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

Issue 16 - Evidence - May 31, 2005 - Morning Meeting

WINNIPEG, Tuesday, May 31, 2005

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 9 a.m. to examine issues concerning mental health and mental illness.

Senator Wilbert J. Keon (Deputy Chairman) in the chair.


The Deputy Chairman: Honourable senators, our first witness this morning is Carol Hiscock from the Alliance for Mental Illness and Mental Health in Manitoba.

Ms. Hiscock, we would like you to make your presentation and then be available for questioning.

Ms. Carol Hiscock, Member, Alliance for Mental Illness and Mental Health in Manitoba: Thank you, Senator Keon and honourable members of this committee. I am the executive director of the Canadian Mental Health Association, Manitoba Division. I am also a member of the Alliance for Mental Illness and Mental Health in Manitoba, which I am here today to represent. Unfortunately, I am here to represent the person who was here to represent the alliance at the last meeting, who was here to represent the president or the chair who was not president. I am the second backup or the second string.

Thank you for providing the alliance with this opportunity to comment on the committee's issues and options report. We welcome the invitation to provide general comments on the work of your committee from our vantage point of the alliance in Manitoba.

The Alliance for Mental Illness and Mental Health is the provincial counterpart to the Canadian Alliance for Mental Illness and Mental Health, which has already made submissions to this committee. The Manitoba alliance is a coalition of 12 professional groups, addictions and mental health service centres and self-help organizations. I have provided a list of our membership, along with the mission, vision, values and principles of the alliance, in the package that we have distributed.

Most important, and of primary interest to us, in the case of the federal arena, we will want to see a national action plan created and implemented. There is no provincial plan for mental illness or health in Manitoba, and we anticipate that the federal government can show leadership to build a framework that would support each province and territory to develop their own tailor-made plans that best would meet the needs of Canadians wherever they live. This is the one major point we want to stress at this hearing. Canadians require and deserve a national action plan on mental illness and mental health.

Provincially speaking, recent data from the Manitoba Centre for Health Policy showed that between 1997 and 2002, more than one in four Manitobans had at least one mental illness diagnosis. During that time they used nearly half the days that people spent in our province's hospitals. Moreover, of the high number of hospital days that people used with one mental illness diagnosis, most admissions were for physical, not mental health reasons. These data impress upon all of us the huge financial and human costs of continuing without a solid national plan for mental illness and mental health.

Turning to some of the other issues listed in this committee's third report, the alliance supports the approach currently being examined within the general health care system of enhancing interdisciplinary collaborative care. We believe it is the only way to go. The initiative takes as its base the understanding that silos must be breached and that collaborative, interdisciplinary teams are the best practice model for managing health concerns.

Using a similar approach then, we recommend that your committee focus on sponsoring initiatives that employ interdisciplinary mental health care teams, as well as interdisciplinary health care teams that employ mental health.

In addition, consumers, their families, and the community at large must be included to ensure the services and programs offered are really consumer driven and approved. Adding consumers and family members as advisers or board members assists in developing broad base support for interdisciplinary programs and services, and ensures that they stay on track by having to guarantee ongoing consumer satisfaction, and family and community commitment.

Furthermore, this approach makes certain there is broad base support for any new project right off the hop. To our mind, that ensures buy-in from many different constituencies.

Thus, we recommend future federal government support be reserved for new initiatives that adopt an anti-silo approach by employing interdisciplinary teams that are overseen by consumers, their families, and community members, to ensure accountability.

Another issue of considerable interest to the alliance is early detection and intervention. In Manitoba, a number of programs and projects are under way that focus on providing evidence-based prevention programs to large numbers of people. I note from the web, your schedule for tomorrow includes presentations from representatives of some of those programs.

In terms of how the federal government should go about supporting early intervention programs, the alliance recommends that money be directed to provincial and territorial governments. I probably need not mention the initiative that Manitoba hopes to move forward with, the chronic disease-prevention initiative, which should be a relationship between the provincial government and the federal government around chronic disease prevention, which would include mental health and mental-illness-related issues.

The usual approach of the federal government to grant funds for a pilot or demonstration project is not recommended. All too frequently, these good initiatives disappear from the landscape as soon as the federal funding runs out. In a community, by the time you have buy-in and good strong family and consumer involvement, the three-year or five-year demonstration project is over and it is not continued; a really sad track record in that area.

Once again, the alliance recommends that the programs being considered need to demonstrate that they are effective and interdisciplinary, with solid consumer, family and community support, and that they focus on the prevention of illness, promotion of good mental health, and/or are recovery oriented.

Effort also needs to be made to ensure that the advisory committee is representative of the community's cultural make-up, and has members that are competent to examine services for children, youth, adults and seniors.

We are a wide province in terms of regional disparity and cultural make-up, and each of those areas needs to be considered in the program development.

Third, the federal government can do a lot to reduce the stigma of seeking help for mental health concerns. One way is to launch a public education campaign that stresses the importance of attending equally to good mental and physical health. You may have seen the CMHA mind + body fitness campaign recently that came out at the beginning of May. It is an example of what we believe is a good public education campaign to link people's thinking around mental health and physical health. We strongly recommend bringing mental health into the general lexicon for a federally sponsored campaign.

Our mission is simple. The Alliance for Mental Health and Mental Illness Manitoba has, as its mission, to facilitate and promote the establishment and implementation of a Manitoba action plan on mental illness and mental health that reflects a shared provincial vision for meeting the needs of persons with mental illness and enhancing the potential mental health of all Manitobans. Our work will be much facilitated by the success of this committee in developing and implementing a national action plan framework.

Thank you for your work, and we eagerly await your final report.

The Deputy Chairman: Thank you very much. Can you expand a little bit on the relationship between the provincial counterparts and the national counterparts in the organization for the Alliance of Mental Health, on a national basis? The reason for my pursuing this is, like you, I think everybody hopes to pursue some kind of national strategy, national action plan and so forth. Some of these organizations already have the infrastructure for that kind of discussion, if resources could be made available to them, and so forth.

Could you expand a little bit on how this organization works? I have had the experience in the past number of years of serving in various positions with the Heart and Stroke Foundation across the country, with all its provincial constituents and the national organization. I served on the national board and so forth, as well as the Ontario board, so I have some idea of how these organizations work, but I would like to understand how yours works.

Ms. Hiscock: Senator Keon, I have a similar experience with the Canadian Cancer Society, and what I can say is the alliance is different from both your and my volunteer experience. I would also to like acknowledge that John Borody and Annette Osted are both here, and are also members of the alliance in Manitoba. I am probably the newest member to the alliance in Manitoba, so if I inaccurately reflect a reality, I am sure they will correct me, if that is all right.

The alliance federally is the leadership of all our organizations at a national level. For the Canadian Mental Health Association, our representation is through the national office. Penny Marrett is our national executive director, or CEO. She represents CMHA across the country at the CAMIMH table or the national alliance table.

We are not as structured as the Heart and Stroke Foundation, the Canadian Cancer Society, or some of the other larger voluntary organizations that have financial support from organizations across the country. We are much more similar to something like the Health Charities Coalition of Canada, which is a fledging, maybe three- to five-year-old organization that is taking a look at the work of the health charities across the country.

The structure is much less formal than you would see in some of the longer standing health charities.

May I ask Ms. Osted to comment?

Ms. Annette Osted, Executive Director, College of Registered Psychiatric Nurses of Manitoba: I represent the Registered Psychiatric Nurses of Canada on the Canadian Alliance on Mental Illness and Mental Health, CAMIMH, the national body. Here in Manitoba I represent our provincial organization.

CAMIMH does not have provincial arms, if you wish. Alberta, Manitoba and I believe B.C. now have established provincial alliances on mental illness and mental health to pursue provincial action plans on mental health, though there is no formal affiliation with CAMIMH, except we share the same goals, albeit at different levels.

The Deputy Chairman: Your organizations, I assume, have enough flexibility that the provincial organizations do not have to correspond fundamentally to the action plan of the national organization?

Ms. Osted: We do not necessarily have to, but we do. Our sole purposes for existing are to align ourselves with the goals of CAMIMH, albeit at the provincial level. However, we have the same goals; we are working towards provincial action plans on mental health.

Senator Pépin: You said that you prefer there be no more pilot study, and also that the money go to provinces. Do you have any specific program or orientation where you would like to see the government involved in the province regarding mental illness? Let us say, if you have some pilot, and we said no to the pilot project, and I understand because after the two, three or five years, if there is no more money, everything dies. How would you like us to make some recommendation where that money could be applied?

Ms. Hiscock: Within the Manitoba government, within Manitoba Health, and within the Healthy Living portfolios, the mental health directorate includes mental health and addictions. I believe that portfolio would be able to spearhead some opportunities within Manitoba. Manitoba is aligned with its regional health authorities throughout the province, so they have independence in determining what their priorities would be within the health care system and their regions. Some of the problems become, what is the provincial priority and what is the regional priority and how do they line up? However, I believe it is truly by having family, consumer, and community involvement at all levels in the planning that you begin to address everything, including cross-jurisdictional issues.

Senator Pépin: We believe that if we get involved at an early age, this is the best way. We also need to keep those people in their family, and to give them a job. After that, they shall be surrounded, and so hopefully it will be accepted.

After that, you said it becomes a public education campaign. I guess we all agree that what we did with the drinking and driving campaign really sensitized many, many people. Then, we should address something like this and — I am a francophone so I am always trying to switch in English — the education of the public to sensitize everybody regarding the difficulty in that. When people say they have, or they know someone who has, a problem with mental health, that would then be in the open and it would be much, much easier for everybody to deal with mental illness.

Ms. Hiscock: I think there are several national campaigns that have been good. There was the work in the 1980s towards a generation of non-smokers, and that is ongoing, another discussion. However, tobacco education and awareness is something that, through public education, has had a huge impact.

The Participaction work of the 1990s also has had a huge impact. Publicly, we know about seat-belt use with some of the advertising that has happened, provincially more than federally; public information campaigns work.

I am new to the mental health field. I have been working for CMHA for only about seven months. However, I have a longstanding history of working, particularly in Northern Manitoba, on women's issues in health care. It profoundly saddens me that mental health has the stigma that it does, when so many other diseases and conditions do not have that same stigma. That is what needs to be addressed. It needs to, excuse the vernacular, come out of the closet, and be seen as perfectly normal. Then you can address, through an education campaign, where the supports are and what kind of help is available.

Senator Pépin: You mentioned human resources in your presentation. You said the model has been developed that professionals are integrated into a large department, the accessibility of the services. You mentioned also that people who need to consult for mental health should have the same services as other people who are looking for, let us say a doctor or any other expert in medicine. Accessibility is important, and mental health services should be in every clinic.

