is a little more of a legal procedure.
Mr. Carten: In B.C., there is no form that needs to be signed. It is just a responsibility on the part of the physician to provide four or five basic elements in treatment.
Senator Trenholme Counsell: That is right — to explain the drug to the patient.
Mr. Carten: Drug treatment, any kind of treatment, yes.
May I ask if one of our members may make a comment?
The Chairman: As long as she uses a mike.
Ms. Lara Pole, Member, Vancouver-Richmond Mental Health Network: I am Lara Pole and I am a member of the Vancouver-Richmond Mental Health Network. I just wanted to respond to what you said about younger people appointing someone to make decisions for them. I think the problem with the current psychiatric system is the model is really, if you have someone in a crisis situation, to lock up and drug first and then listen later. What happens is you can get someone involved whom you trust. That person will have some sort of rapport with you. That person will know you and will be more likely to listen to you, know where you are coming from, and get a better sense of what direction would be helpful in terms of your health. Even if you are 16 years old, you know whom you relate well to. You know whom you can trust. I do not really see a problem with younger people. In this province I think it is 19 anyway, but I do not see a problem with people who are less experienced in life choosing someone who can liaise for them.
Senator Trenholme Counsell: Oh, no. I think it is good that that choice be made. I am just saying that most young people of 16, 17, 18, think that they are well. They are not thinking about serious illness. It is the rare young person who would be thinking about serious illness. This is why we cannot talk to young people about smoking causing cancer. They cannot make that jump in time, especially if it is personal. I am just talking about the practicality of having been confronted. I think that Ron has given us a very good example of how we might be able to do this, because he used the analogy of a car accident. That is very relevant. However, right now, if you have a manic episode at 19, you probably have not thought about it beforehand. That is not to say that we could not do better, and as soon as people reach the age of majority, they make a decision.
Ms. Pole: Right. I think that is interesting and I did think about it, although it is not only a question of that. It is a question of if you have had that first episode at 19, then you have thought about it. Then when you are nineteen and a half and you are better, you are in a position to appoint someone.
Senator Trenholme Counsell: I think that is very relevant. We are probably not doing that and this would be a step forward in society.
Susan, I wanted to ask you about the statement “Women are almost twice as likely as men to experience depression and anxiety.” I know that women are almost twice as likely as men to seek help, but on what is this statement founded? I think men have a great deal of anxiety. I just wonder whether this is correct. Women are in doctors' offices more, but do men deal with their anxiety in different ways?
Ms. Friday: I will be happy to speak to that question. If I might quote from a Centres of Excellence for Women's Health Research Bulletin, which I happen to have with me, it says:
The women's health movement and three decades of health promotion, research and practice have demonstrated that women's health is inextricably linked to the context of women's lives.
In other words, I think one of the main reasons women are likely to seek help, whether it is a doctor's office or counselling or a safe house, is the very real social factors, the social determinants underlying the problem.
Senator Trenholme Counsell: However, do you have a source for saying that women are twice as likely to experience anxiety as men?
Ms. Friday: I got that statement out of this research.
Senator Trenholme Counsell: Is it in there? I just would like to know if there is a source.
Ms. Friday: I got up at 4 a.m. this morning to do my write-up.
Senator Trenholme Counsell: I am not usually out there defending men, but it probably sounds that way.
Ms. Friday: I would say I am capable of considerable empathy for the men folk out there. Yes.
Senator Trenholme Counsell: I think men have a great deal of anxiety.
Ms. Friday: I can well understand. If you briefly observe the human condition at large and the fact that we are all human, I think there is a great existential foundation for the angst that we sometimes feel. There is no mistake about it. Being human is a complex, stress-riddled affair.
If I may, I would very much like to speak to the comparison between being on estrogen and being on an antipsychotic medication. I can definitely speak to the estrogen. I am currently taking estrogen and Provera. They are both female hormones. Being on estrogen is to a great degree a physical issue, although part of it is mental because there are receptor sites in the brain where the estrogen can reside. Therefore, it affects mood to some degree, but I think it is mostly a physical thing. For example, estrogen can make the blood somewhat thicker. In my case I have to take a blood thinner like vitamin E once in a while to make sure that I do not have a heart attack or a pulmonary embolism or something.
