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

Issue 16 - Evidence - June 1, 2005 - Afternoon Meeting


WINNIPEG, Wednesday, June 1, 2005

The Standing Senate Committee on Social Affairs, Science and Technology, met this day at 1:05 p.m. to examine issues concerning mental health and mental illness.

Senator Michael Kirby (Chairman) in the chair.

[English]

The Chairman: Senators, we have with us representatives of the Canadian Agricultural Safety Association. When I saw the name of your association, I had a quizzical look on my face. Then I looked at your material on stress and I understood exactly why you are here. Indeed, the stories of stress that we have heard from people in the farming community are legion.

We also have with us a group from the Mental Health Programs of the Brandon Regional Health Authority. We have heard from some of your colleagues in the Winnipeg branch. We are delighted to have you here.

Mr. Albert Hajes, Regional Coordinator, Mental Health Programs, Mental Health Programs of the Brandon Regional Health Authority: Good afternoon, Mr. Chairman and honourable senators. We represent mental health programs with the Brandon Regional Health Authority and we want to express our appreciation to the committee for the opportunity to speak about some of our experiences.

Brandon is located in western Manitoba, and under the regional health authority structure, provides services for the City of Brandon and the immediate surrounding areas. It is also a regional referral centre for many programs in southwestern Manitoba, which includes five other regional health authorities.

In terms of mental health services, the current organizational structure replaced services that were formerly provided by the Brandon Mental Health Centre operated by the provincial Department of Health.

We have asked for this opportunity today because we believe that we have experiences in mental health that will be of interest to this committee and can contribute to the overall findings and conclusions contained in your final reports.

There are a number of themes that we wish to discuss and for each major theme, we have included a number of key issues. We will include recommendations to several priority areas that we believe are in need of immediate action to improve services and conditions for those affected by mental and emotional disorders.

We have been through the experience of mental health reform, and we have experienced the process of closing a large mental health facility. The Brandon Mental Health Centre in western Manitoba was the principal provider for both in-patient and out-patient mental health services and it served the western Manitoba area for over a century; it is closed. Services were planned for transition to a community model and implemented throughout the period of 1994-99.

Preparation for these reforms began, however, in the early 1990's through initiatives such as the relocation of long-term elderly patients to personal care homes. Additionally, to prevent acute care admissions from developing into long-term admissions with institutional dependencies, clients were returned quickly to the community with referrals for ongoing support to community mental health workers and physicians.

We believe that the closure has been successful and that the transition of services away from an institutional model has worked well for most of our clients in western Manitoba.

The preparation for closure occurred several years before the implementation process through the application of clinical procedures to prevent institutional dependency and long-term admission. As we approached mental health reform, and in anticipation of its implementation, we began changing some of our clinical procedures to ensure that we did not continue the cycle of institutional dependency.

A very important point is that with the closure of BMHC we had to go through a process of shifting the beliefs of patients and staff to one that supported the principle that people could live with mental illness disability in the community and have good quality of life including a greater participation and full citizenship. It required a shift in thinking away from the traditional institutional model not just in terms of the staff and the patients, but also in the general community.

We had to ensure that adequate services for acute care, psychogeriatric assessment and crisis intervention formerly provided through the Brandon Mental Health Centre were maintained and restructured within the general community.

It is a community misconception that the closure of the hospital means that there is a closure of services. In fact, all the services are maintained but are redirected into the community.

Some of the key principles that went with the closure of Brandon Mental Health Centre were, the development of access to normalized good quality housing and the employment and social recreational activities following a model of community integration. We undertook the provision of professional and paraprofessional services to support and sustain an acceptable standard of quality of life in a community setting. We worked at maintaining fiscal support for programs and services to sustain the community model. We hope to discuss these principles today, although we are more interested in talking about what we are doing now.

That leads to the second theme, which is really the development of residential, and community support services, which has been essential to maintaining clients in the community.

A transition of this magnitude was not possible without the development of strong community-based services within the general community to support clients. Considerable work was done prior to the implementation of mental health reform and the transition of services to strengthen the capacity of the service structure and the community to sustain clients.

Key principles included recruitment and training of proctor paraprofessional staff to provide close and frequent contact with clients to assist with their independent living. We worked for the establishment of skill development and capacity building for clients to acquire the abilities to function with relative autonomy. We helped our clients to gain access to resources and have greater participation within the community. We established the full spectrum of services that are needed to support clients in a normalized community setting. These services include programs such as the Centre for Adult Psychiatry, the Centre for Geriatric Psychiatry, the Child and Adolescent Treatment Centre and the Westman Crisis Service. Other services include the Adult Community Mental Health Program, the Psychosocial Rehabilitation Program, the Residential and Community Support Services Program and the Mental Health Services for the Elderly Program. All of these programs are extensions of services that were formerly provided by Brandon Mental Health Centre.

Additionally, there was the need for formation of strong partnerships with other health and social service agencies, hospital services, physicians as well as police, school divisions, property owners and housing authorities and others. We were aware of the need for access to normalized housing, as we wanted to avoid the creation of mental health ghettos. We worked very hard to achieve this goal and Mr. While will speak about what we have done in terms of integrating housing models and the support services. We have been able to create a normalized housing situation and avoid a cluster of mental health clients living in one location and the creation of a mental health ghetto.

As we have moved along through our reform initiatives and the development of community services, we have certainly come across unanticipated issues and we have had to be flexible and somewhat innovative in developing unique models for supported housing to enable optimum client functioning.

The third theme that we want to contribute to honourable senators is our experience in the formation of partnerships for mental health services. An essential principle that enabled the transition was the formation of these partnerships and the support that was received by other health and social service agencies in shifting their thinking and beliefs towards acceptance that the mentally ill can live away from an institution in a normalized community setting.

The adoption of a recovery model with specific values, principles and practices for mental health and education and promotion of the principles of recovery with partner services and the general public were important to our success.

We worked for greater access to normalized housing, education, and employment. We worked with the communities to see that our clients could participate in social and recreational opportunities. We assisted in the formation of peer support and client-driven services and activities and the implementation of a service model that provided strong mental health support services to other service providers when difficulties developed.

If we were asking community partners to share in responsibility for service to mental health clients, we also needed to provide a backup service to them. It was a unique experience for some of the agencies to have to deal directly with mental health clients who were formerly clients of the Brandon Mental Health Centre. We had to provide a strong backup service and work closely with the agencies if the clients developed problems.

One of the other things that we had to do was ensure that as we moved from one system of care to another, we had to be sure that there was no opportunity for an easy return to the old system of care so that the patients were not readmitted for long-term purposes. We had to create a significant reduction in terms of the return access to long-term institutional care.

The fourth theme that we would like to focus on is early identification and intervention. As services are evolving and sustained in a context of full community participation, we are trying to build an increasing capacity to provide prevention, early identification, intervention and a rapid service response in order to prevent a recurrence of patterns of chronic severe disability and dependency on an institutional model of service.

To that end, the key principles are the formation of intensive case manager positions to provide close, frequent and holistic service involvement and a responsive and accessible crisis service available by phone and on-site visit at all times. We saw to an increased emphasis on services to children and adolescents to earlier identify the emergence of mental and emotional health disorders and provide services sooner to prevent a pathway that would impair normal development.