Ms. Hiscock: Access to services in Manitoba is a huge challenge, and I am sure it is something that the Addictions Foundation of Manitoba, AFM, will reflect on as well. We are not like any other province. We have one major centre, and that is Winnipeg. Then we have a second almost-large city, Brandon, 120 miles away, but in southern Manitoba. The rest of the province is really in a have-not position in terms of access to good professional service. Either there is too much turnover in staff or the communities are so small that they are not able to attract professional staff. Access to service for Manitobans is huge. There needs to be a much better way of modeling professions in the communities out of this city.

Senator Pépin: Do they have the same problems with access to medication for mentally ill people? Is it all covered by medicare?

Ms. Hiscock: Yes, they are covered by medicare, or by the federal system for any of the other populations in the community.

Ms. Osted: There is still a problem. There are persons who are on medication for a mental health issue, who, if they are on social services, their medications are covered. However, if they work, then the medication is not covered. They have a choice; do not work so your medication is covered, or work so you have to pay for this expensive medication. It is a real dilemma. It is a no-win situation for the person involved.

The Deputy Chairman: Unless there are pressing questions from Senator Johnson and Senator Gill, I would like to have Ms. Osted do her presentation. We will go through one presentation at a time, allow time for a few brief questions immediately after the presentation, and then have an open panel at the end for cross-fertilization. Is that all right with you, Senator Gill and Senator Pépin?

Senator Pépin: That is okay.

Senator Johnson: I suppose we could ask them to confine them all to the end?

The Deputy Chairman: Not necessarily, but I would like a major discussion at the end of all presentations, if we could do that.

Ms. Dawn Bollman, President, College of Registered Psychiatric Nurses of Manitoba: Good morning, my name is Dawn Bollman and I am the president of the College of Registered Psychiatric Nurses for Manitoba, CRPNM. With me is Annette Osted, executive director of the college.

Thank you for the opportunity to address issues of mental health and mental illness with you this morning. We are delighted that this committee is addressing this most important issue, and we are also pleased that you are meeting with people across the country.

Our submission is about a dozen pages and we will not read it all, but we will highlight some of the content.

The mission statement for the College of Registered Psychiatric Nurses of Manitoba is to ensure safe, effective psychiatric nursing practice for the public.

We, therefore, have a legitimate concern about the discrimination against people with mental illness or emotional problems: the disparities between resource allocation for mental health issues compared to resource allocation for physical health issues; the lack of equity of mental health services between regions; the lack of comprehensive services for First Nations peoples; and the lack of prevention and mental health promotion programs.

Registered psychiatric nurses are concerned with the holistic health of individuals, groups, families and communities. Our expertise is in the area of mental and developmental health, and disorders in relation to population health.

Registered psychiatric nurses were first educated as a separate profession in Canada in 1920, and they form the largest single group of mental health professionals in Manitoba and Western Canada.

Planning for any kind of health service must include planning for the appropriate human resources to deliver the service. Throughout the health service system, we see the concern about human resources, be it registered nurses, physicians, pharmacists, and technicians, et cetera.

This concern is exacerbated in mental health, sometimes simply because of the invisibility of mental health issues. Human resources for mental health are often forgotten.

The college works in partnership with other organizations in Manitoba, through the Alliance for Mental Illness and Mental Health of Manitoba, to promote the development of a provincial action plan for mental health. We strongly support the aim of the Canadian Alliance of Mental Illness and Mental Health in its motion of a national action plan for mental health.

We have sent our submission and we will therefore concentrate our comments on what we believe could be included in a national action plan for mental health.

Ms. Osted: We believe that both provincial and national action plans should include a strong mental health promotion plan based on the determinants of mental health. It is evident that mental illness and mental health problems have significant social as well as physical implications. To ensure the sustainability of our health system for future generations, more emphasis must be placed on the health, including the mental health of our population.

We believe federal leadership and collaboration with and among the provinces and territories is needed in the development of a national action plan on mental health. The jurisdiction for the delivery of health services is provincial, yet it has been demonstrated in the past that federal leadership can have a significant impact. If there is federal-provincial-territorial partnership in this effort, the effectiveness can be at least tripled.

We believe that more content on mental health promotion needs to be included in the curricula for all mental health professionals. The emphasis of curricula for mental health professionals has been on the illness side. This emphasis is understandable and that side must not be lost. However, more content has to be included on the promotion side. Some education programs may develop options for specialization in mental health promotion. Current mental health professionals need opportunities to learn more about what each can do in the area of promotion. That approach supports the collaborative delivery of services that Ms. Hiscock was talking about.

We believe that persons with a mental illness or mental health problem have a right to the same quality of care and service as do persons with a physical illness or problem. We, as a society, would never accept that a complex service or procedure be performed on a person with a physical illness, unless that provider was qualified to do so.

The counselling of a person with a mental illness, or one who is suicidal, is not always perceived as a complex process. It is a complex process and requires in-depth preparation. Education programs should be in place across the country to prepare mental health service providers appropriately.

We believe there is a need for inter-provincial collaboration at the master's and doctoral degree level preparation in psychiatric nursing. There is a need for advanced practice in psychiatric nursing, and there is a dearth of such programs in Canada. There is a lack of research in the front-line delivery of mental health services in Canada. There is a need for evidence-based practice. There is a need for succession planning for mental health human resources, and such programs produce teachers and researchers, both of which are needed to continue the profession.

We were talking earlier about the dearth of professionals in rural and remote areas. One thing that is happening, and we talk a little bit about it in our larger submission, is that registered psychiatric nurses are the mental health resource people in rural and remote areas. They often have consultation with psychiatrists by telephone, or else perhaps once a month when the psychiatrist flies in for a visit. We need to assist those persons to perform those services with competence and confidence.

We believe that the largest group of service providers are families, and that self-help groups are a significant support to persons with mental illness. Self-help groups have demonstrated their effectiveness in Manitoba. They are adjuncts to the mental health professionals for both patient-clients and families. Self-help groups must continue to be part of the system and spend their time assisting their members, as opposed to spending time and resources in fund-raising. Services should be devolved to them. Their individual approaches must be protected.

We believe there must be appropriate mental health resources in elementary and secondary schools. Schools are ideal to begin promoting mental health and to identify potential problems as early as possible. It has been demonstrated that early intervention can prevent more serious problems later on in life. You will hear much more about that from Margaret Synyshyn tomorrow morning when she speaks to you about children and adolescent mental health.

We believe that better services must be provided to persons in personal care homes. I am getting older, so this one is really important to me. The changes in population in personal care homes must be met with changes to what services are delivered and how. Thirty years ago the population of personal care homes were the physically frail and elderly. Today 75 per cent to 85 per cent of the population of personal care homes are persons with cognitive disorders or mental health disorders. However, the staffing patterns, at least in Manitoba, for personal care homes have not changed for the last 30 years. I do not want to be treated that way. There is a concern that personal care homes are becoming the new warehouse for older persons with a cognitive or mental health problem.

We believe that First Nations peoples must have access to appropriate and timely mental health promotion and mental illness services. First Nations peoples are the fastest growing population in Saskatchewan and Manitoba, yet there are still federal-provincial jurisdiction issues that prevent access to mental health services. Population health issues are critical to ensure the health, including mental health, of First Nations peoples. Housing, education, recreation and employment are all issues that impact on health.

Ms. Bollman: Mental health and mental illness issues must be addressed as critical components to an overall health care system. The prevention of mental health problems and mental illnesses can have a strong impact on the cost of the delivery of health services. The effect of prevention programs and mental health promotion programs are not seen overnight. They require long-term commitment, and therefore transcend a political agenda. A national mental health action plan that addresses short-term needs while implementing programs that address long-term goals requires commitment to the welfare of the Canadian people.

Thank you very much for this opportunity to engage in this discussion with you.

The Deputy Chairman: Would senators like to address specific questions about this presentation?

Senator Pépin was a nurse and has been actively involved in every possible dimension of nursing all through her career.

Senator Pépin: I am an old one too, so when you mentioned the same quality of care and the present age of people in care homes, I did not follow you. You say there is a high percentage of persons who are in home care or something like that. Could you repeat what you said?

Ms. Osted: Yes. The Manitoba Centre for Health Policy did a major study on mental illness and mental health issues, and published their report last September. In that report they identified that up to 85 per cent of persons in personal care homes today, which is what we in Manitoba call nursing homes, where long-term care is delivered, have a cognitive problem, a mental illness, or mental illness diagnosis.

Senator Pépin: Eighty-five per cent?

Ms. Osted: Up to 85 per cent; not all personal care homes have that percentage.

Senator Pépin: You believe right now that those people are not very well looked after?

Ms. Osted: We know they get good custodial care, but there are no quality-of-life issues being addressed.

Senator Pépin: Is it because people believe they are elderly, and this is the way to look after the elderly people, or because they do not believe that they have some mental problem?

Ms. Osted: For a long time, we have had discrimination against persons who are older, and we have had discrimination against people with mental illness. You put the two of them together and it complicates the issue.

I also want to point out that I am generalizing. In some personal care homes, they are making efforts to address this issue. In Brandon, there are two personal care homes who have a registered psychiatric nurse on staff, to assist the staff to deal with, or to learn how to deal with, persons who have Alzheimer's disease, dementia or mental illnesses. That is a good start, but it is just a start. If you have one registered nurse or registered psychiatric nurse on a ward of 40 patients who have Alzheimer's or mental illness, there is restraint, and it is often chemical restraint.

Senator Pépin: There is a lot of education to do in that regard.

You also mentioned that psychiatric nurses do the work in the region, and the psychiatrist goes there once a month or something like that?

Ms. Osted: In some of the rural areas, that is what happens. In Manitoba, we have a position called community mental health worker, and in the rural areas it is mostly registered psychiatric nurses who fill those positions. They end up being the resource person to family physicians in terms of psychotropic medications, and they work with the schools, churches and service clubs to help persons reintegrate into the community.

They are the first line of defence, if you wish. They are also direct access to the mental health services delivery system for people. People with mental health problems are referred to them by the police, schools, friends and families. People do not have to go through the family physician to have access to the registered psychiatric nurse.

Senator Johnson: What numbers are you talking about in terms of these care homes, the warehouses? What percentage of the population in a given home here in Manitoba suffers from cognitive disorders, Alzheimer's disease, or whatever?

Ms. Osted: For a long time, elderly persons with a mental illness, Alzheimer's, or dementia were admitted to the psycho-geriatric wards of mental health centres or mental hospitals. However, with the closure of those large centres, these persons are now admitted to their home, personal care homes, if you wish, so it is difficult to say what percentage there is. However, we do know that a larger portion of the physically frail elderly are staying in their homes and having more supports in their homes, and that the populations in personal care homes, therefore, are looking after more of the behavioural issues, if you wish.

