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Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology

Issue 18 - Evidence


OTTAWA, Thursday, June 12, 2003

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 11:04 a.m. to study on issues arising from, and developments since, the tabling of its final report on the state of the health care system in Canada in October 2002. In particular, the committee shall be authorized to examine issues concerning mental health and mental illness.

Senator Michael Kirby (Chairman) in the Chair.

[English]

The Chairman: Honourable senators, we are here to continue our study on mental health. We have four witnesses this morning. Our first witness is Mr. Jean-Yves Savoie, President of the Institute Advisory Board of the Institute of Population and Public Health, of CHIR. We will then hear from Mr. Rod Phillips, President and Chief Executive Officer of Warren Shepell Consultants, who are large in EAP work. Third is Mr. Kevin Kelloway, Director of the CN Centre for Occupational Health and Safety, based at Saint Mary's University in Halifax. Finally, we will hear from Ms. Patti Bregman, Director of Programs for the Canadian Mental Health Association, Ontario Division.

We would ask you to succinctly summarize your presentations. You will discover that our committee likes to ask questions. We can always read your paper, but it is useful for us to be able to exchange in a dialogue with you. We will hear from all four of you and then we will go to questions.

We will begin with Mr. Savoie.

[Translation]

Mr. Jean-Yves Savoie, President, Advisory Board, Institute of Population and Public Health, Canadian Institutes of Health Research: Rather than dealing with the subject of the brief I tabled, I would like to show how it came about that we prepared this brief. To do so, I will be taking a few minutes of your time to talk about my career and my involvement in the workplace. You will then be able to understand the connection between the two.

Thirty years ago I began working in occupational health in the field of toxicology. The thinking in the workplace at the time was that there were contaminants and there were intoxications; this was seen as a dichotomy with a direct causal link. There were workers who were intoxicated. Research demonstrated the toxicity of certain products. Standards were established and applied and there was a significant drop in exposure in the workplace. We can see here a simple relationship between research, application and legislation.

During the 80s, people in the workplace asked me why I was working solely in the field of toxicology and did not deal with matters such as back problems that were recognized as a major problem. I was asked why there was so little research on back problems and so little information on what could be done to treat them. We can immediately see the difference between a toxicological problem where a particular substance causes intoxication and backaches with their multiple etiology. We are talking about the less evident consequences, on the one hand, as well as the entire process that a workplace accident victim goes through. According to a study carried out at the time, 7 per cent of workers with back problems accounted for 70 per cent of the entire costs paid by the workplace safety and insurance boards of Canada for this pathology. Who were the workers making up this 7 per cent? They were people who were lost in the health system and forgotten by the compensation system, several of whom ended up with mental health problems. The boards referred to them as the psychiatric cases. We can see that a toxicology problem became much more complicated when back problems were factored in.

Since that time a certain amount of research has been done and action has been taken. There has been a lot of interaction between research and stakeholders, in particular the workplace safety and insurance boards, hospitals and rehabilitation centres. We can see that an integrated approach was adopted for prevention on return to employment.

During the 1990s, I was the director general of the Quebec Institute for Research on Health and Workplace Safety. When we visited companies, we were told that they were not so concerned about back problems, but absenteeism and mental health problems. We can see that over the period of 30 years three major stages developed. In the case of mental health we are dealing with multiple etiology. What can we do? There is stigmatization in the workplace and a great absence of scientific evidence, notably with respect to the return to employment of people with mental health problems, in some cases before such problems develop into mental disorders.

The connection I wish to make is the following: if research can help us with back problems in the same way as it helped with toxicology, it seems to me it can also be of significant assistance in dealing with the whole range of mental disorders. The Canadian Institutes of Health Research, with which I am associated as president of an advisory board of the Institute of Population and Public Health, set up a working group that should be developing a research agenda for the future starting next year.

There are a few points I would like to make. Contrary to toxicology and to some extent back problems, mental health in the workplace is already an issue of some conflict. There is the matter of compensation that comes up and as you can understand, for certain workers the recognition of their mental health problems should automatically result in compensation from the workplace safety and insurance boards. Employers do not know how to manage the situation. They are aware of the extent of the problem and quite obviously they are worried about the enormous costs that go along with it.

In discussing matters of mental health, we are not dealing with something that is cut and dried. My board of directors was made up of seven employers and seven union representatives and I can tell you that it was not smooth sailing. It is an extremely interesting subject and we have been able to make great progress.

The solution will certainly require involvement on the part of the workplace. We cannot consider the workplace as if it were a school or a hospital. It is an entity in itself, a family with its own rules and its own way of behaving and we cannot do without its involvement.

Is there some way of bringing closer together those involved in research and the stakeholders? We must realize that we cannot remove the problem from the workplace but we can take a worker out of his workplace and refer to him as a patient.

I have no choice then but to work with the different workplaces and their representatives to come up with regional solutions. The experience with back problems, among other possible examples, demonstrates that when research is accompanied by action — we must emphasize the importance of action because urgent measures must be taken — the knowledge at our disposal increases. When there is this increase in the knowledge available, then the problem of disagreement or conflicting views is not as serious because of a better understanding of the situation. The example of the treatment for back problems, something which is now facilitated by the Canadian Institutes of Health Research, illustrates the way in which interprovincial and multidisciplinary research can be useful in the field of mental health. That is the proposal being made by the group of institutes in their brief.

[English]

Mr. Rod Phillips, President and Chief Executive Officer, Warren Shepell Consultants, Global Business and Economic Roundtable on Addiction and Mental Health: It is a pleasure to have the opportunity to speak to you about mental health and the role that Canadian employers can play in that. I am here representing the Global Economic Roundtable on Addiction and Mental Health, and also as the president of our country's largest provider of employee assistance programs. I will deal with some of the statistics and information that the roundtable provides as well as a perspective as a private sector provider of mental health services.

Former finance minister Michael Wilson and former Liberty Health CEO Bill Wilkinson founded the roundtable in 1998 after reviewing a study that had been produced by the Harvard School of Public Health and the World Health Organization. The study dealt with the effects of depression and mental health and projected that mental health — particularly depression — would be the second leading cause of disability in the world by the year 2020.

The roundtable produces information and analysis and it brings together about 100 of the most senior business leaders in Canada to talk about mental health as an economic issue and as a business issue, under the leadership of Mr. Wilson and Mr. Wilkinson.

Drawing attention to these issues, the roundtable reported that mental illness costs Canadian businesses an $11 billion in lost production every year. Furthermore, burnout, stress and disengagement probably you can double that number.

There are a few other statistics for which I provide the sources in my background material. Major insurers such as Manulife, Great West Life, Sun Life estimate that upwards of 40 per cent of their disability claims now have a mental health component. That is a very big number if you think of the amount of money that employers are spending around disability. Absenteeism in Canada averages about 8.5 per cent according to Stats Canada. It is estimated that over half of that is related to mental illness or mental health issues such as stress. Something called "presenteeism" — the workplace version of absenteeism is when people are there, but they are not there, if you know what I mean — is estimated to affect about three times as many employees as are absent. A recent Gallup study said that about half of all workers are disengaged as a result of stress and other things in the workplace. Finally, about 14 per cent of the net annual profits of companies in Canada is lost as a result of mental health issues.

These represent some big numbers for business and, therefore, for Canadians. We, at Warren Shepell Consultants and at the roundtable, believe that the linkage between the health of workers and the health of the economy is quite close.

I would like to touch briefly on mental illness, mental health and our definition of those terms. Mental illness is a series of diagnosable mental disorders: Depression, substance abuse, and other mental illnesses that prevent people from remaining in the workplace or being productive.

Mental health is basically a state where people can be optimally productive and effective. Good mental health or wellness is defined usually as an active process of becoming aware and making choices towards a more successful existence encompassing physical, social, occupational, intellectual and emotional aspects of living.

We differentiate between "mental illness," which is a portal though which people enter the systems that help them — and is something our company does not deal with — and "mental health" — which is what we do in helping Canadian employees and their employers maintain a high level of productivity in their workplaces.

Organizations such as the Centre for Addiction and Mental Health, the Canadian Mental Health Association, and the Canadian Psychiatric Association estimate that approximately one in five Canadians — close to 20 per cent — will be affected by mental illness. We know that the number of people who do not have optimal mental health is much higher than that.

Health Canada suggests that only about one in ten individuals with mental health disorders receive proper diagnosis and care. This happens for a variety of reasons that I am sure you have heard, around the shortage of services and other factors. Effectively, it means that many people are not getting the service they need.