From our experiences in the provision of mental health services to all sectors of the community and from the transition and the methods by which services are provided, we have come to understand that the evolution of services is never complete nor do we ever arrive at a time when we can allow development to plateau.

We know very well from current research data that the disabling effect of mental and emotional health disorders is significant and the cost to society in both functional and fiscal terms is enormous. Yet somehow, unlike cardiovascular disease, cancer and diabetes, mental and emotional health conditions are not understood with the same recognition as physically based medical disorders.

There is an imperative need for strong national leadership to acknowledge mental and emotional health disorders as urgent health conditions. We need our leadership to acknowledge that it is a major source of functional impairment and disability that is equal to what are thought of as diseased-based medical conditions.

We recommend the adoption of a national action strategy to respond to the urgent needs for those who suffer from mental and emotional health disabilities. The Canadian Alliance for Mental Illness and Mental Health whom this committee has heard from previously proposed such a strategy, which includes recommendations for public education and awareness, a national policy framework, improved research and the formation of a national public health surveillance and reporting program.

There is a very compelling need to provide a high concentration of funding and resource support to services for children and adolescents. This population is synonymous with early identification, prevention and early intervention. Our youth represent hope and possibility that long-term disability in adulthood can be minimized throughout a commitment to care now.

Our fourth recommendation if that for those who are affected by mental and emotional health disorders, there must be an assertive effort to create supportive services and resources that build a community capacity for access to housing, education, employment and social and recreational opportunities so that meaningful participation and full citizenship can be achieved.

Mr. Marcel Hacault, Executive Director, Canadian Agriculture Safety Association: I will preface using my French because I do not have much opportunity to use it.

[Translation]

Thank you for giving me this opportunity to make a presentation before you here today. In spite of the lack of sunshine, I simply want to say that this is nevertheless a beautiful day to me because my eldest daughter is graduating from university today. So when I am finished with my presentation here, I will have the good fortune of seeing my daughter bring one stage of her life to a close, and I also have the good fortune of being able to make this presentation to senators today.

Senator Pépin: What a nice day indeed!

Mr. Hacault: As has already been mentioned, I am the director general of the Canadian Agricultural Safety Association.

Our mission is to work to eliminate injuries and diseases on farms. Our members pursue that objective.

We work to change the attitudes of farmers and groups who do engineering work, in order to reduce work-related diseases and injuries. We also work with people involved in the health care system and the mental health system.

[English]

Many of my comments are based on a national survey that we undertook in January.

Ms. Janet Smith, Manager, Manitoba Farm and Rural Stress Line, Canadian Agriculture Safety Association: Good afternoon, Mr. Chairman and members of the committee.

The Farm and Rural Stress Line began in December 2000, so we are a relatively new organization. The Canadian Mental Health Association and volunteers ran the precursor to our organization, but like many good organizations, it went the way of the dinosaurs because of lack of funding. Through the lobbying efforts of a number of agricultural, rural, and health-based organizations, the government reinstated the farm and rural stress line, with full funding, in December 2000.

We receive funding from Manitoba Health through the Department of Mental Health, the Mental Health Branch, and our mandate is to provide free, confidential information, support counselling, and referrals to farm and rural families throughout Manitoba.

Our core services are a telephone support line staffed by paid professional counsellors who also have farming backgrounds. Kim Moffat my co-worker is a counsellor and a farmer herself. She will have some interesting stories to share with you today.

We believe that our service is very important because the farming community has some unique needs and challenges best met by mental health professionals with a farming background. We also see ourselves as part of an overall group of mental health services that our community needs. We also offer an email help line. We are trying to reach out to individuals who would like to access us in a variety of ways.

We refer to community mental health workers throughout the province. Albert Hajes said the program would have community mental health workers as would the other regional health authorities throughout the province. We do a significant amount of outreach. At this time, we have been asked to do presentations on a number of issues related to stress management. One of them is "I'm not crazy; I just can't pay my bills." I think that speaks volumes to the kinds of unique needs that farm and rural families have because at the core of the stress levels is the issue of economic insecurity and the kinds of stresses that that brings upon farm families.

Ms. Kim Moffat, Counsellor, Manitoba Farm and Rural Stress Line, Canadian Agriculture Safety Association: I work as a counsellor at the Manitoba Farm and Rural Stress Line. My background is in psychiatric nursing and I graduated from the Brandon Mental Health Centre which Mr. Hajes was speaking of earlier. My partner and I run a small family farm in the southwest part of this province. We are cattle farmers so we have certainly been impacted by the BSE crisis that is going on right now. I think I have some real life experience and knowledge that has added to my ability to relate to many of our callers.

In the past, I have worked with farm families that affected by the BSE crisis and have worked through with them some of the many issues that they are facing right now with their families.

Our service is a relatively new service and over the past four years, we have certainly seen the numbers of calls grow in both number and in content. As you can imagine, financial stress is the number one topic but the rippling effect of that problem includes marital difficulties, relationship problems with children, and turning to different vices to help them cope through these hard times. It is evident that many of our callers are dealing with anxiety and depression.

As the BSE crisis continues, the calls have intensified. Farmers are finding they are running out of solutions and places to turn to for help to solve some of the many problems that they encounter.

We have spoken to farmers that feel that suicide is the only solution to their problems. The range of issues is diverse.

I am pleased to be here today to bring forth the voice of farm and rural people in the difficulties and struggles that they continue to face.

Mr. Hacault: I have submitted a presentation, but I am not sure how we should go through it. Most of my comments relate to a survey we commissioned. Western Opinion Research Inc. did the survey.

The way I have made comments is I refer directly to the issues and options and the parts there. Therefore, when it comes to delivery of services and supports, we saw that according to our survey results, 65 per cent of the farmers would prefer to meet one-on-one to talk to somebody about stress. If they are feeling moderate to high levels of stress, they would more strongly prefer speaking to somebody by telephone as opposed to those who are feeling lower levels of stress. This supports the experiences of Manitoba, Saskatchewan and Nova Scotia who have farm and rural stress lines.

In footnote 4, we note that the farmers prefer to access the service in the evening. We are not talking 9:00 a.m. to 5:00 p.m.; we are talking preferably in the evening.

One of the biggest reasons we are here is that 9 out of 10 of the farmers feel that is important that the mental health professional be knowledgeable about agriculture.

The rationale that we are putting forward is that the mental health workers who do not have a farming background may find it difficult to understand the issues that farmers may present.

As it comes to specific population groups, which is another area of your issues and options, we feel that the farmers seem to be lumped in something very similar to the rest of Canadians. So, current stress levels, roughly one in five are very stressed and about half are somewhat stressed. I took, on footnote 7, some data from Statistics Can. And depending on how you do the definitions, we fall very similarly with that.

I would put forward that we have unique characteristics. We have unique characteristics, and needs that are different from some of the general population's mental health issues. The basic stress triggers are probably different from the general population. The primary causes of stress within the general population are too many demands on the time, lack of job security and poor interpersonal relationships. That comes from a Statistics Canada report.

When we asked the farmers and this is on footnote 9, the high stress and extreme stress factors were production and price related, and interestingly enough, government policies are included in there and the personal pressure to maintain the family farm, which is something I think that is unique to farming. When I read this, I was a little surprised, but after speaking with friends and colleagues who had taken over the family farm, I understood that there is a great deal of pressure to be successful because you have been given a legacy.