We know that one in four persons in Manitoba will access mental health services. I can go only by what the Manitoba Centre for Health Policy presented. I notice they are presenting to you tomorrow, and they would have more accurate figures than I do, but they did say up to 85 per cent in some personal care homes.

The Deputy Chairman: When we come to discussion with the entire panel, one area I would like to cover is the ideal structure for the delivery of mental health services. In other words, what is the ideal type of community team and community facility, and how do they integrate with the specialists, and psychiatric medicine, psychiatric nursing, the larger institutional facilities that exist and so forth? However, we will leave that to the end, and I would like to move on to Mr. Borody, if we may.

Mr. John Borody, Chief Executive Officer, Addictions Foundation of Manitoba: Thank you, senator, and thank you for inviting us. The chairman of our board is going to give the first presentation and I will answer questions.

Mr. Jim Robertson, Chairman of the Board, Addictions Foundation of Manitoba: Good morning. We are here today representing one of the organizations in this province, whose sole mandate is dealing with those who are directly or indirectly affected by the misuse of alcohol and other drugs, as well as those who experience difficulty with gambling. For the purpose of this presentation, I am going to focus my comments on the alcohol and drug side of our operation.

When I use the term drug in this presentation, I mean the misuse of alcohol and the general use of illicit drugs, as any use of these would be deemed to be a misuse.

Over my past four years as the board chair for the Addictions Foundation of Manitoba, AFM, I have come to appreciate the complexity and diverse nature of addictions.

In the report, you highlight the importance of moving out of perceived silos and approaching addictions, in order to ensure that the delivery of services is inclusive of the needs of the clients. In essence, you would like to see a system that is efficiently run, effective in its outcomes and client centred.

We believe that the experience we share with you this morning addresses the complexity of providing services to our clients, while cognizant of the scarcity of resources. We recognize there can be an overlap in needs with clients who suffer from issues of mental health and drug misuse. In response, our organization has partnered with regional health authorities in Manitoba, who have the responsibility to deliver mental health services. We have partnered with them in the Co-occurring Mental Health and Substance Use Disorders Initiative, CODI, with the goal of ensuring two main objectives.

First, all clients are assessed for a co-occurring condition so they can have a care plan that meets their unique situation. Second, the client does not know specifically who is responding to their needs.

Let us not lose sight that the numbers of clients we see who exhibit co-occurring symptoms are by no means the majority portion of the work that we do in the addictions community. I will speak a little later about the CODI initiative. However, before that I would like to give you some idea as to who we are.

The AFM became a Crown corporation in 1956 through a Manitoba legislative act. AFM based their initial programs on the Alcoholics Anonymous 12-step program philosophy. Since then we have grown into an agency that sees addiction as being better explained through a more biopsychosocial model.

I am not going to take up your time going through all the programs we deliver. We recently conducted a review of our expenditures, and 57 per cent is spent on rehabilitation, 33 per cent on prevention and education, and the rest on other services.

To give you a more in-depth look at the AFM, I have brought our business plan, which gives you the detailed, comprehensive list of our services. We are newly accredited by the Canadian Council on Health Services Accreditation.

Briefly, our mission defines our provincial mandate as, to contribute to the health and well-being of Manitobans by addressing the harm associated with addiction through education, prevention, rehabilitation and research.

We are unique in the health care field as we do not diagnose, provide treatment, or discharge patients back to their homes with care plans.

I am not just talking about semantics. Our approach is much more about teaching individuals how to live with their problem. We assess where clients are in their level of involvement with drugs, and their stage of change. We provide rehabilitative services and educational programs. We develop client-centred rehab plans on the specific client's objectives, and provide ongoing support by linking them to community services and self-help. We have just over 300 staff providing services throughout the province in 26 offices.

How do we approach addictions? There appears to be a dichotomy of opinions of who is affected by addictions. Many participants in the cross-country consultations on the National Framework for Action on Substance Use and Abuse conducted by Health Canada over the past year mentioned that there was a stigma associated with addictions, which results in this issue having a low profile politically and by members of society in general.

As with individuals with mental health issues, the profile of persons with addictions is often negative. Society's knowledge about persons with drug abuse problems is often shaped through its perceptions regarding organizations such as Alcoholics Anonymous and Narcotics Anonymous, or through the visible marginalized street population of persons with drug use issues. However, these groups represent only a fraction of the population of persons with addictions, and this presents the challenge.

In my presentation, the next section deals with some statistics, which you can read at your leisure. I would like to skip it to get to a clear dialogue on the issues.

Addictions are commonly thought of as being a harmful preoccupation with substances such as alcohol or illicit drugs. Addiction is a disorder identified by loss of control, preoccupation with disabling substances or behaviour, and continued use or involvement, despite negative consequences.

Dependence or addiction is not caused by moral weakness or lack of self control or willpower. It is the shame and negative consequences associated with dependence that lead to a significant stigma attached to substance abuse.

I have talked about addiction versus substance abuse and I thought it would be worthwhile providing you with our interpretation of the continuum of addiction. We believe there is a misunderstanding of this phenomena that adds to the confusion of the perceived stovepipe approach that our organization clearly does not support.

Various degrees or stages of substance use commonly occur. They move from experimental substance use, through social and recreational substance use, through situational substance use, intensive substance use, which would be like binging, and finally the step of dependence.

Not every person who uses substances will progress through all five stages. For example, some persons experiment with substances and then stop using them completely. However, once the stages of intensive substance use and dependence have been reached, the individual will often experience negative consequences. While the decision to try drugs is voluntary, by the time the dependent stage is reached, drug use is no longer entirely voluntary and may be viewed as a chronic relapsing condition. Inter-laid within this continuum are those clients who exhibit co-occurring behaviour; in other words, those who might have been self-medicating as a result of mental health issues.

I will provide an overview of the co-occurring disorders initiative. Early in 2001, the AFM and Winnipeg Regional Health Authority, in partnership with Manitoba Health, struck a multi-agency planning committee to examine ways for improving services to people with co-occurring mental health and substance use disorder. The Co-Occurring Mental Health and Substance Use Disorder Planning Committee was established with joint reporting to the partnering agencies. The purpose of this committee was to develop a systems framework to address the needs of persons with co-occurring disorders, and a plan to enhance the effectiveness and efficiency of services through collaboration within existing provincial resources, joint planning for new initiatives, and recommendations for short-term and long-term actions to address issues including access, cross-training of staff, and gaps in services.

Following a review of current best practices in this area, the committee's preliminary report recommended a multi-year initiative to implement a system-wide integrated services model. The first year of the plan called for intensive system-wide cross training to be carried out under the guidance of an expert consultant.

When sponsoring organizational partners hired the internationally acclaimed mental-health-services system-change consultant, Dr. Ken Minkoff and his associate, Dr. Christie Cline, a leadership team comprised of representatives from the three partnership organizations coordinated the implementation of this initiative. The leadership team in turn mobilized a supporting stakeholders group comprised of approximately 70 empowered representatives of key stakeholder organizations or program providers in mental health and addiction.

Following the initial consultation and training contract phase, both the leadership team and the stakeholder group oversaw and supported the development of subsequent phases of the multi-year system development plan.

A third group, comprised of approximately 30 selected leading clinicians and trainers from participating organizations or programs are being trained by the contract consultants to take on the ongoing training and consultation roles needed to support the long-term system-change objectives.

The ultimate goal was not to create one administrative structure to deal with this special need group, it was to establish one process whereby clients get the services they so desperately need. This approach has been successful and has received national recognition as being one that has truly brought addictions and mental health together for the common good of the client.

Key outcomes of the initiative to date include local consensus on the principles to guide the development of a comprehensive continuous integrated system of care for individuals with co-occurring disorders; a viable strategic plan for undertaking system-wide change to enable improved access and continuity in the availability of integrated services; a core of local trainers and consultants to champion the ongoing process of system-wide capacity-building for integrated services; and a training and consultation implementation plan that ensures that the enhancement of clinical and organizational competency reaches all programs that offer services to persons with co-occurring mental health and substance abuse disorders.

We see this as a made-in-Manitoba success, and I think we do so because it goes back to what we as Canadians value. Values are strongly held beliefs about personal and social behaviour. They play a significant role in influencing attitudes towards a variety of issues, including substance abuse and addiction.

In spite of many similarities in history, geography, and the culture of Canada with other countries, Canadian values are thought to be somewhat different from the values of others in a number of respects. When these Canadian values are applied to the area of substance abuse, this paints a picture of a kind, caring approach that focuses on education, health care, and social programs for the prevention, protection, and treatment aspects of substance abuse. However, Canadian values also point to a willingness to consider the law and order approach to the supply side of substance abuse to ensure continued safety, a low crime rate, and a clean public environment.

In summary, this morning I have tried to provide you with a two-dollar tour of addictions and the link to mental health as we experience it. The field of drug abuse clearly touches many in our community and can be influenced by numerous stakeholders.

In Manitoba, the AFM is partnered with acute care, long-term care, public health, mental health, enforcement, the provincial government, and school districts, to give you an idea of the breadth of experience the field of addictions can bring to the table. We have approached the delivery of services to co-occurring clients as one of the client groups with very special needs, amongst others with equally challenging problems.

Thank you for the opportunity to speak to you this morning about this fascinating field of population health that we call addictions.

The Deputy Chairman: This brings us to an interesting point in the presentations this morning. Mr. Robertson, at the end of your presentation you referred to the fact that your initiatives are integrated with a whole host of medical, community and social services. I want to tease out from the other panelists, as we go along, how this is working in Manitoba, and what is in place in the array of facilities that are integrated with primary health care, primary care in a broader context than health, and community services. Then, as we go up the line, I want to find out what is available in specialist services for addiction and mental health, and include the specialty nursing services, in particular, psychiatric services, and of course, the institutional services for the ultimate care of these patients. Who would like to lead us and tell me a bit about it?

Perhaps, Ms. Osted, you would start, because I am interested in hearing how the current nursing services, especially the more specialized psychiatric nursing services, integrate with psychology and some of the other professional services where there seems to be difficulties with the remuneration system in most provinces and this kind of thing.

Ms. Osted: I do not know if there are any physicians in the room, aside from yourself. I think if everybody was on salary, it would be a lot easier.

The Deputy Chairman: It does not bother me. I worked for a salary my entire life.

Ms. Osted: The fee structure continues to be an issue.

The Deputy Chairman: I have always thought it must be a nightmare. I cannot imagine practising medicine on a fee-for-service basis. I never did it; I never had to do it.