In the workplace, the concern is that a majority of people not receiving treatment are also employees or potential employees. Given recent estimates that about 75 per cent of the new jobs in the economy have to do with cognitive ability, not physical ability, and that the heavy lifting in the economy is now being done with people's minds, not with their backs, this aspect of mental disability is more significant than it might have been a number of years ago.

With respect to mental health, we need to think of the workplace in four ways. First, workplaces are a portal for mental health services, where the majority of working Canadians have access to some form of wellness or employee assistance programs. It is a place wherein both employees and often their dependents can get some sort of support.

Second, the workplace is an environment where mental illness and a lack of mental health can cause significant harm and significant cost. There are issues around substance abuse as well as lost productivity.

Third, it is an environment that may — directly or indirectly — contribute to the level of stress in society. Many of the issues that are are causing some of the mental health issues that you will be hearing about are related to changes in the economy and the general stresses around people needing to make a living.

Finally, through their health promotion programs and leadership, employers have the opportunity to help reduce these types of stresses. It is a portal for existing services, but it is an opportunity as well for the future.

Employee assistance programs, EAPs, play a role in the current system of how mental health is delivered in Canada. Essentially, they provide professional assessment, short-term counselling, and referral services as a benefit to employees. In most cases, Canadian EAPs also cover employees and their dependents, similar to drug or other employee benefit plans.

Warren Shepell Consultants is one of the original EAPs. We are also one of the 10 largest employee assistance program providers in North America. To give you a sense of scope, this year, we will deal with about 300,000 clinical sessions for people, through about 1,400 counsellors that we have across Canada through 84 offices. Our experience has been that the need is growing, and that the issues people are facing are more severe. There are many similar providers, so you can multiply that across a whole industry and see that there is a significant private sector component in terms of delivering these programs.

Between 60 and 80 per cent of Canadians who are employed in a medium- or large-sized company, which is over 500 employees, have access to some form of an employee assistance program. There is already a group of people who have access to this sort of short-term program. In fact, EAPs have become the primary portal through which working Canadians often get their first access to the mental health care system.

In many cases, in our experience, you would have about 85 per cent of the people who we see in a given year getting sufficient treatment through the EAP program that they would require no further treatment. About 15 per cent of the people would then be referred into community programs or into the public health care system.

EAPs also have a strong prevention component. Much of the work being done with employers focuses on wellness programs and other preventive aspects that would support a good, healthy, mental health environment.

We would suggest that employers are already bearing a significant burden of the costs associated with mental health in Canada. In that sense, they are subsidizing what we have in the public health care system and, in some cases, compensating for deficiencies in that system. The employers have a vested interest to support a strong mental health system as a result of absenteeism, or loss of productivity, and financial losses. We would suggest that there are opportunities for them to be partners in this and that the committee should consider those opportunities — whether through things such as joint service delivery or tax incentives or other aspects of legislation that could support the existing network of therapists and people providing short-term counselling.

As you look at these issues and ways to alleviate the costs and consequences of poor mental health, we would suggest that the EAPs and other aspects of the health and wellness industry could play an important role in providing both an existing clinical network and an understanding of mental health issues in the workplace.

We already collect and analyze information based on our clients' experience and share it with individuals. We distributed a recent study we did around stress in the workplace as part of this presentation, which showed a 10 per cent increase in people reporting high stress in the workplace over the last three years.

We can share a lot of information. Through groups such as the Global Business and Economic Roundtable on Addiction and Mental Health and through committees such as this, we think the EAP industry can be very supportive of the objectives of your committee in terms of ensuring optimal mental health for Canadians.

Mr. Kevin Kelloway, Director, CN Centre for Occupational Health and Safety: Honourable senators, thank you for inviting me here. I am associated with Saint Mary's University so I am an academic by background. I will try to hit the highlights in my talk today.

Sigmund Freud was asked what a healthy person should be capable of. His answer was telling for the work of this committee. He said that a healthy person should be able "to work and to love." That association of work and health has been central throughout history. In this century in particular, a much research has accumulated on the effects of work stress on both mental and other forms of health.

Issues of mental health are not confined to the psychological or the mental domain. There is a large body of literature relating issues of stress and issues of mental health to a wide variety of outcomes. There are certainly psychological outcomes; there are disturbances of affect and cognition at the low end — at the level of just having a bad day. At the high end, we are into clinical disorders and clinical depression. We have heard some statistics on the increase in those disorders.

We also have a variety of other outcomes. There are very direct and well-established links between psychological stress in the workplace and coronary heart disease. The Whitehall studies — studies of the public service in the United Kingdom — suggest that individuals who worked in a job that allowed very little control over their work environment were 1.5 to 1.8 times as likely to have or incur a heart condition in a five-year follow-up study.

Work stress is one of the risk factors for coronary heart disease. It is also linked to suppression of immune functioning, increased susceptibility to infectious disease and musculoskeletal pain, and to a wide variety of physical conditions. Work stress is also linked directly to behavioural outcomes, lifestyle factors, substance use, smoking, and alcohol use — a decrease in positive lifestyle factors. People under stress tend not to exercise and tend to eat at McDonalds more than a salad bar. All of those things have implications for health care costs.

In organizations, we have already heard some mention that work stress is associated with absenteeism and the notion of presenteeism, whereby people are at work; they are just not doing a good job while they are there.

There are safety implications. There are clear links between increased stress and safety in the workplace. One Dutch study found that bus drivers under extreme time pressure were four times as likely to have an accident as bus drivers who worked a more relaxed schedule.

My first major point that I want to emphasize is that the costs of mental ill health are not just mental. Most of the estimates that we see that focus on stress leave and issues of psychological disability are gross underestimates of the costs we are experiencing.

We have a very good understanding of the causes of mental health in the workplace — that is, the job design feature associated with well-being in the workplace. The National Institute for Occupational Safety and Health (NIOSH) in the U.S. identifies six major categories of stressors: Workload and pace, how fast you have to work, how much you have to do. The role stressors: Role ambiguity — not knowing what is expected of you. Role conflict — having conflicting expectations and/or conflict between work and family roles.

There are Career and reward issues: Issues of job insecurity that are so prevalent in a workforce that continually emphasizes short-term and contracts and the contingent workforce. There are issues of work scheduling: working night shift and weekends or overtime. In respect of interpersonal relations in the workplace, aggression in the workplace is becoming a serious issue for a variety of occupations and not always the ones we think of. Occupations that are at high-risk for violence and aggression include nursing, teaching and counselling and not just police and emergency services.

There are the effects of poor leadership in the workplace. There are clear links. Some surveys have found that employees attribute about 70 per cent of their work stress to their boss. It suggests that this is one point of leverage we have to positively affect peoples' mental health. Job design is a factor — does the job allow one to use one's skills. Does it permit control over the work?

All of these features are associated with mental health and the impairment of mental health. There is also a growing recognition that work is a health resource. Through work, we gain a sense of mastery, confidence, hope and aspiration. All of these things are, by definition, positive mental health.

If I were speaking before a committee on how to design jobs to maximize job performance and economic productivity, I would use the same set of slides. The job design characteristics associated with positive mental health are exactly the job design characteristics associated with performance and motivation in the workplace.

A recent meta-analysis shows this very clearly. The individuals who did the research took measures of job satisfaction. They measured how workers felt about their jobs and whether they were engaged, motivated and involved. They found, at the business unit level, that those two variables were linked to customer loyalty, firm profitability, productivity, turnover and safety.

The conclusion from all of the data that I have seen is very clear: What is good for individual mental health is good for firm performance and it is good for the economy of the country. In this light, the evidence is compelling that the issues of mental health are issues of competitive advantage. There is no incompatibility between promoting mental health in the workplace and achieving a financially viable firm.

Work in the U.S and the literature suggests that there are at least three components to a truly effective approach to work and mental health. First, we need assessment. It would not surprise you that an academic is calling for more research, but we need to understand the job characteristics under which Canadians work. Through such a national assessment program, you can also start to generate standards for job design that can be implemented.

We need a focus on primary intervention. With due respect to my panellists, we will always need employee assistance programs. We will always need treatment. There is no doubt in that.

I have a quote that I would like to paraphrase. Researchers at the National Institute for Occupational Safety and Health, NIOSH, in the United States used to have a very nice line that said something to the effect that we are not aware of any epidemic in the course of human history that has been eliminated through treatment. That is as true for mental health as it is for anything else. The focus on primary prevention, improving job design, improving leadership in organizations, and trying remove the causes of mental ill health will, in the long run, be a much more effective strategy.