The Workers Compensation Board does work with some provincial agricultural associations and I am thinking of the UPA in Quebec in particular, but the unfortunate part in that case, and we will take the UPA's case, is that the farmers are coming to the UPA for help.

The Chairman: Please tell us what the acronym UPA means.

Mr. Hacault: UPA stands for L'Union des producteurs agricoles. The farmers come to the UPA say that they need tools to handle stress at home and the UPA has a partnership with CSST, which is the Comité de santé et securité au travail. CSST will help UPA to fund workplace accident reduction programs, but they refuse to acknowledge that stress is an issue and they will not allow that partnership with UPA to fund programs that might reduce stress.

The reluctance of the Workers Compensation Boards to acknowledge the linkage between stress means that the Workers Compensation Boards do not fund activities related to stress mitigation.

On combating stigma and discrimination, referred to in footnote 10, the farmers are aware of the resources and then asked whom they would turn to when stressed. The first person that seems to get the heads-up on stress is the family doctor and then a mental health professional and then a priest or religious figure.

The farmers are proud and independent and 41 per cent gave that reason for not seeking help in dealing with stress and mental health. Stigma and embarrassment were lower than the pride factor. That information is in footnote 12. Remaining anonymous is very important to farmers.

In terms of human resources, we actually commissioned another report to go with this survey. We attempted to ascertain the type of services that were available to farmers. All the Canadian mental health agencies seem to be aware of a farm and rural stress line if there was one available in their province, but they acknowledge that they did not have resources to target or address the farmer's specific needs.

Although associations such as the Schizophrenia Society and the Mood Disorders Association have a wealth of experience, they are generally inaccessible to farmers. It is also difficult for a rural farmer to remain anonymous while participating in one of these groups.

Two of the most established projects are the Saskatchewan and Manitoba farm stress lines, which have provincial funding. Provincial funding of these lines allows them to focus on the job of assisting farmers rather than fundraising to ensure the lines stay open. The reach of these farm lines was demonstrated during the BSE crisis and the Avian flu epidemic in B.C, when both the Manitoba and Saskatchewan Farm Stress Lines received calls from producers and organizations from across the country seeking counselling and or enquiring about setting up farm stress lines in their areas.

Another concern, and this is a broad statement, is that there seems to be more people offering stress counselling services but it seems there is a lack of standardization and pretty well anybody can hang a shingle and say they can offer stress services. The quality of service is a concern to us.

When we get to research and technology, in a nutshell, we have two centres that we work with at the Canadian Agricultural Safety Association and one is the rural centre in Atlantic Canada and the Canadian Centre for Health and Safety in Agriculture based out of Saskatchewan. They are both funded by the Canadian Institutes of Health Research. Their focus is on rural research with CIHR.

We suggest that these two centres would be two good vehicles to do more research as it relates to stress, mental health and workplace safety.

I looked into tele-mental health because I did not know what it meant. While I was looking at it, I came across report for the Alberta Heritage Foundation for Medical Research State of the Science Reviews. It includes the socio-economic benefits of tele-mental health.

When I was reading through the report it was very interesting that nowhere did it seem to mention what I call "low technology," farmer, rural stress lines, and also they did not seem to mention the farming, the farmers as a client of those services. So the absence I guess was more conspicuous than what was in that report.

As it pertains to the role of the federal government, it is not part of your footnotes, but when I was doing work, there was a Standing Senate Committee on Agriculture and Forestry in a 1993 report. I have copies here and they actually had quite a few recommendations that you may find useful to look at.

The Chairman: That is good because I did not even know it existed.

Mr. Hacault: We support development of provincial 24-hour, and I call it tele-mental health, because right now, we focus on the telephone stress lines, but I think we could move forward into having tele-mental health services devoted to meet the specific and unique needs of farmers.

Like I mentioned, it is frustrating to note that in many of the literature and the assessments done to evaluate, agriculture is conspicuous in its absence.

The lines are often the first contact for accessing the Manitoba mental health services, and they are a non-threatening initiation to the mental health system. Where some may think that it is duplication, I put forward that the farmer and rural stress help lines assist in breaking down barriers to access professional services, whether those services come through the health authorities or community based agencies.

As noted in the survey, the family physicians are often the first stop, as it comes when farmers are dealing with stress. We must develop educational tools for the family physicians to assist them to better understand and respond to the needs of farmers and ranchers. That link has to happen. If farmers go to the doctor for heart problems and the doctor sees that it is stress related, he has to know where to find a stress expert.

I suggest we employ mental health workers with rural and agricultural backgrounds. We recommend that an exchange of ideas occur between the other provinces that offer stress lines so that we can build on the information that they have gathered.

Some Canadian mental health agencies do not seem to have mental health resources tailored to meet the needs of farmers and ranchers. I encourage a consultation process that includes farmers and producer groups. I am not sure how many have made presentations to this committee.

The CIHR centres could prioritize research to determine the link between stress and farm safety. They could determine the cost in human and economic terms.

With the expanded mandate of the Public Health Agency, we recommend that their mandatory coding classification include the external causes of morbidity and mortality codes and the place of occurrence codes as well as the type of activity codes. This information would allow us to ascertain the cause of the accident and the place of its occurrence. This in turn would assist researchers in determining links between farm safety and mental health. We would like to see the use of the ICD-10-CA code on every person who comes into the hospital. Mandatory classification may increase our knowledge of the links between stress and occupational health.

In a nutshell, that is our presentation. Thank you very much for staying awake.

The Chairman: What is the entry point into your system? In other words, we were intrigued with the construction of a single entry point into this system in Winnipeg.

Do you have the same thing, or do you have multiple entry points, and if so, what are they?

Mr. Hajes: We have a centralized intake system in our Brandon service, but we also have multiple entry points, depending on who the client is and what service they are trying to connect to.

Our service is not simply office space, so that the client needs to come to us, to our designated intake workers. However, our mental health services for the elderly team are mobile and they leave the office, go out into the community and will see people in their homes. They also provide service in rural western Manitoba. So they will travel to other communities and see people in their homes or in personal care homes.

The Chairman: How does someone get on that list in the first place?

Mr. Hajes: A person has to get a referral or self-refer to connect to one of our programs.

The Chairman: If it is self-referral, they phone this centralized number, right.

Mr. Hajes: Yes.

The Chairman: If someone goes to see a family physician and the physician says, I think you need help, of whatever kind, does the physician then phone the centralized number? What is the process? How does it work?

Mr. Hajes: It can happen in any of those ways. If a physician is making a referral, we prefer that the physician send us something in writing indicating any medical conditions they have been able to identify. We encourage people to see a physician when they are coming to our service for any mental and emotional health because there of course can be concurrent medical conditions that mimic mental health symptoms.

Connecting to our services is through any of those means. The client can simply pick up the phone and call the centralized number, will be put through to a designated intake worker, who is available all the time, and the process will start from there; or the physician can call, the physician can write, a family member can call, any which way.

Senator Pépin: How long is the wait-time? We hear that patients wait weeks and sometimes months for an appointment.

Mr. Hajes: We are actually very fortunate. We really do not have a wait-time. Our response time can be almost immediate. If you want to have access to an intake worker, you can walk in, and you might have to wait a couple of hours if the worker is with somebody else, but it can be same-day service for those out-patient referrals.

Similarly, the in-patient programs are not running waiting lists. There are sometimes, when all the beds are full, but we have been able to make alternate arrangements with the Brandon General Hospital, to maintain a client in a medical bed for a day or two until a bed is available in the psychiatric unit.