Ms. Osted: We have family physicians now, and the demographics of family physicians are changing drastically. There are a lot more women, and both men and women who have decided they do not want to spend their lives in an office or in hospitals, that they want a personal life. Therefore, people on a fee-for-service basis have to have more volume. One colleague told me that her family physician has a sign in her office now that says, each visit is five minutes only and only one complaint will be addressed in those five minutes.

It has been demonstrated that persons with mental illness have more need for physical health services, as well as mental health services. Thank Heavens I am relatively healthy, but I usually have more than one question I want to ask my physician when I attend.

The Deputy Chairman: Can I pursue that with you? I think you are on to something enormously important. However, I think there is an even greater danger than the fact that they have to see a lot of patients to generate enough income. Even worse than that is they have to see patients with a diagnosis that has a billing number.

Ms. Osted: Yes.

The Deputy Chairman: In other words, to make ends meet, they can see the patient only with a disease that is listed in the numbers that the government will pay for. I think it is one of the areas that we have to address in the whole broad spectrum of medicine, let alone psychiatry. Forgive me for interrupting you. I wanted to have you think about that one also.

Ms. Osted: When we talk about the ideal structure, I think we have to look at certain principles. One of them is access to the right service at the right time. I believe there is much more diversity of services that we could use more effectively. Those services include using psychologists and registered psychiatric nurses, using family physicians and psychiatrists in a different way, using self-help groups to their maximum, and using the patients, clients and families themselves — giving them more support so they can do more for themselves.

I think there are a variety of different models that are being tried in various countries that we could learn from. However, if we look at primary health care, which you have talked about, and community services, one thing we encounter is discrimination against persons with a mental illness even from health care professionals. This discrimination is to the point where I have heard from primary health care staff that they do not want persons with a mental illness to attend the primary health care clinics, because then other people would not come. It sometimes feels that we are fighting a losing battle, and we have to get on top of it.

The concept of primary health care holds promise for persons with mental health issues, as well as persons with physical health issues. There is more access and there is more diversity of health service providers. However, there is still not an integration of mental health services, real mental health service for people who have real mental health problems, in the primary health care system. I am sure this is happening not just in Manitoba.

We have examples of successes. We are fortunate in some ways, in Manitoba. We have some good services that are not in evidence in other areas, such as mobile crisis stabilization units, where people can go who may not need hospitalization, but need a safe place. Those have been very successful and continue to be.

We have the sort of community treatment program that is indeed a collaborative care model, where consumers of mental health services, professionals, and allied health service providers work together to assist people towards recovery and maximum participation in their community. The primary health care concept holds promise, but it is not there yet.

I do not know if that answers some of your questions.

The Deputy Chairman: I think that is universal, it is not just Manitoba.

Ms. Hiscock, you mentioned there is quite a gradient in the level of care between the small communities and metropolitan communities.

Ms. Hiscock: This is a complex question, and if there was an easy answer, everybody would have figured it out years ago. We cannot forget who should be at the centre — the consumer or the patient, whatever language we want to use — and we need to design programs that meet individual needs in a way that is collective, rather than how can we align together the services that we can already describe.

I think services are adequate in terms of what is good enough. Then as well, how much of that service is available? Do we have enough beds? Do we have enough community service support systems? Do we have proper access throughout the province? Then, are we aligning services in the best fashion possible, and in a fashion that is accountable to consumers and their families, so we have a much better, more rounded picture of what things look like?

I find your question provocative in terms of what is the right framework. I think the framework itself is so complex because it should be individually driven.

Mr. Borody: I would like to make a couple of comments, and I will fall back on past experience in my career. I used to be a CEO of a regional health authority, so I have had responsibility as director for mental health, as well as looking after acute care services.

You bring up something that is chronic, even in the CODI initiative. We all know we have limited resources. When we look at clients with addictions and/or mental health, we are dealing right now with those with very low needs. That is because that is all we have the resources for. We know they are time consuming. We know those with high needs can consume a lot more resources, so the challenge we all have as a society, as a system, and as government is, how do we develop systems that give equal access? Right now we do not have it.

With the CODI initiative, the clients we are currently dealing with are at the low level. These are clients that we know we can maximize the amount of people we can put through with the amount of money that we have.

In our case we are lucky, not unlike your experience, in that most of our physicians are salaried, so there is not that pressure to pump through a whole bunch of people to make that income. We take that away from them. What we try and do, as Ms. Hiscock mentioned, is focus on the needs of the client, so the physician who spends time with the individual is not pressured to pump through ten people today to make that money. Physicians are dealing with the needs of the client, and hopefully spending a lot more time.

That will be an ongoing challenge with this system; recognizing there is not enough money to do all the things we want to do. We need to focus our efforts and better define what the health care system is. The mental health and addictions are caught up in that challenge as well.

Senator Gill: I would like to exchange some observations concerning Aboriginal people. I am from an Indian reserve in Quebec. I have been in Winnipeg in the 1960s, I have been here in the 1970s, I have been here today, and my wife is with me. I used to see people with alcohol and drug problems, and things like that. However, it is something that I did not see in Winnipeg. Last night, I was even reluctant to go out myself, because people were asking for all kind of things. Since we know the situation a bit of the Aboriginal people, we are always inclined to give something to the people, and we know the situation. I know also that 2 per cent of the total population are Aboriginal in the country. Here in Manitoba, maybe I am wrong there, around 4 per cent or 5 per cent are Aboriginal but around 70 per cent of the population in jail are Aboriginal.

You were talking about alcohol, drugs, and things like that, and they are a real problem. I hope Aboriginal representatives are coming to us to exchange with them. I would like your perception, because it seems to me that the situation is getting worse and worse all of the time. I am so close to the Aboriginal people, and I am myself Aboriginal. This is my perception. I know that lots of people are working on that and trying to do their best, but what can we do about that?

The Deputy Chairman: Before you go on, Senator Gill, I would like to point out to the panel that this afternoon we will have representatives from the Assembly of Manitoba Chiefs, Norway House and others. If any of you would like to stay and participate in any way you could, you would be welcome, but please respond to Senator Gill now.

Senator Gill: I would like a non-Native perception. This afternoon you mentioned we will have an Aboriginal one.

Mr. Borody: Representing an organization that deals a lot with First Nations people, our program is designed to welcome First Nations people, but there is also a recognition that there is another group in the city of Winnipeg that actually deals with services directly for them. We provide programming that is culturally sensitive, but we do not provide cultural programs. We do not provide sweats and smudging.

We have found, though, that a certain segment of the population of First Nations wants to come to our group and not the other group, and that is fine.

To give you an idea, about 60 per cent of our northern clients are First Nations directly from reserve. About 75 per cent of our youth programs are First Nations, and about 30 per cent of our clients in Winnipeg are First Nations. There is a bit of differentiation depending on the office.

Overall, they are a well represented group, which is the bad news, in the sense that a lot of our clients come from that area. However, not surprising, what makes up our clients? Usually our clients are low income and low education, whether the problem is gambling, alcohol, or drugs, so it is not surprising that we would see them as a group.

The real sadness is, as you walk around downtown, even now at this time of the day, you would see an overrepresentation of First Nations people who appear to be under the influence, and I am not saying they are or are not. That is a group we do not see. We have minimum contact with that group. Part of that has to do with the whole political arena around First Nations. We work with First Nations people; we do not necessarily work in designing programs because that political element comes into it. First Nations communities see federal government, provincial government, and themselves as a government. That stance makes it very difficult for us to talk to them in any health care service. I am speaking on all my experience in acute-care and long-term-care mental health; there is no difference. A real line is drawn in the sand when you start talking about services, responsibility, funding, and accountability. It has made it really awkward.

We have tried to provide services to the clients as best we can, even with that barrier. We are there, but a whole group of people walking around this community have minimal service.

Senator Gill: You talk about the jurisdiction; you know that this is a federal jurisdiction. In Quebec, the provincial government gives services to people who need the services, including Aboriginal people. I am not saying they do not receive money from the federal government.

Ms. Osted: This happens here too, especially off reserve.

Senator Gill: I am talking also about on reserve. Those people who have been on reserve receive services from the hospital, from the medical world, from doctors and things like that, and I know the bill has been paid by the federal government. This is not the case here.

Ms. Bollman: There is a system in which the federal government is billed for people with status. Yes, the federal government pays, so there is a billing process. However, there are difficulties in getting persons such as registered psychiatric nurses to provide care because it is a federal system.

The Deputy Chairman: We are not recognized federally, so how can we be hired to provide services? There are those jurisdictional issues.

Senator Gill: There is no agreement between the provincial and federal government for services for the Aboriginal people?

Ms. Bollman: Yes.

Senator Gill: There is an agreement?

Ms. Bollman: To my knowledge there is, yes.

Ms. Hiscock: If I could add to that, to my understanding there is not a formal agreement in terms of providing provincially funded services on reserve. An initiative in Northern Manitoba, the Northern and Aboriginal Population Health and Wellness Institute, NAPHWI, is federally funded as a pilot project for two to three years, or whatever we have left of it. I hope they made a presentation in writing. I did not see them on the speakers list. That initiative was born as a result of the frustration all service providers, as well as funders, felt in dealing with the cross jurisdictional issues of who can go where.

You have a suicide cluster happening in a small community that is remote, isolated and a reserve, and the expertise in the region is not able to go in. This project, NAPHWI, was designed to come up with successful models that could be implemented elsewhere around service delivery in communities that are remote. In Manitoba, it is a huge problem.

Also, I wanted to speak to some of Mr. Borody's comments around the root causes of homelessness, helplessness or poverty, and what that leads to. This is where we believe it is so important to do public education, a health promotion program around mental health; to begin at a young age to have people appreciate the importance of employment, education, family supports and community in their lives so they are healthier mentally.

Senator Johnson: I think you are all doing fantastic work. I have been working in women's health issues for over 25 years. My dad before me was Minister of Health and involved in this area as well, in the 1960s. We could have a perfect world in terms of mental health issues, but we still have stigma. I have found that situation in my work, especially with women dealing with depressive issues, which is increasing so much during our society. We will not get into that whole side of it.

I do not know if you have any answers. I know this committee is concerned about that, but as I say, even in a perfect world, after all the work I have seen and done and has been done in the main in terms of communicating, mental illness is still not looked upon, for example, like diabetes, like this is a disease that is treatable. It is still in the closet. It does not matter who I know, they are all still hiding in their problem.

To even get a handle on the issue, be it Aboriginal, women or the general population, treatment should start sometimes with children. The latest research shows that depression is a genetic issue, and physical. In all the work you do, are you finding this? I am sure you are, but have you come up with anything else that we can do? I know this committee will be thinking of that. I have not been on it all the time, but I have worked in this field a long time with people.