Finally, we need more education and training. We need to educate business people as to the existence of these relationships, and what they can do about them; and we need to educate mental health professionals about how organizations work. One of the adverse features of our current educational system is we train people in silos. If you are interested in mental health, you train as a clinician and you never learn anything about organizations. If you are interested in business, you train in business and you never learn anything about mental health. We need to bring the two together to truly effect change.

Ms. Patti Bregman, Director of Programs, Canadian Mental Health Association — Ontario Division: I also want to thank the Senate committee, not only for inviting us but also for undertaking a really significant piece of work. You have the capacity to make a difference.

I will start by giving you a little background because you gave me the perfect lead in. The reason we are here, as opposed to other mental health agencies, is that three years ago we initiated a program called "Mental Health Works." My background is as a lawyer, but I am interested in mental health; and part of our initiative was to cross those silos.

Our approach in Mental Health Works was to take the wonderful work that the roundtable has been doing and bring the CEOs together and answer the questions we always got when we went out to talk to people: What do we actually do? What concrete steps can we take in the workplace? I want to start by saying I agree with all three of others, and I am going to skip over those pieces.

I have a couple of key messages that will carry through, and some concrete ideas, based on the fact that we have now been doing this for three years. I have worked in disability law and health policy for about 15 years, so some of this experience regarding disability accommodation and how you make these kinds of changes in the workplace comes from actually working with employers and being in the workplace.

I think the committee can make a huge step forward by bringing recognition to this problem. There is a World Health Organization number and it is important to understand what that number is. They are not talking about prevalence of mental illness, but about how many days you cannot have a good quality of life because of your mental illness. If any other disease were listed as about to become the number one or two in the world in 15 years, there would be a public health emergency declared and crisis. I think we need to start thinking of this as a challenge to be met, not an inevitable consequence.

We have 15 years to change the way in which work and health care deal with these issues, so that the mental illness may be present, but the quality of life and the days lost to disability will not be number one. I would like to see a target set that we want to lower that expectation. It is a very important message; because when you hear that number all the time, it sounds like nothing can be done. I do not think that is right.

The second point is that there is progress in mental health. We need to start communicating to the public that recovery and remission are possible. It is a chronic illness. You may not be cured, but you can improve your life. We need to do whatever it takes to help people live better quality of lives. Obviously, the workplace is an extremely important place for this to happen.

We have approached it as an accommodation issue and a health issue. It is important to do both. When we were looking at the workplace, it is critical that the CEOs take a stand. However, it is equally important that the people in the workplace — the managers and supervisors who have to deal with people's mental illness — get the education and information they need. I was at the roundtable with Mr. Phillips a couple weeks ago, and there are some wonderful things happening.

The number of events we get invited to — last Friday, Mr. Phillips and I were at another one — Benefits Canada is doing a special supplement of this, and brought together 10 people to talk about it. I sat with John Hunkin from CIBC and talked about it recently. I speak at other conferences where I have the managers and supervisors, and they say, well, John Hunkin just came in and one of his performance goals is that we improve employment of people with disabilities. How do we do it? Mental Health Works is really designed to answer that question.

I have some recommendations for you that will also focus on that — what do you do? Your focus is health and I have focused my recommendations on where the health component is. However, I would urge you to keep in mind that there is another piece that is not just health.

The first thing we need is research — very practical research, data collection. Research is important for two things: First, it tells us what we are doing wrong and what we are doing right. Second, it makes the case. We live in a world where problems do not get recognized as important unless we have data to back it up. That is why you will hear us talk about the $10, $20, $30 billion productivity loss. There is work being done at the Institute for Work and Health, there is a roundtable on return to work, there are numerous psychiatrists working at the Centre for Addiction and Mental Health.

However, we need more than research. The gap I would like to see you make recommendations on talks about dissemination, implementation and monitoring. At the Mental Health Association, we work with a research group. Our role is getting those research results out to the public and to government, and putting them into practice. In other words, we have wonderful research, but people do not know it is happening and we do not have a coordinating voice for it.

It does not mean all the researchers are the same, but we need to start letting people know that, for example, $35,000 a year will keep people in treatment and off the street. It is a great research number, but if you do not hear about it, if there is no strategy about how to take the results of that research and make change to respond to that research, it is not very helpful. Therefore, if you can think about how you can recommend talking about dissemination and implementation to make sure that the best practices get implemented.

I look to other health sectors, where you have best practices and guidelines. It would be unthinkable not to implement the best practices and guidelines for cancer treatment, for example. We do not do that in mental health. There are, in fact, some very good guidelines, but there is no implementation. There is no attention to the implementation; there is no funding for it. It is a really critical piece in that respect.

I also think we need to talk about monitoring follow-up. The National Quality Institute is doing a lot of very good work in terms of healthy workplaces. They have a strategy for how you do that follow-up. We need to look at that. Whether we call it a health care auditor or a monitoring and implementation group — we need a body that does not review and try to be punitive or mark people and say they are number one and two, but to give an annual report and say, are guidelines being followed? Do we know if people are being prescribed the appropriate drugs? Do we know that it is making a difference in the workplace? Again, it is a constantly evolving quality standard.

We need really good access to both information and services. In terms of information, I often hear people in the workplace ask, "What do we know about mental health?" "How do we find out what the drugs are?" "How do we help employees who come to us with a question?"

We need be careful. We do not want to turn supervisors and managers into medical practitioners. The thing that scarces them the most when we talk about workplace mental health is that we have an expectation that they will be diagnosing or treating or spending a lot of time listening to people. That is not what this is about.

They do need to know where to get information for their employees and how do talk about mental illness in the workplace. The hardest thing is what do you say to people? How do you disclose to other employees? Making it something that is everyday — in the same way we talk about cancer — comes from having good, accurate information.

They also need access to services. At a recent roundtable, I heard the head of occupational health and safety for Dupont speak. We have been doing some work with them and Dofasco and some other companies who are now saying that mental health problems in the workplace are their leading cause of disability and long-term care claims. The problem they are facing is that although early identification is wonderful and talking about it more is wonderful, the waiting lists can be six months or a year to two years.

We need to be careful to ensure that we are tracking, and that we do not get the situation where people identify mental illness and then cannot do anything about it. I think Mr. Phillips alluded to that. We need to come up with some creative solutions that include the public sector available funds. While the EAP programs are great, not everybody has insurance. For small companies, this is a serious problem.

If we can put those pieces together, starting with leadership from government and from the business community, to raise the issue to make it an important thing to do. We need to ensure that we are addressing the workplace needs of managers and supervisors, with research implementation dissemination. As a result, we will see the days lost to disability reduced because people will be able to work.

There is a remarkable study out of Boston University Rehab. They followed 500 senior executives who had been hospitalized for having a mental illness, which is pretty serious. At the end of two years, when they returned to work they had a 70 per cent retention rate. They were staying at work. When asked why, it was because they felt they could ask for accommodation. They felt as though they had the information and their colleagues had the information to give them support.

It is about removing stigma. We talk a lot about public education. I am not sure that that is as effective as simply providing good concrete information that gives people the real facts.

I hope we have lots of questions. I am looking forward to your report because we will do what we recommend you do, which is we will take your report and work to ensure that it is implemented. I think that is our responsibility.

The Chairman: Thank you all for some very interesting and provocative comments.

Mr. Savoie, at the end of your paper you had short-term action plan. You wrote the paper in March. Has that plan actually been done? Do we know what has happened?

Mr. Savoie: It is underway now. A small group has met and has prepared the basis for action. Then we will enlarge the group with all the stakeholders and other partners to ensure that it is not only a research group, but it represents all the concerned parties. The goal is to have national and international workshop next March at the latest.

The Chairman: Could you or your organization keep us informed?

Mr. Savoie: We certainly will.

The Chairman: Ms. Bregman, at the end of your paper you have a number of recommendations. I do not need an answer now but would you think about how we ultimately make them even more specific?

Perhaps the value of our last major health report was that, in contrast to some other health reports, we were very concrete in our recommendations. We had costed everything, we knew who should be involved, and we had some very good details. To the extent that you can over the next several months talk to our staff to make the recommendations — I would say this to the roundtable as well — make the recommendations even more specific. The more hard-nosed they are — recognizing they may not please everyone — the better it will be.