The Chairman: How do you manage to perform that type of service? Seriously, Senator Pépin is right, because keep hearing stories that people have to wait up to three months to receive treatment for stress related illnesses.

Mr. Hajes: No, no, we do not have that issue in Western Manitoba. I believe that that really speaks to the planning that went into mental health reform.

I have said for a long time that we are very fortunate that we have always had very good support from our executive and our board. We have a significant allocation from the overall budget to mental health, better than all the other RHA's in Manitoba. We certainly also benefited from our experience in the closure of Brandon Mental Health Centre which gave us a good indication of what the community need was going to be and allowed us to structure population specific programs like the Centre for Geriatric Psychiatry. We usually admit an elderly person with dementia the same day depending on the necessary arrangements.

Senator Pépin: Do you have enough doctors?

Mr. Hajes: No, I would not say we have enough doctors. We have enough beds and we have enough facilities, and enough programs to respond to the needs that come to us.

The Chairman: You have enough workers, but they may not be doctors.

Mr. Hajes: We have a large generic workforce of community mental health workers that have credentials of psychiatric nursing, psychology and social work. The Brandon Mental Health Centre employed a similar staff that did not include many psychiatrists and physicians.

In fact, truth be told, we went through a period of very lean years. At one point in time, we actually had one psychiatrist who came from Winnipeg two or three days a week to sign the documents, and we had a couple of physicians with some mental health experience. That developed the capability and the capacity of the non-medical workforce to be able to respond to the needs. The competencies of our workforce are significantly better, I believe, than what you would see in most other mental health regions.

I want to emphasize that I believe very strongly that we have always received very good support from our executive and our boards. They have given us strong recognition both financially and functionally of the importance of mental health as part of the spectrum of health conditions. Their support has enabled us to develop very good planning for services, and thus far, it has worked out quite well.

We have come across some unanticipated difficulties that are associated with the closure of BMHC. We are still working our way through those difficulties. I do not mean to suggest that we cannot use more funding.

Senator Pépin: No, no, that I know.

Mr. Hajes: We do not want to open up more beds, but we certainly need additional services to ensure that there is better flow through with those beds.

Senator Pépin: I am from Montreal; many years ago, we closed the mental health centre of Saint-Jean-de-Dieu. I have the feeling that many of the people that should be in that facility are now on the street, in jail, or elsewhere. The closing of that facility has left a negative impact on the people of Montreal.

I suspect that before the closure of Saint-Jean-de-Dieu there was little planning done such as the planning you did in the closure in Brandon.

Mr. Hajes: I would like Mr. White to talk about the community services planning.

As I said in my opening remarks, we really had the opportunity to plan and anticipate the point at which mental health reform would begin. It was not a governance directed initiative, it was a change in clinical practice in the industry.

As part of our standard clinical practice, we began to recognize that people should not stay in an institution for a long time, and as a result, our clinical methods began to change during the 1980s, and we began to return people home sooner. Somebody with tremendous foresight back in the mid 1970s established a community health program that moved psychiatric nurses from Brandon Mental Health Centre out into the rural communities, where they lived, and they became part of the community. Ms. Smith pointed out the importance of understanding what farm family life is like. Well, you know, we have had that community mental health program operating in Southwestern Manitoba since the mid 1970s. It is not difficult for us to have somebody admitted to acute needs, to stabilize and treat them and have them return home and receive follow-up with their physician and the community mental health worker. We have that program in place.

As for the issue of closure and homelessness, like many psychiatric facilities closures in the last 10 or 15 years, much of the population has been elderly. We were able to make a concentrated effort to return elderly people to their home communities, into normalized settings. Many of them went back to personal care homes. Initially there was tremendous fear and reluctance by personal care homes.

The Chairman: Nursing homes?

Mr. Hajes: Yes, we heard many statements about chaos and aggression, and reactions based on myths and misconceptions about mental health. We did a lot of work with personal care homes and the staff, and little by little, we began to move elderly long-term clients from BMHC back to their home communities where they maybe had not been for 20 or 30 years, but still had family in the area.

We were able to build in incentives for many of personal care homes, if they were willing to take X number of clients. We also promised staff from BMHC as it closed, and some staff had the opportunity to retain their positions and move to another community. Communities benefited from having this experienced staff move and work in the personal care homes as well. The incentive program worked quite well for both parties.

Our planning enabled us to anticipate the issue of homelessness, and we do have something of an issue in Brandon and the community, but nothing near the magnitude that you would see in larger cities. I think this certainly speaks in part to the size of Brandon and surrounding area which makes the operations of the mental health program quite good. Brandon and area has the benefits of a city and is small enough to recognize when the population is in trouble. We are able to spot people who need help and have the facilities to help them get better.

The people that we tend to have difficulty with in terms of homelessness and things like criminal behaviour are people that we have lots of difficulty in engaging in our service. There are certainly those who want nothing to do with us, and in spite of our best efforts, still refuse any service. Those are people who will end up being homeless or otherwise in trouble in the community.

Mr. Brent White, Program Manager, Residential and Support Services, Mental Health Programs of the Brandon Regional Health Authority: In making connections with people, we are not without difficulty. One of the things that emerged out of our closure and relocation of service, in particular for people with severe and persistent mental health problems, related to housing. We believe that the equation for success for better outcomes is to connect the provision of community based supports and supportive services with affordable and adequate housing. And I am sure in your other presentations across Canada, you have experienced similar stories.

We have had a community-based response, again related to our challenges around housing and developing partnerships with other organizations and agencies. We developed an integrated housing model, which involves partners like Manitoba Housing and non-traditional partners that include private and public funders. We work directly with property owners through some very good federal and provincial partnership initiatives, around affordable housing initiatives. That relationship helps in the redevelopment of affordable and adequate housing. We have been able to advance the case for people with severe and persistent illness to be able to access those newly developed residences.

The issue with housing is that it is not only bricks and mortar; it is about providing support services to people so they can engage in the community in a meaningful way. Proper housing must involve the combination of professional and paraprofessional staff.

In Brandon, we have developed something we call a "proctor service," which has been likened to home care service, if you will, for mental health clients. Those individuals provide support services to individuals supporting long-term goals. It involves the client in terms of an empowerment process, engaging them in working towards their goals, which might be living goals, educational goals, vocational, or social goals.

We have paid a lot of attention to the provision of supportive social programming as well for people. One of our strong partners, as an example, is a local downtown church. The church has opened its doors to people to participate fully in whatever they have to offer. That type of partnership is very helpful. It is not an office-based practice in terms of community mental health; it is not a 9:00 a.m. to 5:00 p.m. piece. It follows people that need help and forges relationships with them. We are hopeful that through the provision of supports and adequate housing, we will see long-term better outcomes.

The Chairman: When you talk about your community, do you mean Brandon exclusively? You service a very wide-spread area. Am I right in assuming, particularly with your reference to the other services, that the supportive housing program is really in Brandon? If someone in one of the rural communities has a problem, do they have to come into Brandon for assistance?

Mr. White: It is partly correct. One of the realities of rural life is depopulation, and for a long time, there has been a lot of relocation to larger centres to access service. There is, similarly in the Assiniboine Regional Health Authority, the ability to access mental health proctors on a smaller of scale. However, the reality around provision of supportive housing is it has emerged as being something of a model in the Brandon area. We have collaborated with the Assiniboine Regional Health Authority as part of that model as well, but the reality is many people do end up relocating into Brandon to access supportive services.