Ms. Hiscock: One expert, Madeline Boscoe from the Women's Health Clinic here in Winnipeg, is speaking tomorrow afternoon, I believe. Their work on gender and mental health issues I think will perhaps be very informative.

Senator Johnson: It is not gender; I am talking about the whole attitude towards mental health.

Ms. Hiscock: The stigma, yes.

Senator Johnson: It is the biggest issue we face.

Ms. Osted: It is true. Schools are a good place to start. We learn a lot of our values from the school environment. Both at the provincial and national levels through CAMIMH and AMIMH here, we have tried to have mental health included on the overall public health agenda. Once it is perceived that way by policy makers — politicians — as well as bureaucrats and health care professionals, then we can start instilling some of those values in the public at large.

Also, for example, Dr. Carolyn Bennett, Minister of State, Public Health, was in Manitoba and jointly, with Minister Teresa Oswald, the Minister for Healthy Living in Manitoba, made an announcement about a physical health program for children. Why was mental health not included? We start by demonstrating our beliefs, and if we demonstrate them long enough, then people will start understanding them. It is more than words; it has to be actions.

Ms. Hiscock: When we talk about silos internally within the health care system, we talk about silos externally. It is often difficult to get what are healthy mental health issues into the school systems at this time, because their curricula are already finitely prepared. Also, we need to address the silos of other jurisdictions.

Senator Pépin: I think you said, and I want to be sure I understood, that there is a probable link between mental health and substance abuse. Do you see a link between the two?

Mr. Borody: We do ongoing assessments on our clients that go into our residential programs. About 35 per cent have an active mental health issue; they have already been diagnosed with mental health issues of depression, schizophrenia or something, so yes, there is a definite link for about 30 per cent of our residential clients. That is not so for other programs. That is why this program was set up.

Senator Pépin: Madame Osted, do you have any Aboriginal nurses; psychiatric nurses or not?

Ms. Osted: Yes we do, though we cannot give you numbers because it is a self-reported issue and we do not ask. At least two of them are actively involved in the Aboriginal health and mental health communities. However, our membership still does not reflect the cultural reality of the province.

The Deputy Chairman: Thank you very much for taking time out of your lives to help us on this report. We should have an interesting presentation in about five minutes from the Partnership for Consumer Empowerment. Again, I invite you to stay for as much time as you have throughout the day and help us in any way you can. It is very interesting, in some of the other hearings, the tremendously important role of consumers helping each other, and that in the appropriate community setting, mentally handicapped people, who feel disenfranchised from society, find a home, an identity, and this kind of thing.

Senators, our next witness is Jason Turcotte of the Partnership for Consumer Empowerment.

Mr. Jason Turcotte, Canadian Mental Health Association Office in Portage La Prairie, Partnership for Consumer Empowerment: Honourable senators, I am here today in place of Horst Peters, who is on his way to Montreal to present a recovery workshop at the national conference of the Schizophrenia Society of Canada.

I am a consumer of mental health services, recently employed by the Canadian Mental Health Association in Portage la Prairie, a community about 70 kilometres west of Winnipeg. I have also recently become a volunteer at the Partnership for Consumer Empowerment, PCE, program.

I ask your patience and understanding, as this type of presentation is a new and anxiety-provoking experience for me. For this reason, I will read from my notes.

I will not read all of Mr. Peters' presentation, which you have before you. Instead, Mr. Peters has asked me to provide you with a brief overview of the Partnership for Consumer Empowerment program of the Canadian Mental Health Association, Manitoba Division, and to provide you with his responses to issues and questions raised by this Senate committee in the November 2004 report, Mental Health, Mental Illness and Addiction: Issues and Options for Canada.

PCE is a provincial consumer initiative mandated to provide recovery-from-mental-illness education; develop consumer capacity-building training materials to train consumers to develop the skills to participate in the design, delivery, and evaluation of mental health services and systems; and provide expertise related to recovery, self-determination, and consumer participation to organizations and individuals in Manitoba.

The printed package you have before you gives a detailed description of the program and its activities.

Before addressing the issues in question, I want to draw your attention to another item in the package. You will find a brochure from the film, Inside Out, a performance piece written and performed by Winnipeg artist, Nigel Bart. This film was produced about PCE and is a dynamic, powerful educational tool featuring some of Mr. Bart's experience with schizophrenia. It also addresses stigma and recovery. Several copies of the film have also been provided to the committee. I encourage members of the committee to view the film and read the script included in the brochure.

I will read Mr. Peters' responses to issues and questions as he has prepared them. The responses are based on his experience and opinions developed through his work at PCE over the past seven and a half years. The response begins on page 6 of the document provided. I will address these in point form.

In Chapter 1 of the Senate report, "Delivery of Services and Supports," the first issue is patient and client centered services.

A client-patient centered system requires the establishment of clear, definitive standards and policies. These must make it abundantly clear that nothing less than a person-centred system of services and supports is acceptable. These standards and policies must be entrenched in all systemic levels from federal, provincial, regional and down. These policies and standards must include clear, measurable descriptions of client-centered system and service outcomes.

Furthermore, systems, services and supports must be held accountable for operating from a client-centred approach. It is essential that users of mental health services are included at all levels of the development, implementation and evaluation of these standards and policies.

The second issue is system coordination and integration with strong focus on community-based delivery. One of the committee questions was: How can the burden of coordinating and integrating services and supports be shifted to the system itself and away from affected individuals and their families? In my opinion this is the wrong question. I believe the more important question is, how can the system eliminate the barriers to individuals and families' navigation of service options, coordination, and integration? It is my opinion that a focus on shifting the coordination and integration of services raises the risk of more systemic and professional control and management, and less client choice and self-determination.

Let me suggest that a better solution, one that is consistent with the client-centred approach, lies in eliminating barriers to service and support-resource access, and educating consumers and families in the skill of assessing, coordinating and integrating services.

What incentives are needed to overcome the difficulties associated with getting existing organizations to work together? Address the current funding realities that often pit organizations against one another for the limited dollars available. Establish funding incentives for partnerships and service collaborations; however, refrain from instituting punitive funding policies for stand-alone organizations and services.

Another question was: How can duplication of services offered by non-governmental organizations be eliminated? Do not create monopolies or take away from consumer choice and options. What appears as duplication of services provides people with the option of choosing services whose various subtleties provide them with the opportunity to choose services and service providers that best fit with their desires, goals, needs, and personalities. This approach supports the principles of a client-centred approach and self-determination.

In Chapter 3, "The workplace," one of the issues was federal income security programs. There was a question: Should the federal government change the Canada Pension Plan Disability, CPP-D, to provide partial or reduced, rather than full, benefits to enable individuals with mental disorders to retain a portion of their benefits while still working part-time? The all-or-nothing approach must be eliminated. To provide benefits only to someone while they are 100-per-cent disabled is discriminating, disempowering, and a disincentive to recovery. People with psychiatric disabilities, and all other disabilities for that matter, require the opportunity to gain or regain skills, confidence, physical and emotional strength and stamina, and to establish a stable personal economic foundation. A policy of reduced and partial benefits along with the 100-per-cent retention of part-time employment income will enhance the recovery of persons with mental disorders.

The next question was: Should CPP staff members receive training to increase their awareness of mental addiction? Yes they should, and that education must include training to increase their understanding of what helps people recover, and the barriers to recovery. Users of mental health services must be involved as educators.

In Chapter 4, "Specific Issues," one of the issues was stigma. The question was: Has the word stigma become a polite linguistic way of justifying discriminations? Yes, it is much softer than prejudice, discrimination, social ostracism and second class citizenship, which are the markers of what we politely refer to as stigma.

Another question was: Is there a role for the media in trying to change Canadians views towards individuals with mental illness and addiction? The media must change its attitudes, principles, and values — if they even have them — and polices before they can change Canadian's attitudes. Media has played a major role in the establishment and maintenance of the current environment of prejudice, discrimination, social ostracism and second class citizenship faced by persons with mental disorders and addictions.

One of the other questions was: Are there public awareness strategies that have been particularly successful in Canada to reduce stigma and discrimination, and from which lessons can be learned? The most successful strategy is that of consumers telling their stories; their illness experience as well as their recovery story.

Should Canada create an ambassador bureau composed of individuals with mental illness and addiction who are trained to speak to the media and employers about their experience? Yes, and the audience should be expanded to address all Canadian society. Furthermore, these individuals — speakers — should be paid well for their contribution to the education of Canadians.

Should the federal government, working jointly with the media, develop a national mental health strategy to teach journalists how to report in ways that do not stigmatize individuals? Yes, and use persons with mental disorders and addictions as educators, paying them well for their expertise.

The last question was: What can governments do to increase everybody's awareness that mental health is as important as physical health to the well-being of Canadians and that, as a corollary, the delivery of services and supports for mental illness and addictions is as critical as is the provision of health services for physical conditions.

One, develop a national action plan. Two, publicize the cost of mental disorders and addictions and its impact on our economy, employers, families and health care system. Three, priorize mental health and health care through the use of effective standards and policies. Four, support the development and growth of consumer organizations and networks or coalitions. Ensure they are funded adequately to engage in public education and awareness, raising as well the development of persons with mental disorders and addictions to participate in this work.

In Chapter 5, "Human Resources," the issue was supporting caregivers. Unless I missed it, the report fails to recognize the need for families and other natural supports to work through their own parallel recovery process. Families require support and education resources to aid them in their journey of recovery from their losses, shattered dreams and personal pain.

In Chapter 6, "National Information Database, Research and Technology," the issue is research. Existing research funding seems to be directed primarily at clinical, biological, and genetic research. What is required is increased funding for research into the environmental, social, psychological, and spiritual dynamics of recovery from mental disorders and addiction. The Knowledge Resource Base detailed in the New Framework for Support published by the Canadian Mental Health Association provides an excellent foundation and justification for this type of research.

Persons with mental disorders and addictions need to have a prominent place and influential voice in the development of a national research agenda.

In Chapter 7, "The Role of the Federal Government," we need a national action plan on mental health and addictions in Canada. The federal government must define the values, principles and standards for a person-client-centred recovery-orientated mental health and addiction service and support systems. The government must implement an accountability process that defines, measures, and holds systems and services accountable for quality and effectiveness of services. The bottom line is: One, are persons with mental disorders and addictions recovering? Two, are persons with mental disorders and addictions participating as full and equal citizens in Canadian society? Three, do persons with mental disorders have a prominent and influential voice at all levels of service and support systems design, delivery and evaluation?

The last point was: I conclude with the mantra of the psychiatric consumer-survivor-ex-patient movement for more than the last 30 years: Nothing About Us Without Us.

Thank you, and that was Horst Peters.