One statement you made in your brief stunned me. You made an observation that public health community health budgets in Ontario have been frozen for 12 years. It is essentially an 18 per cent to 20 per cent reduction in real purchasing power. That is a staggering number. I cannot think of any other government service that has been frozen for 12 years.

Ms. Bregman: There is not. It is not just the providers. In Ottawa for example, there is a five-year waiting list for case management services for people with serious mental illnesses. Half the people on that waiting list have attempted suicide.

The Chairman: A five-year list?

Ms. Bregman: Yes. These are staggering figures. Keep in mind that the other thing that is distinctive about mental health is that government funds only services for people with serious mental illness. That is why getting access to services for employees is so difficult because we do not fund mental health services beyond those very specific targeted groups.

I think that primary care practitioners provide 75 per cent of all mental health services. It is becoming a growing part of their practice. It is a huge issue in terms of getting access to really good service.

The Chairman: We are not looking at this purely from the narrow mental health issue.

I am fascinated by the rise in the stress issue. Let me be provocative to make a point. How do you know that it is a real issue, as distinguished from a phoney issue? When someone breaks a leg, it is obvious they have broken a leg. With back pain, I was fascinated by the fact that new protocols were developed and back pain disappeared and stress emerged. There is a lot of skepticism in the country. There is the view that people say they are stressed in part because they are allowed a number of days of sick leave and they need a reason to take them so they can have a few days off. Back pain used to be the way of doing it. Now it is switched to stress.

I am saying that to be deliberately provocative, but one of the important issues with which a committee such as ours must grapple is to separate fact from fiction — or to understand true reality. That is not to argue that there are not significant mental illnesses in the workplace; it is obvious there are. How do you suggest that we come to grips with that issue?

Ms. Bregman: I am not a clinician, but we actually send that same message when we go out and speak, because we want to ensure that employers are differentiating between stress and mental illness and it is a continuum. I do not think it is a one or the other.

In respect of criteria that are used for diagnosis of a mental illness — depression for example — there is a list of symptoms and a question as to whether you had a certain kind of symptoms for more than a two-week period. There are clinical criteria that can be used to determine a mental illness. Stress can make a mental illness worse and it may even trigger it. However, it is important to make that distinction in your report.

Senator Morin: Mr. Kelloway is giving a completely different picture and I fully agree with the chairman. There is the stress of work, but there is also the stress of being unemployed. There is always stress and some people work better under stress — whatever stress means. I think it is a vague concept. It is like "burnout," many people do not agree on the definition of the term.

I am surprised that no one has spoken about this. There is stress, but there is also the employment of schizophrenic patients and no one has mentioned that. There is the employment of patients with depression. I think that is something we should address.

If you work too much you are stressed; if you do not work enough, you are stressed. If you are in a position of responsibility, you are stressed; if you are not in a position of responsibility and have no control over your work, you are stressed. If you are bored, you are stressed. You are stressed all the time. The alternative is being unemployed and what is the stress level of being unemployed?

I worked in hospitals all my life and I see people in the emergency department and so forth who work under all sorts of pressures and stress. They are certainly not unhappy. This is what they have chosen.

I am extremely worried because if we go down this line, everyone will take leave for stress. Senator Robertson has been stressed from sitting next to me right now.

Mr. Phillips: The issue of back pain is an interesting corollary. If you want the toughest adjudication of these issues and whether they are real, a good place to start is the insurance industry.

Let us put aside the word stress for a moment because that might be a popularized glom of many mental health issues. Insurance adjudicators, by and large, are not softies looking for reasons to give away their employers' money. If over 40 per cent of disability claims they are paying now are related to mental illness and mental health related issues then that is one way to answer your question of focusing on the real importance of this. They are not in the business of giving away money; if anything, they are in the business of not.

In terms of characterization of stress, let me tell you the good thing about the fact that people refer to being stressed. Talking about being depressed or being schizophrenic are tough topics for people. One of the huge issues around dealing with this matter is the stigma, which Ms. Bregman mentioned.

We now have a popularized term — "stress" — with which people feel comfortable. In fact, it leads them into the potential for treatment; it leads them into conversations about the nature of their problem and challenge. Sometimes it is merely the fact that they are working really hard and having a hard time coping with it. A number of other times, there are real issues that can be treated.

In respect of the realm of physical health, everything everyone does is not healthy every day at work. There are things in a workplace that we would suggest people do not do because it is unsafe or not good for their physical health. People will continue to do them anyway. That does not mean there is not a better way to do it. That does not mean that some of the issues around how you can structure work cannot be improved.

There probably is a clinical definition of stress, but I am not a clinician so I do not want to speak to what I do not know. However, it is a gateway through which the people who need support can feel comfortable starting to get it. For that reason, I do not think it should be minimized.

Mr. Kelloway: Obviously, if you see my report, I am not as willing to dismiss the concept of stress.

The Chairman: Let me be clear. We did not indicate we are willing to dismiss it. It is important that we ask the tough questions because the reality is that a significant group of people is highly skeptical. Since much of this skepticism exists within major decision-makers in the public and private sectors, unless we can find a way to address that scepticism, progress will be really hard to achieve.

Mr. Kelloway: A lot of the scepticism seems to orient around the fact that the only way you know I am stressed is to ask me, so you have to accept my word for it. There are no other indicators — or not exact indicators. There are some physiological correlates of stress such as increased blood pressure, cardiac reactivity, and salivary cortisol measures — all kinds of things you can use. When you use those, you find they correlate very well with self-reports.

When we go to objective measures of job conditions — not measured by what people think their job is like, but very objective measures such as deriving from the employer or job analysis or something like that, you get essentially the same results.

There are also a variety of other areas where we rely on the individual to report symptoms and we accept his or her word for it. When I get back to Halifax on Monday, I am going to my optometrist. When he checks my vision and asks if I can see better when he changes the lens, he accepts my answer as my word.

There is always the potential for fraud, but there is very good evidence that, in fact, objective work conditions are associated with stress. Stress is associated with all kinds of objectively measured outcomes, including coronary heart disease and physical symptoms, so I do not see any reason to suspect them. I realize there is a problem, because we are not willing to trust people when they tell us that they are experiencing a lot of stress. It is complicated by the fact there are individual differences in stress tolerance. Some individuals may be able to tolerate more or less stress.

Mr. Savoie: I would like to make the remark that back pain has not disappeared. Eighty per cent of people will have back pain at some point in life. What has changed is that the prevention measures in the workplace have improved; but also the disability case management has tremendously improved over the years.

With mental health, we could sort of disregard the problem and say it does not exist. However, the reality in the workplace is it is there. What are we going do about it? My feeling is that we think that if we put too much attention on that issue, we will take money away from other health care services. We will put it to mental health where maybe it might not be justified.

Let me remind you again, the major part of the solution will come within the workplace itself. This is a not a money burden for the health system. It might in fact save money. I agree with Mr. Kelloway; it has been demonstrated again and again. Some people may lie, but most people do not lie all the time. When people tell you something, normally you sit down and listen carefully.

Is it like a mood or something that will disappear over time? I do not think it will disappear in the very short future. However, again, what back pain has shown is that we can do something about it. If we put ourselves together, there are things we can do.

To manage the world, we used to divide the world; and to manage research, we divided research. Clinical research, health research, sociology and many other disciplines will contribute. This issue affects everyone in business — from managers to engineers to workers. It is the same in research. The linkage among all the entities has not yet been done. I think we must look at it that way.

Senator Roche: The witnesses should know that this committee brings a lot of sympathy to the subject of mental illness. We have heard some heart-rending testimony over the past few months that has really affected me, and I think my colleagues as well.

We do not want to dilute the importance of our forthcoming report by letting the skeptics overcome the real message of mental illness that we want to get out with our recommendations — that is, doing something about it in an appropriate way. If we were to take the avenue that depression will be the leading cause of work days lost and the growth in stress as a reason for paying attention to mental illness, I am concerned that we will have diverted public attention — and maybe governmental attention — away from the centrality of our message.

As a layman here, I am uncertain of the relationship between stress and mental illness. As Senator Morin says, we all feel stressed. I am wondering if the increase in stress is not so much like mental illness, but a growing inability of so many people to cope with the crises of the world. There are crises all over the world, all over our country — SARS, beef, the Middle East. Stress is everywhere. I wonder if the pressures of the modern world and the pressures of coping with all the things we have to deal have become so extreme that it is adding to stress to be sure. However, is it necessarily building up mental illness?

If we pitch our report on the growing stress and growing depression and pay attention to us — I think I have said enough. You get my feeling here. I am worried that we will have diluted the attention I want to pay to the clinical problems of mental illness that need to be repaired.