Senator Pépin: We speak about the elderly, but what about the same services for the young people in that area. Do you offer the same kind of services and if so is the accessibility the same?

Ms. Elaine Morris, Project Mental Health Worker, Children's Medication Follow Up Project, Brandon Mental Health Programs and Brandon School Division, Mental Health Programs of the Brandon Regional Health Authority: The Child and Adolescent Treatment Centre is a facility that is in Brandon for young children. It has an out-patient component and an in-patient component as well as a day treatment component to it where middle years and adolescents can attend individual and group therapy sessions. We also have a school program. Much like the other services, we have two intake workers at the facility. It is a 10 patient, in-patient unit. People can walk in or call, or a physician, or parent, or the school can make a referral to the Adolescent Treatment Centre. They can come in and see an intake worker who determines if they should have a psychiatric evaluation, see a psychologist, or one of the community mental health workers.

Some of the out-patient workers go directly to the schools to meet with children right because there is still a stigma involved in mental health issues and some children do not like to come to the centre. They are seen as a bad child as opposed to just having some issues.

The in-patient unit is a 10-bed unit, and I am not sure what the waiting lists are but they are not long. Like with the adults, if they can be accommodated in pediatrics in the Brandon Regional Health Hospital, they will hold them for a day or so if necessary until other arrangements can be made.

We have certainly seen a shift towards seeing younger and younger individuals. When I first started in children's mental health, we would have never admitted anyone under the age of 13, and now we are seeing seven and eight year olds being admitted for significant emotional issues.

Senator Pépin: I think it is great comfort to know that they can go to such a facility.

Mr. Hajes: If I may just add an additional remark. One of the key initiatives is the transition of adolescents into adulthood. This is an area where we have found difficulty because after 18 years of age these children seem to disappear. We have developed a practice that at 16 years we begin to bring the adult services and the children services together to anticipate the point of transition and do some planning for what services they are going to need when they turn 18. That transition involves mental health programs and often Child and Family Services where some of these children stay in group homes. We try to determine their needs and engage them in preparation for the transfer to adult services. We have a development team that is trying to make the transition seamless.

Senator Keon: Let me tell you how glad I am to hear from you. I have been looking forward to hearing about this operation for quite a long time. You have got great propaganda on the outside — no, I mean publicly — you deserve it, but the word is out that this is a very, very unique operation.

I am going to make a passing comment that I have never made before about the transition of children to adults, because it just keeps coming up and it is such a terrible problem. As our chairman has pointed out, there are kids in Ontario that are lost for two years because there is a two year gap between when they are a child and when they become an adult.

Quite frankly, in my past life I have dealt with this and it was not a problem at all. When the child turned 18, the records from the Children's Hospital in Ottawa were turned over to the Heart Institute, to the adult congenital clinic, and it was as simple as that, their next appointment was automatic. I do not know why other systems just do not use that system. For what it is worth, it never seemed complicated at all in our life and in my past life.

Let me come back now to first the Brandon program. Mr. Hajes raised the delicate balance that occurs in providing community support where these people can form their own little club to help and reinforce each other. He spoke about how community support provides these people with an understanding that they cannot get from the rest of society.

On the other hand, they cannot get too cozy or they get "ghettoized" as you mentioned. Frankly, I think you are the only people in the country with that problem because nobody else has been organized enough to get them in a cozy environment.

You have mentioned a few things about making certain that you had the right mix in housing, and they did not all go to one place and this kind of thing. Perhaps you can expand on that a little further because I think we need to implement your model across the country.

Mr. White: It is interesting that you make that comment. As part of mental health reform planning, we discussed whether to integrate or segregate community opportunities. I think, like all good Canadians, we came up with the answer that they should be both. What we have developed is a range of services that offer fully integrated experiences, and there are opportunities for people that may be in the clubhouse lines.

Historically, I think in Brandon was the first place that organized around the clubhouse model. We have Brandon Community Welcome based on the Fountain House model out of New York, which had a number of pillars around how consumers themselves, would organize themselves to become empowered, and look at their needs around housing, socialization, and certainly the needs around employment. Even before the closure of the Brandon Mental Health Centre, there was a clubhouse in operation in Brandon.

To add to all of that, we have tried to work cooperatively with our community partners to provide a range of services. Our community partners are the Canadian Mental Health Association, and church groups. We meet people with interests in things like fishing, woodworking, and music. Music is an excellent example. We have a street person's music group, for want of a better term.

What is significant about that is that these are the same things that in our own lives we look to as quality of life measures. We need to pay attention to those other measures, like whether people are working or not, because if we do not pay attention we miss significant opportunities to engage people in a process that should in the long run help them have better outcomes.

Ms. Smith: I just want to share an example, also from another life. I was a proctor in Mr. White's program. We live in Brandon. The Brandon mental health system's vision and belief system is that people with mental illness are people first.

I was a proctor yet I do not have a background in mental health care. I am not a mental health care worker. However, I have connections within the community. In my capacity as proctor, I worked with three men who suffered from schizophrenia, and through my community connections linked them to other community activities.

This is not rocket science; it is about relationship building. It might be as simple as spending the time to go shopping or to a movie with these people; otherwise, they might live very isolated lives. We must reach out to these people once their day programs have finished. I have invited these people to join my family for dinner and participate with them in a community garden project.

So it is not rocket science. I think it is just about relationship building. I do not know if that is unique in Brandon or not, but I know it works.

Senator Keon: It is very interesting, is it not, that you have a community that can care for these people who cannot care for themselves. "It takes a village to raise a child."

How many community health centres do you have in Brandon?

Mr. White: I just want to come back to the housing issue. I do not want to leave that today without really underscoring the importance of affordable housing. It sounds like we have good services, and I believe that we do, but we have very much been challenged by the whole housing part of the equation. The gap to market rents is a substantial problem. Rent supplements, really can make a big difference in whether people are able to sustain themselves in the community.

As part of our community development principle the regional health authority offices are located in the downtown core area. Historically, mental health facilities were located outside of the city itself.

The Chairman: I grew up in Montreal and it was called the "insane asylum," but it was designed to be not near anybody. Out of sight, out of mind.

Mr. Hajes: And literally on a hill overlooking the city, yes.

Mr. White: When mental health reform planning began, one of the most significant developments was the new location of mental health services, community based services and the regional administration offices. All of these facilities are located in a downtown shopping mall in Brandon. That is a community economic development principle, but it is also a principle around accessibility for people.

The Centre for Adult Psychiatry is close to other health services. It is located on the grounds of the Regional Health Centre, with all of the other departments. That in itself is "de-stigmatizing" as well.

Crisis services are located in the downtown area, not in a specific building per se, but in an older Victorian house, again in a community based setting. Residential services locations are available throughout the community as well. We have really worked hard to not exclusively use one building within social housing. We have looked at trying to incorporate and integrate it across the board. As new housing developments occur, rather than having a floor or a building that is dedicated to mental health housing, it is integrated. There might be two units one place, there might be three in another place. The idea is the distribution of services throughout the community.

The Adolescent Treatment Centre is located immediately next door to a local high school, not off somewhere separate. The close proximity of this centre helps to remove the stigma associated with mental illnesses.