The Deputy Chairman: Thank you very much, Mr. Turcotte. We will hear from Mr. Marshall, and then we will address questions to both of you before we move to the other side of the table.

Mr. Roman Marshall, as an individual: I am a consumer advocate of 14 years, an individual with mental illness diagnosis and experience in how the mental system works, a former employee of the Winnipeg Regional Health Authority, and a long-time member of numerous self-help groups in the community.

I thank the committee for the privilege of speaking today, and for your tireless efforts to improve our mental health and addiction systems.

I am going to itemize my comments. The first item is a proposal to introduce therapy to persons dealing with a mental illness, changing from a current over reliance on medication to a system based on the services of psychologists trained in various appropriate therapies, including behavioural therapy.

In this model, the services of psychiatrists would continue to be utilized to determine the psychological treatment required, and to provide the effectiveness of that medication. These two approaches, psychology and psychiatry, must work in concert and in partnership with the consumers.

At present, most people with mental illness are provided only with pharmaceutical or attended psychiatric services.

The second item is the issue of safety of in-patients in psychiatric wards. Although legislation and regulations demand the protection of any person from abuse, these protections are not effective in preventing the abuse of patients in psychiatric wards. This is a huge and ongoing concern that I urge the commission to address.

In Manitoba, we have taken measures, and when I was part of the Canadian Mental Health Association, we tried to encourage the other divisions of the association to get on board to have these changes take place. Here in Winnipeg, they have made a great difference. It is an important issue, and we should not be stigmatized at that level of care, and have that kind of sexual and physical abuse happening.

A third item concerns the need to confront the stigma on a national basis through changes in the film and television industry. To do so is logical, extremely cost-effective in the long term, and promises great inroads in our efforts to deprogram society regarding the myths of mental illness. It will remove the source of misinformation which is harmful to consumers' recovery.

Film and television have used mental illness to add drama to their productions by suggesting the character may be, or is, suffering from an illness, regardless of whether or not the character's behaviour could be attributed to other causes, either emotional or physical. The industry must be alerted to the damage these actions are inflicting on the mentally ill, and the harm they are doing in stigmatizing persons with a mental illness.

A comprehensive national program to provide accurate information on mental illness is required. I recommend further that this program enlist and financially support self-help organizations to work locally, provincially, and nationally to encourage the film and television industry to change.

I will stop at this point and say that I have come up with some responses to how these might be achieved.

The fourth item and final recommendation concerns the utilization of an electronic health record system to approve treatment options for the mental health professionals to collect data of successful case studies to develop a reference book. This reference book would outline methods used to bring about long-term recovery, and include enough history and lifestyle information to assist the doctor to identify any correlation to determine using similar methods. This would, of course, be in the successful treatment procedures.

It is my hope your final report will reflect the views of consumers like me and others across Canada. We are here today not only to discuss the fate of the mental health system, but the fate of those who access its services. Thank you.

The Deputy Chairman: Thank you both very much. In what we have heard so far as a committee, there have been overwhelming requests for involvement of the patients; in other words, a patient-centred system based at the community level that allows access to the community's social service resources in the way of housing and financial support, on an interim basis, or long-term basis if necessary. Other resources would include job finding, all that kind of thing, as well as the mental health services provided in a primary care setting, with a multi-disciplinary team to provide that primary care. This comes from patients like you, and both of you have reinforced that again this morning, so we are groping now for how to describe this in our final report.

Senator Kirby and I are currently groping for how to design a primary care system that could provide an infrastructure for this also in a separate paper that we hope to publish over the summer. Therefore, what you have said is of tremendous importance to us.

The other component that has been emphasized and that I want you to comment on, before the other senators ask your advice, is the fact that we have heard repeatedly that there is tremendous support from the peer group; in other words, the group of peers that are using a community facility get to know each other, they become a family, they reinforce each other, and they drive one another to the doctor or hospital for other illnesses. They drive one another to the employment office or to the welfare office for financial resources, if they need it, or whatever.

With that background, would the two of you try to tell us how you have lived with this, what is missing, and what you would like to have in an ideal world?

Mr. Turcotte: Like I said, I have been recently employed by the CMHA, and I do support housing work for them; peers helping peers. I have an anxiety disorder and I cannot help everybody, but at CMHC I take people to their doctor appointments, I pick them up and give them hands-on support. We have a little club where they can come for coffee and stuff like this, and I think we are making leaps and bounds that way, but it is not enough. We need bigger spaces. We need more people.

I am not sure if that is exactly what you wanted, but there are some things already in place, and more to come. Programs like PCE are needed.

The Deputy Chairman: That is very, very good.

Mr. Marshall: I know the Winnipeg Regional Health Authority would disagree with me, but I worked for them for a time, and I might say very successfully. I had a good rapport with my clientele. Even people that had frequent relapses were out for several years under my care, and I helped them to gain independent living.

My ideal scenario would be that, regardless of whether it is the mental health field, consumers are seen for our abilities and not designated to work in a part-time situation. I have my counselling certificate for applied counselling, and received very high grades and I have a lot of experience over the last 14 years doing counselling in the community and help. However, they do not want to put consumers into social work or anything like that because they stigmatize and say, we did that once before and the person got ill and quit. We are all individuals with different coping skills.

A similar thing applies to governments and different organizations that are hiring people. They put limitations on people with mental illness to protect them. Someone mentioned earlier about the attitude of parenting or protecting, overprotecting, and not allowing a person to stretch to the limits that they can. I think we are aware of our own limitations and we can say, hold on, this is getting a bit overwhelming and I need to take a step back or I need to cut my hours, or whatever the case may be.

This brings me to the comment that I read in the committee's report about the businessman who said he did not want anyone with a mental illness working in his organization because of the sick days and mental health days that the person would have to take off. If you have a poor work environment, an unhealthy work environment, that is bound to happen to anybody; anyone in this room or anywhere out there. I think that is stigma again.

Stigma is one of our greatest enemies. Even consumers stigmatize against consumers. In the self-help organizations, a great proportion of consumers cannot get in because consumers in the group feel they have reached a level of recovery, and if a person comes in that has behavioural problems, it is like oil and water, gas and water, or whatever.

Senator Gill: Mr. Turcotte, I would like to mention the phrase that you mentioned — I got it through the translation and I will try to pronounce it in English — nothing on us without having us involved. I think you should repeat that often to all the people. I have been living with problems myself as an Aboriginal. People try to organize others who they feel are not organized, so you should repeat that often. Say, do not do anything without having us involved. It is very important. It does not mean that people have bad faith; people have good faith, and they try to do the best. However, you have to be involved if you want the right things to be done, and you should do the things yourself.

Senator Johnson: Thank you for your presentations. You both mentioned the power of the media in terms of influencing people's attitudes, and the lacklustre job you feel they are doing. I produce a little film festival, but I am also on the Standing Senate Committee on Transport and Communications that is doing a media study right now in the country. Can you mention, or give me one example of, both of you, in terms of the media, one thing that could be done positively at this time?

Mr. Marshall: Yes. As I suggested, finance the self-help organizations. We already tried this here in Manitoba. Failed the attempt right away because I contacted Chris Summerville from the Manitoba Schizophrenia Society and said, this is the problem. For example, you probably do not have time to watch TV, but last week I watched Crossing Jordan, Medium, and Outer Limits, and they all use drama, like a mental illness kick, to make the story more interesting. They also used a vision of mental illness from 50 years ago; people wandering around and bumping into each other in a big room. Mr. Summerville contacted all his contacts across the country and said, Could you come on board with us and can we send this letter off to these different companies? Everyone said, we have been allotted this money to work on stigma and we are doing this, we are doing that, we are doing whatever, and we cannot do that. We have not got the financial resources for a one-time project like that to try to change society's view on mental illness. This would affect the whole spectrum of society.

Senator Johnson: You are talking about the way things are portrayed? You are talking about the way programming portrays —

Mr. Marshall: Yes, give them the information of how that impacts people, and give them a letter signed by all the self-help groups, ministers of health in every province, and the federal minister. Provide the funding to compile this information and send it out. We talk about the need for education in the schools and everything else. This would be one way of doing it. Anybody who watches TV, and everybody does, maybe we would not do it in the summertime —

Senator Johnson: A media study will tell you that 70 per cent of Canadians get most of their information from television. Even with the Internet, 70 per cent of the information nowadays is from television. That is why I am curious. There is a stronger and growing film population, especially for independent films. Independent films could be one way of telling some of these stories. I believe you can tell them as stories, and that is what people watch and what they respond to. That is what I think could be mentioned in our report in terms of the unbelievable power of the media. Telling stories is the way to get the message across.

Mr. Marshall: I believe it is important to have self-help, and everyone else I just mentioned, involved in contacting all the television and film industry because it will have a much larger impact. You do not allow racism, or different things like that. When a movie is put out, and it is obviously geared towards racism and putting down Aboriginal people, and projecting everyone as being that way, people rise up. Take for instance, Me Myself and Irene. When that Jim Carey movie first came out, a lot of people were very upset about how schizophrenia was portrayed. I did not find it funny, but I did not find it that offensive — I am not that serious all the time.

However, funding is needed to try to make that difference; to at least allow them the choice to try to make that difference. We have to deprogram society.

Mr. Turcotte: I have had anxiety since I was eight years old. I was scared, from watching TV all of my life, to actually say anything to anybody. If I feel that way, and it took me until I was 30 years old to seek help, can you imagine what it does? That is all I really had to say. It is the power; if we could completely educate the media, it would be a big turn around for us.

Senator Johnson: That is a good, insightful comment, and I think you are right.

Senator Pépin: In your presentation you speak about employment, and you said that the provincial and federal government need to ensure that opportunity exists. You said that the provincial and federal governments have to get together so that people with a mental disability could be employed, like the past legislation for Aboriginal people.

Mr. Marshall: Yes.

Senator Pépin: You said it is important that you have the possibility to be employed, and you wish there could be legislation by the government on that one.

Mr. Marshall: Yes.

Senator Pépin: Also, you mentioned passing legislation to protect the patient under care from physical and sexual assault. Could you elaborate a little bit about that?

Mr. Marshall: I had just spoken about it earlier. Several years ago, when I was on the CMHA board, we actually had them change that. I worked with a person who had been raped several times in a psychiatric facility. We tried to convince the other divisions of the Canadian Mental Health Association to come on board with us, to address the federal government and their own provincial governments about safety on the wards. It is already a law that this protection is provided, but it is not being provided on psychiatric wards, for whatever reason.

Senator Pépin: It is not implemented?

Mr. Marshall: It is in Manitoba, but not in other provinces. Does that answer your question?

Senator Pépin: Yes.