Now, let us say I was in a state of crisis and I was admitted to a psychiatric ward, and a doctor, a psychiatrist, without consulting me, wants to decide what kind of antipsychotic medication I should be on. Let us say he decides that I should take a medication like Seroquel or loxapine, which are both neuroleptic medications, and he does not tell me anything about the side effects. I have to go and find out for myself what they are. I can say okay, on the one hand, with estrogen there is some risk of blood thickening and you have to deal with that. Now, with the neuroleptic and antipsychotic medication like, for example, Seroquel or loxapine, right off the bat there is a serious issue. It is called neuroleptic malignant syndrome, in which you can get hyperthermia, which is a greatly increased body temperature that can cause you to suffer from serious dehydration and cellular damage.
Getting back to dopamine neurotransmitters, you can suffer from permanent alteration of dopamine neurotransmitters in the cortex, which can lead to permanent alteration of the personality, especially with long-term use of these antipsychotic medications. I think there is a definite risk that your personality will be altered in the long term, in that your capacity to feel empathy towards other human beings could be affected. You might become a more indifferent person.
Senator Trenholme Counsell: In fairness to the debate, do we not have to differentiate between the acute drug therapy, when you or any other person cannot decide, and the ongoing therapy, where you should have a role in the decision making? Would you agree that that is fair?
Ms. Friday: Some people would argue that if it is an acute crisis and you are administering antipsychotic medication, it will only be for the short term, just for a few days. However, there is a danger that the patient might get trapped into or hooked on the medication and find it increasingly difficult to get off it. Some people would argue it might be best simply never to be on the medication in the first place.
Senator Cordy: Bev, you said 5.4 per cent of British Columbians have mental health care needs. Out of those, 76 per cent identified acceptability of services and supports as a barrier. What exactly do you mean? Is it that the supports are not meeting their needs? I wonder if you could just clarify that for me.
Ms. Gutray: I wish I could. I think that is one of the pieces of research that we need to really begin to understand. In the StatsCan survey, people are saying, “Yes, I have a problem, but no, I would not go for help.” Now, it may be a range of reasons, and I think that is a piece of research that needs to occur, because often we have built our mental health systems around the idea that we need more. There has always been a “more” dimension. If we just had more services everything would be better. Even if you add more, if it is the same thing, it will not address why people are not coming for service.
The Chairman: I used to be in the market research business. The danger in that question is that it could simply reflect a level of expectations on the part of clients that is so high you would never be able to produce services that are acceptable. Therefore, with that 76 per cent floating out there, it is critical that we understand what it means in the real world.
Ms. Gutray: I agree, and that is why we are talking about the research that needs to be done.
The Chairman: Do you know if anybody is planning to do that?
Ms. Gutray: No, not that I know of. It may be that you could recommend that somebody do that.
Senator Cordy: You would like that to be in our report. However, it is a high percentage, as the chairman has said, 76 per cent of the people who are in need of services.
Ms. Gutray: We do not know what that dimension means. It could also reflect the level of shame, discrimination.
Senator Cordy: That is true, and that is my next question. You have also raised the question of stigmatization that certainly we have about heard over and over. You spoke about a two-day training program that the Vancouver-Burnaby Branch of the CMHA is doing. Who takes this program? Do you just advertise it and people take it, or is it focused on people involved in the system?
Ms. Gutray: The target group of the mental illness first aid program is actually other service providers, so it could be the sheriff’s department. It could be the income support workers. It is people who have a lot of interaction with people with a mental illness and most often do not have a lot of accurate information on what it means, what are mental illnesses, and what are some very successful supportive things that they can do.
Senator Cordy: How did you determine that their confidence in recognizing and responding jumped from 30 to 90 per cent? What method did you use to test it?
Ms. Gutray: It was a survey.
Senator Cordy: Just after they finished the course?
Ms. Gutray: Yes.
Senator Cordy: Was the survey taken the day of or two weeks later?
Ms. Gutray: It was taken shortly after.
Senator Cordy: The day of. Okay.
Ms. Gutray: You are speaking to the need for another piece of research that needs to be done, and we all know that, but it is a relatively new program. It has had a positive response. I think the unique feature is that the co-trainers are a professional and a person with mental illness, who are compensated, who are seen as professional team leaders.
Senator Cordy: It is a great start. Do people volunteer to take this program or are they selected?
Ms. Gutray: They are selected.
Senator Callbeck: I have a couple of questions dealing with Darrell's brief, but anybody can comment on this: the sentence “…non-profits are more likely to deliver services more cost effectively, not relying as heavily on scarce, licensed professionals…but experienced college level practitioners.”