Ms. Bregman: Perhaps I can help put together a framework. We are all saying similar things but from different perspectives. I do not want to dismiss stress as something that is not important. There is some relationship between stress and building to mental illness. However, I do think, as you said, we do need to differentiate for a couple of reasons. One is because we do have to start acknowledging mental illness. It is as much about saying the word as it is about solving the problem. The other thing is that solutions are different. We need to focus on what we say about them. Talking about stress is not necessarily something that would dilute your report if what you say about stress is focused on the solutions for stress, not depression, and then move along the continuum.

For example, if you prescribe an exercise program such as yoga for someone who is stressed, that kind of primary prevention is great; it improves people's sense of health and well-being. However, that will not treat depression. Part of the reason we make that distinction is to make people understand that just dealing with the things that help with stress will not assist with mental illness. We need to talk about the continuum of responses that are available.

Stress, as you said, is defined as how you respond to the world. When we do stress-prevention education, we are helping people to change the way in which they respond to the things they face. That is not what we do with depression.

Therefore, I would encourage you to make sure that when you address each of these issues, you encourage the appropriate responses to them — be they mental illness or stress. They are not the same. The responses required in the workplace are not the same.

Senator Roche: It is clear that stress is not the same thing as mental illness. I am stressed all the time, but I do not think I am mentally ill.

Ms. Bregman: I am not a clinician. There is a continuum and there is a significant amount of discussion about this. Definitions are always the hardest thing to do. I do some consulting from time to time. I am writing a paper for the European commission on defining disability for new legislation. These things are a struggle. Maybe we can go back and look for some research that might assist you.

Senator Roche: Are you distinguishing between stress and depression?

Ms. Bregman: Yes, I am.

Senator Roche: Stress does not lead to mental illness, but depression is a form of mental illness?

Ms. Bregman: There is some research that indicates that stress may lead to mental illness. When you tease out the definitions, the World Health Organization number 2020 talks about unipolar depression only. It is not even the whole range of mental illness. We tend to make it more generic.

Mr. Kelloway: There is some terminology confusion going on. Part of that is disciplinary. When I think of mental health, I do not think of mental illness. I would distinguish between the two. I mean in no way to dispute the focus that the committee would like to place in their report. I would be fully supportive of a report that dealt with mental illness and how we treat mental illness. That is a crucial issue for society. I do not think of it as a mental health issue, I do not think of it as the sole definition of mental health.

I respect your view. If you include a wide variety of mental health issues, you will write a report that deals with mental health, but may not have a very clear focus on mental illness.

The Chairman: Can I be clear? I think we all understand what we mean by mental illness, but you are saying that someone could have a mental health problem but not be mentally ill?

Mr. Kelloway: That is correct.

The Chairman: In some sense, mental illness is very clearly defined from a clinical standpoint. We all have mental health of some form or another, some of it may be a 10 out of 10-point scale and some of it may be on a two. Two does not mean you are mentally ill, it means you are not mentally healthy?

Mr. Kelloway: Agreed. There is the diagnostic and statistical manual of the American Psychiatric Association that is used to establish the diagnostic criteria for mental illnesses. The diagnostic criteria for something like depression, is very much a continuum. We have chosen a level of symptomatology and said if you hit that level we will diagnose you as being clinically depressed — suffering unipolar depression.

The Chairman: You are into the mentally ill category?

Mr. Kelloway: If you are two steps back from that you have a mental health problem.

Senator Morin: You are not unhealthy? If you have a cold, are you ill or unhealthy? What you are saying is it is a grading of symptoms. It is the only field of medicine where you have this distinction. In any other field, you are either healthy, or unhealthy, or sick. If you are sick, you have a diagnosis. What you are saying is you are unhealthy but there is no name to it. That is unbelievable.

This distinction between mental health and mental illness creates an unbelievable disservice to the patients who really need our help: the schizophrenics. Here you are talking about the workplace. Nobody has mentioned the fact of the employment of those patients who are unemployed and need work. These are the schizophrenics, the mood disorders and all these patients.

We are talking about someone who had a fight with his boss. Twenty years ago, he would have wept on his wife's shoulder and the next day he would be back to work. Now he can take a week off for that. That is it. Of course, he is stressed.

How could you put this in the same field as a patient with a mood disorder and with schizophrenia who is facing unbelievable problems in the workplace? They cannot find a job. They are discriminated against; nobody is out there to help them. They are unemployed all their life.

I am not alone saying that. I heard a professor who wrote a paper specifically on this topic. He spoke to it at the mental health advisory board — it was not at this committee. He spoke at the advisory board of the mental health institute of CIHR. He said it is creating a great disservice to those patients with mental illness.

I am not saying that there is not a gradation. A cold is not SARS. I am sorry if I get a bit upset on this, but there is a danger here. The employers should also address the problem of mental illness, not only mental health. I know why they are not doing it: there are problems associated with employing a schizophrenic. We should address that.

Mr. Savoie: I will throw a rock in the pond. Senator Morin is saying that the industry in general does not do its job by hiring people with mental health problems and mental diseases. I agree with him completely. On the reverse, if I have a company and I say I have a problem and you will not listen, that is a dichotomy. There is no possible dialogue. You are trying to tell the industry what they should do and they are asking you for help. You say that it is not sufficiently important; they should not receive help.

If we want to have more people integrated into the workplace, there is knowledge to develop there. It might start with the industry's problem and then once they learn how to do it, they can start hiring other people. I am not talking on behalf of employers here; I am totally neutral. However, that is the feeling that I have. They have a problem. They want to express it. If we do not listen to that, because it is not important enough, they will not listen to ours.

Mr. Phillips: The passion about it is fantastic. Perhaps we are not dealing with some of the more difficult clinical situations you raised — I think you answered yourself — because many of those people are not in the workplace. The response on one level would be whether it is an employer's responsibility or not, they are trying to address those people in the workplace where there are issues.

Although the issues can be minimized, they do not seem minimal to the person whose spouse just phoned them at work and said they are leaving and walked out, or the person who is dealing with substance abuse or other serious issues. The glaring piece of this is that we have a public health care system in Canada that does not deal with this. There are provinces in Canada where they screen people who have an EAP and will not let them into the public system if they have one. They prefer to off-load them to employers.

In a system where we pay taxes to have the government handle health care, the employers are already dealing with a very significant burden around providing basic mental health care — not dealing with mental illness in a substantive way, but basic mental health care. When it can take from six months to five years to get assistance, I think it is not just employers who are on the hook for not meeting their responsibilities.

Ms. Bregman: I want to address Senator Morin's comments. It is important to note that there actually is work going on as well for people who are seriously mentally ill. That is the population we are addressing. It is the only population that our initiative is addressing.

We did not put a lot about it in our brief because it is addressed from our perspective as an accommodation issue. We have been working with CIBC and Scotia Bank now for three years on improving employment opportunities for people with disabilities — mental illness in particular. We have material on our Web site and we have developed training for managers and supervisors that focuses on that. It focuses on how to have the conversation with someone? When you notice it is a performance issue and that they have a serious problem, what can you do about it? What are the steps that you can take?

What is encouraging to me, having done this in different contexts over 12 years, is that employers are now much more interested in this. That is for a couple of reasons. First, prevalence is higher. Second, the legal framework of human rights has forced them to ensure that they are complying with human rights. The banks, in particular, are doing it because of federal employment equity legislation. In addition, mental illness hits people when they are older. They are finding that their very valued employees are suddenly sick, so there is a connection.

Within the corporate sector, we are finding a willingness to begin to address some of these problems. We talk to them about accommodating. You can do very cost-effective accommodation for people with a mood disorder, with schizophrenia. We ask, "How do you talk to their colleagues? How do you have that interview?" We have actually done a little 10-minute video of a good interview and a bad interview to show the managers and supervisors. Those are the people who are dealing with it.

However, there is a disconnect. The business leaders are now talking about it, which is really good. However, the people on the ground have been dealing with this for a long time. I think there is a crying need out there for information, not only about accommodation. They want to know about the medication a person might be on so that they can understand it. They want good, factual information about mental illness so they can better understand it. Their fear is they will become the clinicians. That is where the question of access to services becomes so essential.

If someone walks into their office — and they do every day, I get a lot of call from the corporate world — and says, "I have this problem," the first thing they ask is, "What can we do?" That is where they are stymied. I agree it is a really critical thing and we do need to talk to it. We also need to send that message of encouragement that mental illness is a chronic disease, that you can have recovery-remission; but it requires dedicated treatment when you are at that level. That is what we are not seeing.