The Deputy Chairman: Well, we have to move on, but if you would kindly stay where you are, maybe we can come back to you at the end of the panel. Thank you both for your candid presentations and for sharing your lives with us. I can tell you it has been helpful.

Senators, we will now hear from an organization called Well Connected.

Ms. Heather Dowling, Well-Connected: I would like to thank this committee for the amazing work you are doing and also for the generous opportunity to present this morning.

My name is Heather Dowling. I am the mother of three, and with my son just turning 18, they are all now young adults.

My experience with the mental health system is on a few fronts, most profoundly for me as the mother of a daughter with a severe eating disorder for a number of years, and who continues to work towards a healthy life.

As a public health nurse, I am aware of how the mental health system works in my little corner of the world. As a member of the steering committee for Well-Connected, a local eating disorder support group, I am often asked by individuals, parents, or school counsellors for appropriate help. When your child breaks an arm or a leg, you know where to go. You know that when you go there, someone will help you. You go to the emergency department and the nurse sees you, the doctor comes, you have an x-ray, and either you are given a cast, or worst luck, you need surgery, but you get help. It hurts, and it wrecks your aspiring NHL career, but with care it gets better and you get on with your life.

If you have an eating disorder, it is not like that. You do not know where to go. Your parents do not know where to go for help. Lots of doctors and nurses do not know what to do for you. Many of them blame you for being sick. However, you are sick, really sick. Trying to get help is a frustrating, lonely journey.

Most people make many, many calls in an effort to get help. When you finally find something that looks hopeful, you get on a ten-month waiting list. To get back to the broken bone analogy, it is like showing up in emergency with a broken bone and being told, yes, it is really broken, so try and do what you can with it and we will see you in ten months.

Now, you would probably survive. To be sure, that limb would never ever be the same again, and to fix it they would probably have to re-break it. However, even if they did that, it would never heal the way it would have if it had been attended to when first broken.

That seems a ludicrous example. No one would ever do that, nor should they. However, this is what happens with mental illness all the time, and somehow it is acceptable.

At age 11, my daughter's treatment and ours as a family would have been very different if she had cancer rather than an eating disorder. Along with state-of-the-art medical treatment, we would have had social workers and counsellors to help us cope with that very difficult situation. The experience of having a child with a mental illness has all the fear, doubt, searching for answers, trying to cope, stress, and emotional trauma of having a very physically ill child, without any of the supports that a serious physical illness receives. You feel very much alone, and left alone.

Parents do the best they can to provide help and care for their child, and many incur huge expenses in the process. In Manitoba, the challenge of finding appropriate, effective help for eating disorders is difficult enough if you live within the city of Winnipeg. If, like many, you live in rural Manitoba the challenges are almost insurmountable.

What would it have looked like in our situation if eating disorders received the same quality of health care as other life-threatening illnesses?

First of all, there would be physicians trained to screen and treat individuals with eating disorders. There would be nurses in the clinics and hospitals educated in recognizing and treating individuals with eating disorders. A counsellor would be attached to the medical clinic that could have started seeing her early in the process and would have worked with us as a family on the road to recovery. There would be hope that she could be well. We were well into two years in the struggle before anyone ever said to me that she could get better.

There would be a professional network for the doctors, nurses and counsellors involved in trying to treat her, to provide for them with the opportunity to share ideas, to support each other and to earn from one another.

There would be support groups for her, her siblings, and us as her parents that were not be a five-hour return drive away.

There would be ongoing access to a counsellor or treatment centre to regroup when the setbacks occur.

In the course of my daughter's illness, and in an effort to save her life, she required an extensive stay in our local hospital. With a great deal of creativity, effort, compassion and support for the staff involved, this piece worked quite well. I suspect there are many such stories around the country like that. The trouble is, very few know about them and we all keep reinventing the wheel.

In your packages there are two articles, one from the January 2005 BC Medical Journal, and the other from the University of Glasgow in Scotland. Both these articles represent new ideas in ways of treating eating disorders. There are also two information sheets on two treatment centres that I am aware of that provide excellent models for residential programs.

It is my very great hope that 20 years from now we will treat eating disorders completely differently from the way we treat them today. Treatment will be different because we have learned so much and come so far and become so much more effective. Thanks.

Ms. Ruth Minaker, Chairperson, Well-Connected: I am a social worker at an acute-care mental health centre and the chairperson of Well-Connected, a non-profit organization dedicated to working with people who struggle with eating disorders. I am also the mother of a young woman who has been dealing with an eating disorder for the past five years. In the past seven years, in my roles as professional volunteer and parent, I have had contact with almost 100 people who have battled an eating disorder.

The members of Well-Connected want to express the thanks of our entire organization — individuals, parents, spouses, and professionals — for the opportunity to participate in this hearing.

We also wish to thank you for the work you are doing. Your efforts to listen to the people most affected by mental illnesses give us reason to hope that positive changes will result. Your reports indicate that you "get it." You have identified many of the most pressing problems and challenges, including lack of national leadership, the complex array of political jurisdictions and private providers in mental health, fragmentation of services, unequal access and lack of resources. We believe that you have also correctly identified many of the needs corresponding to those challenges.

Yes, we need a national action plan, coordination, accountability, communication between stakeholders, improved access and more resources. We need a national information database with ongoing research that is not funded entirely by the pharmaceutical industry. The principles of mental health, which you have endorsed, are central to improving the delivery of services.

Prevention, as you have noted, must include improved social conditions and a focus on mental well-being. Teaching coping skills and resilience in schools is a good example. Early detection and intervention is critical. Enhanced access to appropriate services in a timely fashion is vital. Client-centred care has been emphasized in your report, and a strong consumer voice was underscored in Phil Upshall's presentation, as well as in the presentations we heard earlier. The shortcomings of primary health care, as a medical model, are addressed in your report. Multi-disciplinary teams are essential for effective treatment.

In referring to mental health services for children and adolescents as the orphan's orphan in your report, you have highlighted our main concerns. Most mental disorders begin in childhood or adolescence, but as you point out, children in adolescence are the least likely population to access services, and have the least services to access.

Here is where we have information to share with you. Your prevalence data with regard to eating disorders is the lowest figure we have ever seen. We believe the actual rate is closer to 10 per cent of the general population than .1 per cent, and we also believe it is growing at all ages and in both genders. Numerous studies support our observations. I could quote you chapter and verse, but I will spare you that.

If you consider the number of adolescents who have significant symptoms of disordered eating, but may not meet all the criteria for a clinical diagnosis, the numbers soar to almost one-third of adolescent girls. That study was quoted in the Canadian Medical Association Journal in 2001. The author's name is Jennifer Jones.

Eating disorders have the highest mortality rate of all mental illnesses. They have one of the highest rates for co-morbid disorders. In fact, I cannot recall having seen a client with only an eating disorder. Usually it is a package deal with one or more of the following: depression, anxiety, obsessive-compulsive disorder, substance abuse and sleep disturbance. Personality disorders and post traumatic stress disorder are other co-occurring disorders.

The average length of time for a recovered person to have struggled with an eating disorder is five to eight years. We know many people who have battled this illness for 20 years or more. We also know several who have died.

After nearly four years of raising awareness in our corner of the world, we are hearing more frequently of young men with eating disorders, and of middle-aged women who are developing an eating disorder for the first time. The same factors that lead people to depression, anxiety or substance abuse are also related to eating disorder. Our society's pre-occupation with body image and the pursuit of an unrealistically thin ideal provide fertile ground.

Some people seem to have a vulnerability to developing an eating disorder. An international study is being carried out currently on the genetic influence on anorexia, similar to research done previously on the genetic component of bulimia. Highly intelligent, articulate, sensitive and perfectionistic young women are overrepresented in the people we see. They live with the burden of shame, secrecy and silence. We want them and their loved ones to know it is not their fault. They are not alone; there is help and hope.

I have attached some recommendations from us to your committee, and we have grouped them into five categories. We could have gone on at length, but we tried to be succinct.

The first category is prevention. In common with the prevention of other types of mental illness, prevention of eating disorders would focus on health promotion. Developing self-esteem, coping skills and resilience would be key, beginning in childhood. Unique to eating disorders would be an emphasis on healthy body image.

The second category is early identification and intervention. To effect this, training for health care and education professionals would be essential. Routine screening for eating disorders in primary health care settings would need to be implemented. Community-based treatment by a multi-disciplinary team would need to be available. Use of telehealth links and the Internet could facilitate this.

The third category is client-focused treatment. Clients and their family members deserve to be treated with respect and empathy. Treatment team members must maintain a hopeful and patient attitude. Empowerment of the client and individualized treatment are necessary to recovery.

The fourth category is support for families. Any mental illness extracts a terrible toll on family members. Family members require information, education and support. Only when absolutely necessary for the sake of the client should family members be excluded from the treatment process. Pathologizing families is almost never helpful. In fact, the reverse is true. Long after the treatment team has delivered its services, in most cases the family will still be involved in the life of the client.

The fifth category is national research, data collection and information dissemination. There is much to be done in the field of eating disorders. Not enough is known about the factors leading to the development of disordered eating, the prevalence or the most effective treatment. Best practices will change as new information emerges, and sharing information in an organized fashion would be helpful.

The Deputy Chairman: Ms. Minaker, before turning you over for questions from the other senators, would you give us what references you have so we can correct the understatement in our report?

Ms. Minaker: CMHA indicate that the prevalence of eating disorders, at best guesstimate, which is about all we have other than a few studies, is 1 per cent of the population of women have anorexia in their lifetime; and 3 per cent have bulimia. I believe those statistics were also reported in A Report on Mental Illnesses in Canada, that government publication, so those publications should already be available to you.

The Jones study of the Golden Triangle Area, which was done with several thousand school-aged girls about eating patterns, behaviours and so on, was quoted. It was written up in the Canadian Medical Association Journal in 2001, so that should be readily available to you.

There are a number of other studies, and one of the people best positioned to answer those questions is Hilary Grammar, policy analyst with the Mental Health Branch and Addictions of the Province of Manitoba. I work with Hilary and Yvonne Block on the provincial network for eating disorders. Hilary is at work on a publication which should be ready shortly, and she has done a stellar job of assembling current statistics and treatment methods, and evaluating them and so on.

Senator Johnson: Thank you, Ms. Dowling and Ms. Minaker. I am very sorry about your daughters, and I hope everything is going well with them. I had a sister who went through this, but it was caught early and we had great success. It was back in the late 1970s, so you can imagine there was nothing available then.

Having said that, is the majority of people involved with eating disorders at this time, the percentage, not greater for women than men, especially young women?