Mr. Burnham: Well, to be honest, if you have 10 people on the ground delivering service and the average wage is either $35 an hour or $20 an hour, that is the difference. If you have one licensed professional overseeing the nine other workers, other colleagues, there will be a huge difference in terms of the cost of delivering service. The other point is if you integrate peer support workers or train clients in that role, it changes the service profile. It is often more acceptable to clients. Services that are run through non-profits or are community based are often more accessible. They are not seen as threatening. There are no psychiatrists on-site, so the idea of a pink slip coming out and sending someone away is generally not in the picture. You can foster a lot of informal supports, peer-to-peer support. In a lot of the group settings, people find their solutions not necessarily from the professionals, but from someone next door who has dealt with the same issue and may have figured out a way to overcome it. There are a lot of ways, not just five professionals delivering a discrete service. Does that answer your question?
The Chairman: It is worth putting on the record here that it just so happens in the last two weeks two studies have been released, one by the Alberta Auditor General and one by Eleanor Kaplan, who used to be the Minister of Health in Ontario, but was doing this as a royal commission. They both did studies into the delivery, in this case, of home care services in their respective provinces. Both studies had a clear conclusion that states that the ownership structure of the home care service has no bearing at all on either efficiency or quality. In both cases, they looked at a full range. They looked at government-owned services. They looked at not-for-profits and at for-profits. Their studies were actually of something else, but they concluded categorically that they could find winners and losers, good and bad in all three systems, and that the ownership structure was irrelevant to the quality of care. I just thought you ought to know that. My guess is if that is true in home care, which is probably the social service with the greatest range of types of suppliers, it is no evidence.
Mr. Burnham: A range of discrete services too.
Senator Callbeck: Who are the experienced college-level practitioners? What do you mean by that?
Mr. Burnham: Normally, a two-year mental health certificate at Douglas College. We often have a lot of people with degrees in psychology or degrees other than registered social worker. Normally, it is two years or more of college. We also have masters-degree students, but they are masters in psychology and are not registered.
Senator Callbeck: You say there is a two-year course?
Mr. Burnham: Yes.
Senator Callbeck: I also wanted to ask about PSR. I do not understand what you mean by the PSR approach.
Mr. Burnham: It is a philosophy of service. It has many principles that help the clients direct their own care, where they want to go with it. It provides some principles of self-determination. I should have brought a list of the principles.
Ms. Gutray: I can add a little. Psychosocial rehab is grounded in a lot of occupational therapy training. There is a base to it. Unless it has changed, the training was originally out of Boston University, with people like Marianne Farkus, et cetera. It is really about belief in rehabilitation. It is a rehabilitation approach, a recovery approach, an approach in which service providers are trained to work with people on what their hopes and dreams are versus what traditionally a lot of service providers have believed people can accomplish. My information may be a bit dated, but that is how I understand it.
Senator Gill: I do not want to start a long discussion, but you know that in society we have different groups with different values, cultures, education and things like that. I would like to know if Aboriginal people are involved in your networks or association. I know the Aboriginal people of this province are receiving services of some kind.
Ms. Friday: I could speak briefly to that question. At the Vancouver-Richmond Mental Health Network, as the central core of our network we have 11 facilitated groups with group leaders. One of those is a native group. They engage in a native talking circle. Any consumer/survivors who have a native background, and others as well, are welcome to join the group so that they can have their say and engage in a healing process of mutual support, a form of peer support. They can talk about their issues openly and receive support.
One thing I could briefly add is the client-centred approach is extremely valuable both for recovery and creating an atmosphere of psychological safety so people feel free to move in any direction.
Senator Gill: I want to know if they receive some services or attention from groups here.
Mr. Burnham: Certainly in the Vancouver area, the Musqueam Band receives services through a mental health team and has supports on reserve. There are many Aboriginal people in the downtown core, probably a disproportionate number, who are receiving services either through the Aboriginal support system or through mental health systems like ours. We have a number of members.
Senator Gill: Does the provincial health system apply to them?
Mr. Burnham: Off reserve.
Ms. Gutray: I can just comment on what we do as an association. We certainly work in partnership with a number of bands when we have our National Depression Screening Day, which rolls out across the province. There is a fairly high component of Aboriginal people involved in the delivery of that program. It is not enough, but it is one indication of our trying to reach out to the population.
Senator Pépin: I would like to quote you.
The funding body can work to increase the benefits and minimize the problems associated with NGOs by creating incentives for collaboration as opposed to competition.
The Chairman: What is your reaction to the idea of effectively putting a condition on an organization getting public funds that they must, in fact, cooperate? You said that the original driver of cooperation was fear of what the provincial government was planning to do. Do we incorporate that into an ongoing process by saying if you want support, you have to play the team game? We thought we would save the best question for last, like they do on the quiz shows.