Senator Cook: You have said that you not clinicians and I understand that. Your focus is a healthy workplace with a healthy person sitting in it — a workplace that is governed on one end with me receiving remuneration for being employed and on the other by that balance sheet. You are looking at competing forces in this workplace.

At what point along the continuum will your mental health be compromised? Is it when you become dysfunctional when you are doing your daily tasks? What are the triggers that the employer-employee relationships begin? Again, in the complexity of the workforce, you have the person who hired you. You have regulations. You have unions. You have people who advocate for you. It is almost like a vortex.

I know that mental health is desirable for outcomes and industry. Somewhere along the continuum, if those stressors are in place, you will become mentally ill. That is what my mind is trying to unravel — that point along the continuum.

That may be okay for Bell Canada, the large drug and multinational companies where you can write off A, B and C on your balance sheet. However, for the smaller businesses, where people work for minimum wages, how do we manage a workplace to ensure that the people in it are healthy, recognizing that there are stressors along the way that will move you over the line?

Mr. Kelloway: I am not sure that I have the whole answer, but I have a couple of observations. This analogy of a continuum works very well for some mental illnesses, depression being the obvious example. It does not work quite as well for schizophrenia, bipolar affective disorder or a host of other "psychoses" that have biological as well as environmental determinants.

That notion that as we continue to stress people they will eventually develop a mental illness is debatable depending on the form of the illness. I would not at all be prepared to argue that one develops bipolar disorder or schizophrenia as a result of increased workplace stress. There is much stronger evidence for depression. I do not want to focus too much on the continuum. Even within the diagnostic manual, there are very clear distinctions between classic psychoses and other forms of mental illness.

Mr. Phillips: Your question had two parts: one was around smaller business and one was looking at how and when. There are certain things that we see in what we do that can anticipate issues within workplaces. We provide EAP services for about 75 per cent of the health care institutions, hospitals and others in the GTA right now. Senator Roche mentioned the issues of situational events and things that put stress on people. There are things that happen in an outside environment and an inside environment within an organization — restructuring, downsizing — that can point to additional pressures and can be triggers. Those are reasonably definable on a broad base of experience. Then you can call for additional support in those cases to prevent moving from just a difficult situation to mental illness.

The key we see — and it would be the same for small or large workforces — relates to supervisors and supervisory training. Most often, it is people for whom people work or work with who see the symptoms, if they know how to identify them. If they can learn to identify those symptoms, they are most likely to see what amounts to a change of behaviour, or an unexplained change in behaviour. If they are educated — as they are in some workforces — they can then do something whether it is a small or a large workplace.

What that something is, is another question. To emphasize your point, smaller workplaces are far less likely to have the kind of built-in supports through benefits and other things that would allow people access to EAP programs, or even drug benefits that would allow them to use anti-depressants or other things in a comfortable fashion. It is a more significant problem in those sorts of workplaces. The mechanisms to work with those workplaces are not all there.

The roundtable, however, has taken some initiatives because the CEOs of the five large banks are participants in the roundtable. For instance, the network and relationships that almost all workplaces have to have with the bank might be a point we can use as a node to educate people, because we know that they are interfacing with their bank. The bank might be the cause of their stress in some cases, but we know they are interfacing with their bank. That becomes an opportunity to reach out to those small workplaces that are typically going to have fewer resources across a range of health related services.

Mr. Savoie: I am taking Senator Morin's comments very seriously because I think the case has to be made. In regard to long-term disability, the insurance companies' figures show that these are the highest rates they have seen in years. When one applies for disability, he or she sees many specialists and is analysed thoroughly. There is something there. It is not artificial; it is real. That is an increase of disease, not only the diminution of mental health.

It is clear that if we must treat the problem as it comes into the workplace. I agree there is no one single stress factor that leads to a disease. This is a more statistical approach. A number of factors could affect a person over time and result in the development of a disease. If we do not act on that, the burden will come directly to the health care system. Affected persons will go out of the business and into the health care system.

I used the example of back pain. Do you know what happened with people after one or two years? They ended up on social assistance. They lost their jobs and there was nothing left. Their expenses were assumed by the society. Senator Morin has a point. We have to show the relative importance of the problem. If we do not look at it, two things will happen. First, the costs for business will become too heavy and there will be less income for the rest of the society. Second, the burden will be supported by the health system.

Ms. Bregman: The small business point is an important issue when you are talking about accommodation. We have been trying to work with small business. We have to address the fact that they will rely heavily on the publicly available services. They are going to be the most hurt by the fact that those services are not available. At the same time, often the small businesses actually know the people that work for them.

From our perspective, moving away from stress or the non-stress, there are a couple of things we have learned. One is that when you are talking about serious mental illnesses such as mood and affective disorders, there is evidence that early intervention helps. You want to identify it and treat it fast. If you do that, people tend to stay at work.

Where people end up on long-term disability — and, as a lawyer, I can tell you that getting long-term disability for stress is not an easy thing to do — for longer than six months, the likelihood of return is much lower. The goal should be how to address it so that it can be recognized in the workplace and treatment can be sought. Some of the barriers we have identified have to do with the unwillingness to disclose. I hear people say that they are afraid to go to their supervisor and say, "I am depressed." In our video we use a vignette where the supervisor says, "I am stressed, too." There is this downplaying of mental illness that we need to be able to differentiate and say this is not just about feeling blue today.

We recently did a session with the Ontario Hospital Association. That is a stressed out sector; they have one of the highest rates of people off from mental illness in everything — particularly with SARS right now in Toronto. They had two consumers who both spoke about the 10 years they spent in hospitals with postpartum depression and the problems they had. People would say, "I had postpartum depression and I cried for a day or two." This was someone who seriously wanted to kill her child.

We need to have that education and awareness. We also have to talk about and in some ways use stress as the entryway to talk about mental illness. It is building on what Mr. Savoie was saying. Use the opportunity of conversation about stress in the workplace to educate about mental illness. Take the door that is open to us to remove the stigma.

When I talk to managers' groups, it is almost inevitable that someone will say, "I am so glad you came in." I always say to them that the first thing they should do, as a corporation, is make it clear to people that you have an accommodation policy and you are willing to address the subject of mental illness. You do not identify everyone. Every single time someone discloses. That is what happens when you work in mental health. When I do a media conference I will have the cameraman come over and say, "my sister committed suicide." We need to open the door to communication. Then we need solid communication and treatment to follow it. Those steps are critical in this process.

Senator Cook: I am trying to relate this to Senator Morin's principle. Let me give you a case in point. A 20-year-old young man with a master's degree in administration develops behavioural problems. He is in and out of the psychiatric wards for a period of two to three years. Then the system determines that he is able to return to his job, which is a challenging one with a multinational company. He had to fight human resources to get his job back because the system would not believe he was competent for work. Yet, they allowed it to move along a two to three-year timeline. He developed schizophrenia in his 20s. That is what you are talking about, that piece?

Senator Robertson: This will be one of the more difficult tasks that this committee has. As you can see, it can be all over the map. The care, whether it is in the home, school or the workplace — as we all know — really starts with prevention. I want to be very specific, because I want to focus on work-related stress and problems that come from that work-related stress.

Earlier, One of you talked about how the health of the worker and the health of the economy are interwoven. That relationship is extremely important for the success and the development of any country. We must be cognizant of the problems that we are facing in the employment field.

What I should like to ask you is how other developed countries have handled these issues? Where is Canada in that line-up?

Other witnesses have told us that we are lagging very badly on other issues, not work-related stress. We have the usual problems of too few professional and para-professional people. Is there somewhere we can turn to get guidance on how to proceed in a more logical manner? Not very long ago, we were told that the age of technology was going to free up people to have plenty of time off and life was going to be rosy. Well, people are working longer because they cannot get the phone out of their ear; they have their systems at home, so they never get away from their work field. I do not know how other countries are handling it, but I would be most interested to know.

It is not easy, but is there a shining example of good progress in this area of work-related stress?

Mr. Kelloway: I do not know how shining they are. In 1990, the National Institute for Occupational Safety and Health in the United States did two things. First, they published their list of the 10 leading causes of workplace death. Stress was clearly identified as one of those 10; and they articulated the national strategy for the prevention of stress- related disorders in the workplace, upon which I drew heavily. That is where I came up with assessment, education and primary intervention — these are really their ideas.