Ms. Minaker: We believe from what we have read and what we have experienced that, yes, most people develop an eating disorder in adolescence. Although we are beginning to see changes, as I noted in the presentation, we see a few women developing eating disorders for the first time in middle age. I think that speaks to our societal values, the fashion and diet industries, and the media play given to that unrealistic and unachievable thin ideal.

We also know that eating disorders are growing in young men. These disorders tend to be more about the six pack abs and the physique than about being thin. Often, it goes along with steroid use or abuse, but we are seeing some young boys, two this year who came to our attention, aged 11 and 13, who have classic symptoms of anorexia. That seems to be a disturbing new trend. We also note that eating disorders are being identified more in the gay population.

Senator Johnson: I totally agree with you about the younger men, and I think that is also societal pressures. I think one of the biggest concerns of a city like this, of course, and for everybody, should be that it is increasing. Teenage girls are smoking more to stay thin. They are unhealthy. They are not fit. There is not enough emphasis, as we know, on sports, recreation and that sort of physical activity in our society. Studies going on now because of obesity but there are just as many of these young people, boys with their weight, and the whole nine yards.

We are finding as well that as these young girls grow older, they are susceptible to osteoporosis in their thirties and they are not able to reproduce, so their whole body and physical being is affected, and that affects their role in our society.

Along with obesity and other physical issues in our world today, anorexia and bulimia have to be recognized. These diseases involve mental health, as this study is focusing on, because the thinking that goes along with them is not appropriate. Wherever eating disorders start, they are a vicious circle. Does depression kick them off, or do they happen because people are susceptible to other influences in terms of their eating, and what is on television today, which is what 70 per cent of what kids watch growing up, and what is on the Internet? All you see is the girls that are silhouetted at weighing one ounce, and photographed to look even thinner.

I do not know what you think in terms of the national plan, how mental health and physical health go together, but as the Greeks used to say, a good healthy mind and a healthy body. Perhaps in promoting this and connecting, that could be part of it as well in terms of this study. I think it is huge, and it is huge amongst our youth.

Ms. Minaker: Indeed, it is. One thing we find very concerning is that a lot of the public health system has gotten on board with the media campaign about the obesity epidemic. There have been a number of studies, fuelled by pharmaceutical corporations, to document the obesity epidemic. The fashion industry and the media play into that. That has really affected the care that people receive when they go to their family doctor. Often the comment that the doctor makes is about a person's weight first, especially if that person happens to be a young girl or a woman. I cannot tell you how many people I have seen devastated when they come out of the doctor's office because they have been told that they are obese. That is almost the same as a racial epithet at this point. It carries the same amount of stigma.

I want Heather to tell you about her reaction with a pediatrician who told a mom about a baby being overweight.

Ms. Dowling: This was an eight-month-old baby. The mom has only breastfed this baby, done nothing else — it could not have been eight months because you would start feeding solids around six months, so maybe it was a five- or six-month-old baby. It is a beautiful baby, gaining weight, great. However, the physician told the mom that this baby was too heavy. All she was doing was breastfeeding him. I was fairly horrified with the message that sends to people,. The mom came to me and said, what should I do? I said, nothing, keep on going, this is all good. They will start walking and it will be fine.

Obesity is a problem and our physicians have to face that. It is a problem in our culture. We have to be careful how we do that. When you look at statistics, 80 per cent or 90 per cent of eating disorders begin with a diet. You have to be careful how you use language and what you tell kids. Obesity is more a problem of not getting up and doing something than it is about what you are eating.

Ms. Minaker: We know that diets are 90 per cent ineffective. People can lose weight initially and they gain it back. It is harder to lose it the next time. They revert to more extreme methods. Many of our young women, as you mentioned, have resorted to extreme methods to lose weight and control their eating, including a burgeoning use of crystal methamphetamines. We will reap a dire harvest of all the behaviours that women and men engage in to control their eating behaviours.

The Deputy Chairman: It is very interesting sitting here and listening to you. I have been guilty in my past career of pushing prevention programs aimed at normalization of body mass; in other words, normal height and weight ratios in young people. I have spent my life in cardiovascular disease and was pre-occupied with premature onset of arteriosclerosis and so forth. I must say that I did not appreciate perhaps some of the damage that was done with the rather brutal approach to the subject. There was no intent of being brutal, but it probably was.

Ms. Dowling: The reverse can also be true. Because you do not know where to go for help — you know you need help or you know as a parent that something is wrong — the first place you show up is your physician's, because where do you go? You do not know how to do this.

I know a number of girls who have gone to see the doctor, and the parents are worried that this child's eating is out of control and that they have a problem. They show up at the doctor's office, and doctors are like nurses: they are programmed and they weigh and measure things; that is what they do, and it works for them. However, the comments then are, you look great, you are thin and you look good. To a girl on the edge of an eating disorder, yes she does but that is not at all helpful. It works both ways.

Senator Pépin: I have to admit the same thing for me. I knew there were eating disorders, but never the percentage that you said. You mentioned you believe it is 10 per cent; one third of all adolescent girls. You also mentioned use of the telehealth link and the Internet. I think it will be great and that has to be done, I agree with that. However, my worry is people who maybe do not have an income or a high income and cannot get the Internet. Maybe there is a group that we will have to think. I think it is very important and it should be there, but people with lower incomes maybe would not have that possibility.

Also, Madam, you said share ideas; a professional network of doctor, nurse, and counsellor should share ideas. Everywhere we go, when we speak about mental disorder, everybody says that we have to find a way for everybody to share information, work together and try to coordinate everything because nobody knows what the other group is doing. It is the same thing. I have to admit that I learned a lot today about eating disorders. I was not aware of that.

Ms. Dowling: I also think it is important for people who are treating eating disorders, because it is really hard. Part of the reason it is hard is because we are not particularly good at it. I do not think there are lots or really great studies. I think we are scratching the surface of how to treat an eating disorder. That is what I mean when I say I hope 20 years from now will be very different. For right now, the people who are treating eating disorders have to be able to connect with one another, because they too can feel lonely and alone, and that it is a frustrating, hard, long journey.

Senator Pépin: I agree.

Ms. Dowling: And it is.

Senator Gill: You say you have to wait ten months to get an appointment?

Ms. Dowling: The good news is, my daughter was really, really ill, and she probably topped the chart on the end you do not want to be at. One of the first doctors that we saw said to us, 97 per cent of girls never present as ill as she is. That is a really terrible thing; you do not want to hear that. The good news is, if she can get better, anybody can. This disease does not have to control you forever; you can get better. As I said, we were almost three years into it before anyone ever said that to me.

Senator Gill: Is it a new phenomenon?

Ms. Dowling: I do not think it is new.

The Deputy Chairman: It has been around for a very long time.

Ms. Dowling: Yes, I think it has been around for a long time. Manitoba Theatre for Young People did a production last fall called Dying To Be Thin; it was a one-woman play. They took it to high schools in the province, and there were 17,000 high school kids who saw it. You probably have heard about it. I talked to the actress that performed that, and she was amazing. It is in some ways a frightening play for me, because if you were sitting on the edge thinking, I might do this, there was enough information in that play that you could really do it well. When I talked to the girl who was the actress, she said, yes, the stuff in here is really scary, but girls who are coming up and telling me what they are doing to themselves is way worse than this. The really depressing part is, that play was written 17 years ago, and it is more relevant today than it was then, and that is frightening.

Ms. Minaker: There are documented cases of eating disorders centuries ago. Some of the Christian mystics probably had eating disorders, if we want to go back and look at that. There were women in the 1800s who would have their lower ribs surgically removed in order to have the wasp-waist look, so there have been body-image problems and eating disorders for hundreds of years, probably as long as people have existed.

What we are seeing now, we believe, is an explosion of eating disorders. Eating disorders have become normative behaviour in the junior-high and high-school populations at this point.

We know from hearing it from students that there are groups of girls who go to the bathroom to throw up together. That is way beyond my idea of togetherness, and it is not something that we want to promote. We know that there are 40 per cent of nine-year-old girls who say that they are on a diet. Nine year olds should not be thinking in terms of dieting. It is not healthy. We make it normative. They grow up with moms who say, my butt is too big and I will never get into this outfit. They learn that with their ABCs. We have to change that.

Senator Johnson: Was the first anorexic research not done on a 10-year-old boy?

Ms. Minaker: That could well be. I have not seen that particular piece.

Senator Johnson: Your information is so accurate. I have many nieces and nephews, and I know the kind of pressures they are under. Our emphasis in our family is healthy eating and working out. Of course, in the schools you do not have a chance to have a physical education program, and what is the parental responsibility? Are there any programs in Winnipeg or Manitoba?

Ms. Dowling: For adolescents in Manitoba, the Health Sciences Centre has an adolescent daycare program. To meet the criteria, you have to be really sick and really want to get better, and that is a tough combination. You have to be there from eight in the morning until six in the evening. There is nowhere for you to be after that but that is difficult enough for someone in the city.

If you live in rural Manitoba, how do you make that happen? I know families where one parent has taken leave from their job, moved into the city, got an apartment, stayed here, and they are there for three to six months. There is a residential treatment centre just outside Brandon — their brochure is in your package — that is totally privately funded. They have increased their beds and doubled the size there. They get no public funding and their clients are mostly Americans, because to pay in the Canadian dollar what we charge here is really cheap for them.

Then, there is a centre at Bridgepoint in Milden, Saskatchewan. Saskatchewan, like Manitoba, has a lot of rural population, and that residential program works in modules. You come there for three weeks, you work through a whole lot of stuff, and you go back to your life. You access that as many times as you need to. That centre gets some funding from Saskatchewan Health. That is a program that I think works really well. Basing everything in the big cities does not help lots of us that do not live there.

Maybe if we get to the place where we can intervene sooner — my daughter was 11, if she could have had a counsellor to talk to and know what was going on — maybe we would never have gotten to the places we got to, and they were terrible places to be. Maybe there will always be people who wind up that sick and have to be in the hospital. When she was hospitalized in our local hospital, none of us thought that was making her well. We all knew we were just trying to keep her alive.

Ms. Minaker: We are working with the provincial eating disorders network here in Manitoba, developing a proposal for residential treatment. Along with that, we want to develop a traveling troop, a core team, who can go to all of the different Regional Health Authorities of Manitoba and train local caregivers on how to provide appropriate care and treatment early in an eating-disordered person's life. That way, they do not have to progress to be so sick that they can go to the tertiary care hospitals.

Right now in Manitoba there is nothing available for residential treatment for an adolescent. I believe there are three spaces available in the adult eating disorders program at the Health Sciences Centre. If we look at population statistics, there would be thousands of women alone, without counting men, in Manitoba needing treatment.

The Deputy Chairman: Unfortunately, we are running overtime. Thank you all very much, Jason, Roman, Heather and Ruth for being here.

The committee adjourned.