Ms. Gutray: It is such a big question. Different models work in different places, and I will use a different model to respond.
The B.C. Partners for Mental Health and Addictions was a model where we were all forced to the table to work together, so it was not a voluntary partnership. As mental health and addictions agencies, there was an additional dimension, because many of us believed we could do each other's work just as well. That has been a very difficult partnership because there has been a difference in values from one organization to another that we have had to come to terms with, and are still coming to terms with. Also, because the funding environment was completely destabilized, it was unclear whether the ship we were jumping on would sink or float.
Yes, collaboration should be the preference of the funder. However, the analysis of the groups that you are pulling together has to be done very carefully because not everybody will make good partners. In Williams Lake it did not come from the funder. It came from the groups, who said “We have to control our response to the funding environment. We have to take charge of this.”
I guess I am saying that you can prescribe — it is just like writing a prescription — but you will not find that the same medication works well in two different patients, and more likely the co-op model will work well if it is prescribed for some and not others. There are different dimensions, and that is what I was trying to point out.
Senator Pépin: I agree with you that, depending on where you are, the approach could be a little different, but maybe the fact that it is mandatory funding forces people to work together, and after that to exchange information. Do you believe that sharing should be mandatory if you want to get funding?
Ms. Gutray: Do I believe it? No. I think it should be strongly suggested. It should be something that you consider in your funding application.
The Chairman: You like the godfather approach rather than mandating it?
Ms. Gutray: Yes.
The Chairman: Make them an offer they cannot refuse.
Senator Pépin: We went to Brandon, Manitoba, last week and they told us that they closed a hospital and now they have started a system whereby they are collaborating and sharing information and it really works very well. You have an approach also.
Ms. Gutray: Right. Absolutely.
The Chairman: I will ask you for a comment, Darrell, but since Senator Pépin mentioned Brandon, you would love the fact that what they have done is essentially create a single point of entry to the entire system. You know what forced them into it? There was only one psychiatrist in the entire Brandon area so, in fact, all the services had to be provided by people who were not sick. You would have liked the model. It did not force the cooperation, but the right personalities came along to make it work and now it is unbelievable.
Mr. Burnham: I think some financial inducements often work better than a more challenging response. For example, if there was a way to keep the savings from collaboration, the ability to say “If you can organize yourself more efficiently, we will not claw it back.” Where is the motivation there? That can either be pooled or the savings kept individually. That would be a very strong inducement. It does not cost any more, but there is some motivation, a reason to try to find a way to make it work, because our experience with partnerships is they are all different, and it is like a marriage. If there are five organizations, it is a marriage of five people, and you know how hard it is with one sometimes. With four or five, you have to work through it. To legislate it, to me would be scary.
The Chairman: So it is a real motivation.
Ms. Gutray: That was the model in Williams Lake. They were allowed to keep the savings and reinvest them in other areas as they decided. It is important.
The Chairman: I thank all of you for coming.
Do you want to say something, Ms. Nazif? I know you appeared before the committee this morning, but we would love to hear from you.
Ms. Joan Nazif, Chair, Family Advisory Committee of Vancouver Mental Health Services: I would like to make a comment about people having to take medications. My daughter was 27 when she became ill. She was not a child. She was extremely delusional. She was on the streets of Vancouver. She contracted cellulitis. It was suggested that she should go to St. Paul's Hospital every week and get an intravenous antibiotic, and that was all anybody was prepared to do for her. She contracted cellulitis because she had a mental illness. She needed neuroleptic medications. Unfortunately, she needed almost two and a half years in hospital because she was refractory. People who are psychotic need treatment. It is fine for those of us who are well enough to decide if we want to take medication. My daughter would be dead today if she was not put into enforced treatment. She would be in the cemetery, so for goodness sakes, let us be sensible about this. There are times when we need to prescribe treatment and medication against people's wishes. She did not want to be treated.
The Chairman: Thank you for that.
Ms. Gutray: I would like to respond, senator. There is mental health legislation in every province that says there is a time when we have to intervene. I will use our own act as an example. We have a community committal provision that allows people who have a mental illness to be committed while living in the community. However, that provision does not take individuals' direct experience with previous treatments into account. If I have not been compliant in the past, it might have been because of the side effects of the medications or the combinations. What I hear Ron saying, what I definitely hear family members saying as well, is it needs balance. It needs a reasonable, balanced approach. Thank you.
The Chairman: Thank you all for coming.
The committee adjourned.