Senator Keon: You get the picture very clearly. I think it is important to know.

Mr. Hajes: Seamlessness is a cliché that many people talked about, but our administrative design keeps all of the mental health programs under one administration, while other jurisdictions experienced the fragmentation of their mental health services.

As the program coordinator, all of the program managers report to me, and we all operate together as a management team. The program manager for the Centre for Adult Psychiatry in-patient unit sits at the same table as the adult community mental health program director. All of our programs compliment each other, and enables us to sustain a seamless system, because people talk to one another, and have the same pathways of accountability.

In other jurisdictions, the services for the elderly are over there, reporting through one stream, adult services somewhere else, and those paths never cross.

Senator Keon: I want to congratulate the Canadian Agriculture Safety Association on the tremendous concept of providing telephone consultation. I think that is a tremendous idea. I think it is tremendously therapeutic for people to talk on the telephone. Although, I have only got one daughter and she went to England for her education, and she married a guy and stayed there, she now has three children and her therapy is talking to her mother for two hours everyday, at my expense.

Ms. Smith: We will leave you our card.

The Chairman: I am very much looking forward to voice over the Internet.

Senator Keon: The other thing I was chuckling about is I grew up in a rural community in western Quebec, and as a boy, there were probably about 30 people on the same telephone line. So listening in on this party line was the most interesting thing you could do at night. How interesting it would be now to listen to the therapy of Ms. Smith on the rural line.

I want to make a comment about tele-health. In my previous life, I had a lot of experience with tele-health, and used it extensively. One of the problems you run into in tele-health is the technocrats will price you out of the market if you are not careful. You know, they want to the broadest band you can get so you can send everything across the screen and this kind of thing, and you really do not need all that service.

At the home care program that we ran out of our institution before I retired, people just used their television sets as receivers, and you can to that very cheaply. You can have face-to-face consultation quite cheap instead of going for the deluxe installations, and I caution you to look into that very carefully before you are stuck for a major bill.

I think it is tremendously important that rural people have access to this service. They have been left out of the system; there is no question about it, in every way when it comes to health, but particularly for mental health.

I encourage you to continue, and will ensure you that Senator Stollery and I will be highlighting this in our report so that it does not get lost in it.

Ms. Smith: I think we recognize the limitations as well as the benefits of telephone counselling. Certainly, for the individuals who live in rural and remote areas, it offers them immediate access. It is toll free and it is confidential. Our hours of operation are not 24 hours, however, so we do not have funding to offer that service. Mr. Hacault mentioned that most farmers want evening and overnight service so that is a problem. Our service is available from 10:00 a.m. until 9:00 p.m. Monday to Friday, and 12:00 p.m. to 5:00 p.m. on Saturday. We recognize the benefits and the limitations of what we can provide.

When we identify that a client may be experiencing severe persistent mental illness we take advantage of our link with the community mental health workers. We have lists of all of them throughout the province. We are kind of a first line, where they first stop, because of the pride, the stigma, and the lack of understanding of mental health services. Clients might not initially go to see a mental health worker, because their stress is associated with the inability to pay bills. So why would you go to see a mental health worker to talk about bill problems?

We understand fully that the outcome of financial triggers, if you will, is things like depression, anxiety, suicidal ideation, and marital difficulties, all of the kinds of things that professionals located within communities can help client's to overcome. Therefore, we see ourselves as part of services that can and should be offered to special populations.

Senator Johnson: I was away just for a minute there telling my colleagues about this fantastic work you have done in Brandon and it is a model for I think the country in many respects.

Can you tell me, what the cost differential is between the Brandon Mental Health Centre and the way you are doing things now? Is it a more costly venture to operate at the community level?

I would love to take this to Interlake and I would like to know what kind of money we are talking.

Mr. Hajes: I do not actually know.

Senator Johnson: You cannot put everything in dollars and cents, I am just curious to know is it going to be a hugely expensive sort of thing to promote.

Mr. Hajes: I do not think it is significantly more costly than the other system. I do not believe it is cheaper, because it does take significant funding to provide community services. If people are looking at significant cost savings as a driver for closing mental health centres and de-institutionalizing, I think that is the wrong reason.

I think the funding transferred gradually from the institution to the community programs. We have not noticed a significant effect in terms of the impact on our funding. We have simply used the funding that we have had available, and we have made submissions to Manitoba Health as we have proceeded for new initiatives, and some of those have been successful and added to our funding base.

Senator Johnson: Could we do this in the rest of the province, do you think? Could we do more of this in Manitoba?

Mr. Hajes: Yes, and some of that is being done.

Senator Johnson: Could you tell me where it is being done?

Mr. Hajes: All of the regions are submitting initiatives to Manitoba Health with requests for funding, particularly in areas like population health, in an effort to do more early intervention, early identification.

I am part of the provincial mental health network, where all of the managers for the various programs in the province meet on a regular basis, and these are the types of topics we discuss. I know that there is a strong interest in early intervention in Interlake.

Senator Johnson: I live in Gimli for part of the year and I know that it is almost impossible to get any intervention at all. While I am there I talk to people in the community, and I help them to access services, just because of my knowledge of the system, but it is very difficult for the rural areas to get that type of service.

Mr. Hajes: I agree, and the further north you go and the more rural the area becomes the more difficult it becomes to access those services. It is unfortunate that people are penalized by virtue of where they live.

We have a very good situation in Brandon in part because of our geographic location and our mix of urban and rural environments. And it really is an issue of a lack of capability to expand programs and develop the mental health programs the way they need to, in order to respond to community need.

At the point of mental health reform, and again at the point of regionalization, programs and their funding were frozen. Truthfully, there have not been many initiatives approved with funding. There have been some areas that have been targeted. Supported housing is one of them where funding was released for that purpose. However, some of the other service initiatives that we resubmit every year rarely find their way to Treasury Board for approval.

Senator Johnson: Well, I know that there is a tremendous amount of stress in the rural areas such as Gimli. I see many of these people and it is hard to know what to do for them, other than to try to put them on a path that you and I both know. Getting through the system is very difficult and I am happy to see that the process is working so well in Brandon. I am hoping the authority is going to be fast-forwarding some of this process into other areas.

Mr. White, is there any such activity on the farm side?

Mr. White: I am not doing much with the farm area, but for a couple of years before, I worked exclusively in Brandon and travelled to Assiniboine as well. My job at that time was to find individuals to work as proctors to provide supportive services in the rural area. Rural recruiting is challenging. You can find people in every town, but they are often providing home care support already.

Mr. Hajes: Senator Johnson, there is likely a community mental health worker in your home area.

Senator Johnson: Yes, there is.

Mr. Hajes: Now, I am not sure how accessible that person is to the population.

Senator Johnson: There is the new community health centre, but there is nothing really in place at this point in terms of that service.

Mr. Hajes: I want to comment that although the farm and rural stress line is located or based in Brandon, it serves the entire province. From my perspective, as the coordinator for mental health programs, I want to affirm the importance and value of that service and compliment the very good work that they do.

Ms. Smith: One of the main things that we do is try to identify the main issues that our callers want to discuss. If it appears that they might benefit from the assistance of a community mental health worker, we make that referral. We refer according to the region in which they live. I do not know that we have had the experience of people saying they have been unable to access that person.

Senator Johnson: In terms of how to access more than anything else.