The second major thing they did was partner with the American Psychological Association. The joint effort for that was actually the emergence of a new field known as occupational health psychology. They instituted graduate training to try to address the issue that we train in silos. If we are going to deal with work-related disorders, we need to cross those silos. They are trying to deal with that.

Very similar things have happened in the European Union — particularly in the U.K., but there are also very exciting things happening in Holland much along the same lines. This new field has been emerging and there is training in very concentrated research in this area.

In Canada, we have suffered from the lack of a unitary organizing body such as they have in the States. Those formal structures have not been put in place. Canadians are among the main contributors to this research literature. However, there is no formal training, for example, in occupational health psychology within Canada. If you wanted to make this a specialty, you could not. The best you could do is go to an institution such as St. Mary's, or Queen's, find people who do this work and work with them. However, you could not actually specialize in that discipline. In that sense we are very much behind.

Mr. Savoie: Occupational health research at large was not even mentioned in the Medical Research Council's, MRC, time. It was only mentioned when the Canadian Institutes for Health Research, CIHR, was created, amazingly. Second, there are two provinces that took the lead from the Workers' Compensation Board money: Quebec, with the Institut de recherche en santé et en sécurité du travail, IRSST, and Ontario, with the Institute for Work and Health, IWH, that funded research in that area.

If you do research with a social partner, there are certain things that are harder to touch than others. Mental health in the workplace is conflictual, so very little was done on that issue. Although we may lag behind, I think the new CIHR structure is a great facilitator of this interlinkage, not only among health researchers but all those who are in the outside partners in research, but close by to help research. What was not feasible a few years ago suddenly becomes not only feasible but also very interesting.

As an example, there is currently a summer school for disability or handicap prevention about low back pain that involves all the provinces across Canada at one place. That would not have been possible before CIHR. This handicap prevention program deals with some mental health concerns also.

Mr. Phillips: If I use the presence of an EAP program as one proxy for a commitment to the mental health, Canada would track about 5 per cent or 10 per cent behind the United States in terms of the penetration of these programs into large workplaces.

Furthermore, generally speaking, employee assistance programs are a North American phenomenon. From that perspective, that particular aspect of employers investing in mental health, Canada would rank well relative to Europe and other places. As an employer, the Government of Canada and other public sector governments in Canada lag behind the United States in taking a leadership role. I say this carefully, because the Senate of Canada has a wonderful EAP program provided by Warren Shepell.

However, generally speaking, our programs are of a lower quality relative to the U.S. government, which has seen their 4 million-employee base as an opportunity to walk the talk, if you will. They also require suppliers to the U.S. government to have some form of EAP — particularly around addiction and drug issues. They have used their buying power and leverage in the market to promote high-quality programs.

In the United States, there is a presidential commission and someone who reports directly to the office of the president who deals with mental health and addiction issues. It was started by President Clinton and has been continued and enhanced by the current president. That office and function has responsibilities around organizing — both from an industry perspective and from a public sector perspective — mental health professionals and the delivery of mental health services in the workplace. That is a very specific commitment from the most senior levels of their government.

Ms. Bregman: We were talking about it on our way here because it is a complicated question to answer. In the U.K., for example, the government has set up a work life balance trust to actually spend a lot of time — they have employers and the government involved — to focus on this work life balance issue. Yet, in Europe and the U.K., there has been no disability discrimination legislation until the last couple of years. For the most part, mental illness is not recognized as a disability issue. The recognition in the workplace is quite different; you do not have the right to work if you have a disability.

I hear a lot about where you place this issue. Half the people — whether it is in Canada, the U.S., Australia or New Zealand — who are looking at this issue, will place it in occupational health and safety. That is true when you go into the corporate world as well: half the time we are dealing with the occupational health and safety department, other half with the equity people.

My question is how do we bring all these pieces together? I think, in certain areas, Canada is looked to as a leader. The National Quality Institute here has done some very good work on wellness in the workplace. In other areas, we lag behind. However, comparisons are very hard to do because of very different legal structures, health care structures and access to services.

The Workplace Safety and Insurance Board, WSIB in Ontario, has basically said that workplace stress is not a compensable illness unless it is very specific post-traumatic stress in very limited ways. We are sending a message that it is not something employers have to worry about. That is a concern. We can debate whether stress should be compensable and how you would discuss it, but when they removed compensable illness as a potential workplace problem, that does send a message that we do not need to care about it.

Even though I am a lawyer, and I used to litigate disability rights cases, the law really is not the way to solve it. Conflictual resolution is not the best way to go. However, laws do send a message. You need to look and see where policy and public support are. I think they are not there.

Senator Robertson: Usually there are measurements in various fields that you can look at to see how well you are doing. I do not know what the yardsticks would be here, but I suppose national productivity might be one. Perhaps we should compare our national productivity with other national productivities. I am just musing out loud here now.

Does a four-day workweek in France work? Has that increased productivity and reduced health problems for the country?

Mr. Phillips: It sounds good to me.

Mr. Savoie: I think they live longer, but maybe that is because of wine.

The Chairman: I have been working on that solution myself.

Mr. Savoie: I am not familiar with that. However, a public health specialist from the United States told me that France really has better hope of living healthy than we do. However, again, it could be wine; I do not know.

Mr. Kelloway: I do not know specifically about a four-day workweek. I do know that in the Scandinavian countries — and now more broadly spread through the European Union — there has been a greater focus on regulating the workweek. For example, in the Scandinavian countries, they have much more vacation time than we do, and tend to work a shorter workweek. I do not know the comparable productivity figures off the top of my head, but I have not heard any suggestion that their economy was in collapse lately. I do not think it has done them a great deal of damage.

The Chairman: Mr. Phillips, I want to come back on your comment that Canadian companies are second to the United States in terms of the amount of money they are putting into mental health. I want to be sure that number is not misleading. I do not know the answer so I am asking the question. To what extent are public mental health programs in European countries, for example, significantly better than ours? If they were, there would be no need for the employers in those countries to make that investment, in which case, while your statement would be factually true, it would also be misleading.

Mr. Phillips: To be clear, the penetration of employees with EAP is lower. I do not know the direct investment figures between Canada and the United States. My perception is that in some parts of Europe, they have a more integrated social welfare system that probably supports a number of the issues that contribute to mental illness. It is also an emerging field — for our company and others in Europe — which would suggest that there is a market for it.

The Chairman: One has to be a careful with international comparisons, because to the extent that the public infrastructure is better, the private sector does not need to do it?

Mr. Phillips: The Canada-U.S. comparison is interesting because, although there is difference in the principal delivery of health care, we have similar economies in terms of the nature of the workforce and other culture-related issues.

Senator Léger: Mr. Kelloway, may I ask you to repeat what you said about Freud in your first sentence?

Mr. Kelloway: Freud was asked — in German so this is the rough translation — what are the capabilities of a healthy individual and his response was "to work and to love."

Senator Léger: I guess that is quite the base, the value of work.

[Translation]

There is a particular image that comes to my mind. I am thinking of the song by Félix Leclerc where he talks about how you can kill a man. He can be hanged, gassed or electrocuted. But the surest way to kill a man is to give him money to do nothing.

[English]

I think the value of work should be in between the lines.

There is much research being done on the mental health of the employees. Do we have an equivalent for the employers — that is, the managers and supervisors? I do not know if I will go to the CEOs because they are usually quite well set, mentally. Is there an equivalent amount of research being done at the same time, with the same degree of importance, for the supervisors and managers?

Mr. Kelloway: There is an established line of research on executive stress — and I hate to say stress now — but on the stresses experienced by those in management. One interesting line is when we put programs in place to deal with some of these disorders, they are almost always excluded at the managerial level. Therefore, if we put in place a program to help people deal with work family arrangements, whereby you can work part-time, or from home, or have flexible hours, managers are told — subtly or not so subtly — they can take advantage of that program but if they do their career is over. Even as we open things up and make things available to employees, we are often excluding the managers.

Ms. Bregman: Most of the studies do not differentiate between managers and line employees. I think that is an area where there is more research needed.

Your comment about the CEOs was interesting. We seeing an increase in the number of business leaders who are coming out and talking about their own mental illnesses —not only minor ones. This was lead, for example, by the Lieutenant Governor of Ontario, who has been very open about the fact that he has a mental illness, has been suicidal and continues to be on medication. Another example is the former CEO of CNN who was interview by Larry King about his illness.

It is true that bipolar disorder may prevent some people from getting to the top. However, there is some research that suggests that certain kinds of mental illnesses might actually help people move up. An example might be someone who is manic and works for 24 hours a day. We encourage certain of the traits that are related to certain mental illnesses. I worked at a Bay Street law firm where if you worked 24 hours a day that was a good thing. People survive. It is important to ensure that the programs cover everyone.

Senator Léger: Because there must be a relationship between the employee and the employer?

Ms. Bregman: The Boston study to which I referred did look at senior level managers and CEOs and executives. There were 500, which is a fairly large study. These are all people who have been hospitalized for a mental illness. They talked about their ability to return to work. They indicated that it is easier for them to return to work because at that level, they have the respect of their colleagues. In addition, they have more control over their ability to work. Those are important components of accommodation.

Senator Léger: Every time I hear reports about work in industry or the research, the accent is put on productivity, not on health. We lose so many millions of dollars through absenteeism and so on. It is not necessarily the health message that I receive as an ordinary citizen. I receive the message that we are not producing enough and so the economy is going down. The accent is on that too often. When the industries do want to participate in helping, you do not hear the word health too often.

Mr. Phillips: We are in an interesting dilemma as an industry that provides mental health services, because many people will accept the services because they are good for their employees. They want them to be healthy, happy employees and they want to be a best-in-class employer. I guess I see it as dual pressures. There are altruistic employers who provide the service for good reasons. In every CEO, or every CFO as well, there is another part of their personality — which is the part they deal with 98 per cent of time and that is the people who demand that their quarterly or their annual results be good.

The correlation that is drawn, in the case of our work, between productivity in is to help with that other 98 per cent of the time. We believe there is clear a connection. It is not just demonstrated by the research and numbers used, but by common sense. It makes employers feel better about encouraging and promoting a healthy workplace.

The orientation you are talking about is simply the orientation of business. We find it in the public sector as well — there is more orientation around service delivery versus strictly the health of their employee.

Senator Léger: Sick leave did not exist in the past; therefore, we all lived up to 9 to 5. We raised families, tended the farm from five o'clock in the morning on took care of the animals or fished. There was no sick leave then.

Today there is all this stress and coping with events of the world around us as Senator Roche pointed out. That is something that we must look into. We should put emphasis on the situation of actual life day in our report. There was no sick leave before. Today, everyone uses it up.

There are other things in the same line. You see the word "multi-tasks." We are proud of that. People are killing themselves, working 24 hours a day — I am a victim of that. It is treated as a good thing. Then we are zapping all over the place; we jump from one thing to the other. That I think should come out in our report too. Is that not mental weaknesses — not to say mental disorders?

Mr. Savoie: I do not have the answer to that. However, I would like to make two points.

About 20 years ago, I met with the union representative and a human resources director from a hospital. Bluntly, I asked what happened with older nurses on the wards where it is particularly demanding and tough. The union said that they did not have any problems. The human resources director said that they had a perfect record of health and safety.

The next day I received two phone calls. The first was from one from the union representative who said they had no problems because the nurses had all gone somewhere else. They had found other jobs, but that is not something that people can do easily now. Organizations have all been cut to the bone.

In the second call, the director of personnel told me that although they had a very good health and safety record, the health insurance costs had tripled over the previous two years., we have a very good health and safety record. The only problem is that the normal health insurance has tripled over the past two years. That is the transfer from one bank to the other, so they have not solved anything. I think that what we could do before, you cannot do anymore.

I was invited to the Chamber of Commerce because employers had problems with Workers Compensation Boards; they were stressed by the injured workers' cases and could no longer handle the volume. I asked them if they thought it was their real problem.

In my early days, we used to take a week to write letters and wait another week for a response. Then the fax machine came along. You could have an answer in about one day, but you still had time because you had to retype you response. Now everything is on-line. Some people like it, but others do not. The work pace has increased and there are a lot more stressors in real life than we used to have. I am not sure the evolution of the human species has kept pace with technology. That is a reality. The bottom line is the impact on industry is important.

Mr. Kelloway: There has been much empirical research that makes exactly that point. It is not so much what we are doing or how much we are doing; a lot is how we feel about what we are doing. If one really loves his or her work and works long hours at it, that can be a very healthy thing.

The people you really want to focus on, from a mental health perspective, are those who have to work two jobs to make ends meet and they hate both of them because they are such lousy work. That is where your mental health problems will emerge in the future. It is not how long you work, it is what you are doing.

Senator Roche: Mr. Savoie put his finger on it when he talked about the rapidity of instant communication adding to pressures of getting everything done. I do not know what we can do about that. However, it brings me to what I think has been a theme that I picked up here. The quality of the workplace is related to the subject of mental illness. Therefore, if you improve the quality of the workplace and you make a contribution to reducing mental illness.

Ms. Bregman said, in one of her last interventions, if we deal with employees on their stress, it opens the door to us to probe and get more empirical evidence on mental illness and so on. That seems to me to return us to where we were a little while ago, to the relationship of stress to mental illness.

I still have a concern that if we advocate a shortened workweek — a four-day workweek or something — to improve the quality of the workplace, we will divert attention and make a controversy over working conditions per se. That will take away the attention we want to focus on the clinical problems of mental illness that are so desperate and have, in my view, very little to do with the quality of the workplace as such.

I do not want to diminish the importance of the testimony that we have heard from the witnesses, Mr. Chairman. However, I leave here still a bit confused as to what degree improving the quality of the workplace will reduce mental illness.

Mr. Savoie: More than that has been said. It is not only improving the quality of the workplace. It is how to better foresee a case coming, how to better handle the cases, and how to better facilitate return to work. This is all within the mental illness process.

Second, we know that some work organization factors lead to problems and could be alleviated. However, you do not have to stop doing one thing to do the other. I understand your point that you would not want to could deviate the interests of the population in your report or make recommendations that are too broad in focus. However, I think there are places for both in this issue. Workplaces are asking seriously for help and that could be provided without putting a high burden on the costs of the health system. This is a different approach.

The Chairman: I want to thank you all for coming. I also want to give you a challenge as much as a request for help. It picks up exactly on the point that Senator Morin and Senator Roche have made.

There is no question that we will want to deal with the mental illness system. It is also very clear that there are problems in the workplace; there are economic costs associated with attitudinal problems or mental problems, on the part of employees. We want to produce a report that is useful. Therefore, we want to what I call "ring-fence" very tightly the conditions that must exist for someone to be included in a program when they are in the workplace. Let me give you two good examples.

Our last report is having a significant effect in terms of implementation because we did not talk about pharmacare; we talked only about catastrophic drugs. We gave an exact definition of the point at which the cost of the drugs became catastrophic to the individual. Therefore, none of the governments were scared off by a massive pharmacare program — it was "ring-fenced."

Similarly, on home care, we talked only about post-acute patients — those leaving the hospital and going into home care. That was the only way you could get into our home care program. It made economic sense because it was cheaper to move them out of a $1400 a day hospital bed into a home-care bed. Again, that program is starting to develop interest in a number of provinces and the federal government precisely because we ring-fenced it so it was not seen as an open-ended thing.

The danger I see — and it is not just me, you have seen it with our colleagues today — in not very specifically ring- fencing the work issue is that it will be seen as an open-ended program that would be absolutely uncontrollable. If governments think it is open-ended, rather than do something, they generally opt to do nothing.

We can deal with the mentally ill problem. Where we really need your help in creating very tight definitions on what could be included in a work-related program that would, at the very least, make a step in the direction you people would like to go. We are not going to do everything all at once. However, we want to take a step that would deal with the issue of opening up a Pandora's box that is absolutely not containable.

Frankly, from a public policy standpoint, if we really want to do something on mental illness, we would make a huge strategic error if we entered into support for a program that was not tightly ring-fenced and therefore tightly cost- controllable. If we have to take the option of doing nothing in that area, versus having an open-ended solution, we will have to choose to do nothing. I am giving you pragmatic policy advice here, and that is what you have seen coming from my colleagues.

What we need from people like you over the next few months is criteria by which we can define that program. How do we get it ring-fenced so that it makes sense to start moving on the issues you have all raised? We all recognize the issues, but we need proposals that do not leave us in the situation where we have opened up a Pandora's box resulting in the entire proposal being tossed out.

I am obviously not looking for an answer now. However, I ask you to go back to the roundtable and to the Canadian Mental Health Association and to others in employment groups. We really need your help. If you can give us that information over the next few months, that would be great.

Thank you all for coming.

The committee adjourned.