Ms. Smith: For sure, and we get that response from people. They ask just what a community mental health worker does and ask why they should visit one of them. They say they do not need to see the worker because they are not crazy.

We provide our callers with information concerning our services. A caller is unlikely to just walk in the door and ask for a mental health worker but through a referral we can often, with that person's permission, speak with the mental health worker and put them in touch with one another. We help open that door a little bit of a crack.

One of the limitations of a phone service is that we do not do a lot of follow-up, however, our priority is to offer this service to strengthen the link with the client until he or she establishes a connection with an on-site mental health professional.

Ms. Moffat: I have noticed that one of the barriers relates to economics. I received a call not too long ago from a person who was unable to access mental health services because he did not have the finances to put gas in his car to get to our facility. There is clearly a financial limitation to get to where the services are available.

Senator Johnson: Well, I have to say that it has taken years to get our women's crisis centre in Gimli. We still do not have a safe house, and make do with the bottom of the old school. There was a safe house at one time but then it became unsafe, so you have to keep moving. We cannot even get the funding.

I have helped them to access some resource money from the provincial government, so that they are dealing with the women, but we still do not have any place for them to go. It is a very frustrating situation. I know that rural women are not suffering any less than the men who are dealing with other critical problems.

[Translation]

Senator Pépin: I know the agricultural field pretty well, in fact, because my grandparents were farmers. If one looks at everything that has happened over the past two years, the stress-related problems are quite normal. I did not think that farmers could suffer to such a degree; but that is to be expected.

[English]

You say that you have an open line and the people can get you through email correspondence.

Why do you not follow-up on callers? Is it because you have too many calls coming in?

Mr. Hacault: Just before Ms. Smith answers that question I want to you know that Manitoba and Saskatchewan are the only provinces that receive full funding for these services. We are talking about almost anomalies within all of Canada.

Senator Pépin: That is great.

Mr. Hacault: I think Senator Keon mentioned that although it is low technology, it probably suits the function.

Ms. Smith: I believe our budget is $165,000 for the year. It is a very, very low cost program.

Regarding your question of follow-up, thank you for that. It is something that is also unique. Many crisis lines are unable, due to call volume, to provide that very important service. We are actually a program of Klinic Community Health Centre, which is located in Winnipeg. We are one of six counselling programs. We are located off site, we are located in Brandon to service the farm and rural population. Klinic has a 24-hour crisis line, and one in seven calls is answered, due to the busy signals.

Ms. Moffat is involved in research concerning our provincial crisis line services to look at the gaps in the service to see how we can work more closely together to provide access to the people that need it.

In the farm situation, and likely in other situations, we must be available to take the call because it is perhaps the only call that the person will make. In fact, they usually place the call when they are right at the end of their rope, because they have tried everything to get through the situation on their own.

We believe that it is very important to offer that follow-up service. I would say that we appreciate the offer, and we often will have half a dozen or a dozen calls with the same individual before they will actually access any additional services if, in fact, they need them.

The Chairman: So you are the follow-up in that sense?

Ms. Smith: We are the follow-up.

The Chairman: Do you get calls from other family members or just the male members?

Ms. Moffat: In the first two years, we received more calls from women.

The Chairman: That is hardly surprising. They do not ask for help and they do not ask for directions.

Ms. Smith: Right. Women often called about their husbands.

The Chairman: Do sometimes teenagers call?

Ms. Smith: Very few. Just recently one of our counsellors has started a youth outreach project where she is linking with the schools 4-H groups, and talking to kids about what some farm and rural issues are around stress. So that is fairly new, but I think it will probably prove to be pretty useful. As we know, kids are certainly part of the picture when mom and dad are having difficulties; it is playing out in all relationships of the family.

The Chairman: What is the Children's Education Follow-up Project?

Ms. White: It is a partnership between the Brandon Regional Health Authority and Brandon School Division, and I do medication monitoring for students diagnosed with attention deficit disorder and take medication.

The Chairman: What do you mean by "medication monitoring"? Do you mean to see if they actually take the pills?

Ms. White: No, I work in the student services at the school division, and work along with the psychologist in the school. We do a number of checklists throughout the year that look at core symptoms of attention deficit disorder, like the inattention, the hyperactivity, the impulsiveness. We try to identify whether medication is effective, or if there are any problems with it such a side-effects. We send this information along to the parents so they can discuss it with their physician.

The Chairman: Are you involved in the diagnosis of ADD or ADHD students?

Ms. White: No, by the time the student comes to me he or she has received a diagnosis and the parents have chosen a course of treatment. The child might have seen the school psychologist, a private psychologist, or the Child and Adolescent Treatment Centre. When I meet the child, he or she is already on medication. I provide educational resources to parents and teachers.

The Chairman: Anecdotally, we get the impression that an increasing percentage of children, in both elementary and high school, receive Ritalin or something like it for ADHD. This is purely impressionistic, so I want to know if I can get the facts to support or reject this argument.

We hear that because of increasingly larger class sizes teachers recommend that the one disruptive child in the class take medication to stop the disruptive behaviour. The first move is to medicate the problem child regardless of whether or not it is the right strategy for the student.

Do any of you have time series data that shows that the pharmaceutical treatment for ADD or ADHD is increasing over time?

Ms. White: Well, I think over the years it has increased. When I went to school I did not know anyone who had attention deficit disorder or took medication for anything, so public awareness has certainly increased.

The Chairman: When I went to school, there were kids bouncing off walls and the comment was that they had too much energy. I swear today that I would have been on Ritalin years ago.

I asked the question seriously because I get the impression that we are using medicine to solve a behavioural problem as opposed to trying to treat the student. That is what troubles me.

Mr. Hajes: You have Randy Fransoo from Manitoba Centre for Health Policy coming later this afternoon, and he has a gem of a study that looked at health data in Manitoba.

The Chairman: Can you send us that study?

Mr. Hajes: Randy Fransoo from Manitoba Centre for Health Policy is coming later this afternoon, and he will have that data.

Another related issue is that you will see the imbalance between the diagnosis between boys and girls. One theory is that boys, of course, have much greater motor restlessness when required to sit in a classroom for long periods of time, and certain age ranges are less capable of doing that than girls, so they are more likely to create the appearance of having ADD and are diagnosed in that way.

The Chairman: That is interesting.

Mr. Hajes: We have a high prevalence of ADHD diagnosis in Brandon and we need to do something to address that situation. We need to validate that it is indeed ADHD, and if it is not, then we need to do something to bring those numbers down.

Ms. White: We need to have a thorough assessment policy. It is not enough for a teacher to suggest to a parent that their child might have ADD. There are associated problems that can look like ADD.

The Chairman: I have the feeling that there is too much treatment and too little assessment. That is just a gut feeling, but we will talk to the policy people.

Ms. White: My daughter did not receive the ADHD diagnosis until she was in grade two. We all knew there were problems, but as parents, we were reluctant to place her on medication. We certainly tried many different treatment remedies before we ended up putting her on medication.

Our experience with the medication has been very positive. The mental health worker was very thorough, so we really were able to rule out that it could be anything else but ADHD.

I think some parents are perhaps too quick to make the decision to place their child on medication. We took a lot of time and we realized it was in the best interest of our daughter to place her on medication, and we have certainly seen a huge difference in her ability to concentrate.

The Chairman: Thank you all for coming. I know we kept you way over time, but I am sure you did not mind it, and we were delighted to have you.

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

The Deputy Chairman: Our next witness is Randy Fransoo.

Mr. Randy Fransoo, Researcher, Manitoba Centre for Health Policy: I am here to give you a brief overview of a report that was published by the Manitoba Centre for Health Policy in September of 2004. The report is a population-based study on the prevalence of mental illness in Manitoba and the patterns of use of the health care system among those people identified with mental illness. I believe you have copies so I will just page through it briefly. There is more information available if you need it.

One of the highlights of the report is that there was a very high treatment prevalence of mental illness in Manitoba, higher than was expected by many of us. Along with the high treatment, came a very high use of the health care system by those people, which I will be able to detail a little bit more in the next few slides.

The report deals a little bit about access to psychiatrists. Now, we need to be careful because we are not suggesting psychiatrists are the only people who are helpful to people with mental illness, but they are a key part of the equation, and it would be good if everybody had access to their services. We did not see that access was the same across the province. Those from low-income areas, rural areas, and the elderly seem to have considerably lower rates of visits to psychiatrists than other groups.

In the area of suicide and suicide attempts, we saw that suicide and suicide attempts were strongly affected by the person having been diagnosed with a mental illness in the previous year. So in a sense, we took this as a sign that people who are attempting or are committing suicide are not just coming mysteriously out of the woodwork, but they are people who are known to the system and have seen a health care provider for a mental illness disorder. We thought that presented a bit of a window of opportunity, as it were, for the health care system to intervene with those people.

The report covers a five year, which is helpful in terms of having a picture of a mental illness that you can sort drift in and out of over time. You can suffer from depression for a short while and then be okay afterwards, so we wanted to see if we could capture the prevalence with a bigger view.

When we did that, we started looking at all the mental illnesses that we can reasonably accurately identify in our data. Now, this is not a survey or interview data, these are just an analysis of health service records. So for instance, when we categorize someone as having depression, that meant they had to have either seen a physician or been in a hospital and been identified as having depression. Many people with depression never see a doctor or go to a hospital. Overall, the records are reasonably robust.

We found we could identify anxiety disorders, substance abuse, personality disorders and schizophrenia. One of the surprising early findings s was how much co-morbidity there is among these illnesses. Even if we looked at those five disorders, a great number of people who have one of them also have one of the others, and also with other mental illnesses.

We struggled a bit with the analysis and ended up using the categorization of the "cumulative group." That was anybody who had one or more of those five because there was so much co-morbidity. When we looked at that group overall, it is 24 per cent of the population, and another 13 per cent that has other mental illnesses. Outside of those five illnesses, 63 per cent showed no health service use or mental illness.

Now, that of course varied pretty drastically by sex. The prevalence numbers for both of the other cumulative categories are considerably higher for females than for males. That was expected and not surprising in that sense.

Moving on now to the health service use, here is where the really interesting results came to us. We took the cumulative disorders group and then the people in the no disorders group and compared their use of physicians, hospitals, personal care homes, nursing homes, home care and pharmaceuticals. We found a consistent pattern that the cumulative disorders group used between two and five times more health care services than people in the no disorders group. It is not just that this extra service use is related to their mental illness directly.

It will be helpful to look at the graph at the top of page 4, where we look at the physician visit rates for each sex, and then it is sort of by cause, as it were. Therefore, the pairs of bars are for females on the left and males on the right, and then within each there is the cumulative disorders group and the people in the no disorders group.

So overall, the first thing you will see is physician visit rates are a bit higher for females than males. That is expected and well-documented.

The second thing is that for the cumulative disorders group, their visit rate is just over twice as high as the no disorders group, but it is not just for mental illness. If you look at almost every one of those other categories, for respiratory health, circulatory health, musculoskeletal health, the people in the cumulative disorders group visit physicians twice as often for every one of those disorders as well. This information suggests two likely explanations. The first and most obvious one is that there is a great amount of physical co-morbidity associated with mental illness. The people in the cumulative disorders group that have mental illnesses also have a reasonably high burden of physical illness. Part of that may be that the mental illness was not properly diagnosed in the first place. A patient can see a physician for a sore back or for sleeplessness and it is categorized into a physical illness category. Later on, the diagnosis may change to mental illness because these are all part of the same thing. We cannot tease out all of these effects in this data but you can see there is a very high burden.

The very same situation occurs in hospital service. The hospitalization rates of the cumulative disorders group is twice, for both males and females, as those in the no disorders group. Among home care and nursing homes, you get a very similar picture, a very high use, much higher use than people without a mental illness.

The last section is about suicide and suicide attempts where we see marked sex differences. The suicide rate is considerably higher among males than among females, but the suicide attempt rate is considerably higher among females than males. The biggest likely explanation is the difference is in the methods: women more often choose methods that are less lethal while men choose hanging and gunshots. Men choose the more lethal method and are more successful than women are in their suicide attempts.

One of the last graphs shows that in the five years before their suicide or suicide attempt, people who had been diagnosed with a mental illness were at much, I mean, dramatically higher risk of attempting or committing suicide.

The main picture on the left shows that the probability of anybody attempting suicide in a given year is very low, even among young girls where the attempt rate is highest. Among the lowest income areas, it is still only 2 per cent or 3 per cent likelihood that a given young woman will attempt suicide. If we look at the group of young women who have been diagnosed with a mental illness in the year prior, we are up to about 33 per cent. Therefore, one in three young girls living in poor areas in Northern Manitoba is likely to attempt suicide in that year.

It is not that it was associated with most of the suicide attempts but it is a strong predictor of who might attempt suicide. We thought, particularly hopefully, that there was help sought beforehand, and they contacted the medical system and identified as having a mental illness. I think that leaves the possibility that we might be able to help avoid the suicide or the attempt in the future.

The Deputy Chairman: Thank you very much. That is interesting data and we will be back to you in a few minutes, but perhaps we can go ahead with Ms. Palmer first.

Ms. Deborah Palmer, Clinical Director, Laurel Centre: Good afternoon. The Laurel Centre is a non-profit agency that deals with sexually abused women. These women come to us for treatment from childhood and adolescent abuse.

We step back from the picture a bit and we look at the cause of the mental health issues. We look at the impact of childhood sexual abuse on an individual. We address it from a social/political issue. Child abuse is not new; it has gone on for centuries. However, only during this second wave of the women's movement has childhood sexual abuse become an issue.

We provide a broader context to these women's lives. We work from the empowerment perspective, and our trauma model is circular because these women cannot heal in a linear process.

Our clients report to our facility with anxiety, depression, suicide issues, and self-injurious behaviour. Often the symptoms of unresolved trauma mimic bipolar depression. There is a biphasic response to trauma where the body goes into a hyper-vigilance anxiety place or a hypo-arousal place. The hypo-arousal phase includes the abused to paralyze, and freeze. Our normal response to danger is to either fight back or flee, but for trauma survivors it is impossible to fight back so they paralyze and freeze. Over the years, the body conditions its response in that way. When women come to us for help it is often on the advice of a physician who has given the diagnosis of depression anxiety, suicidal behaviour and self-injurious behaviour.

Our statistics show one in three young women suffer childhood sexual abuse and one in seven boys, although, I think the boys numbers are under-reported.

I heard all of the statistics on mental health illnesses but we like to step back and look at the bigger picture to see just what is happening. Given that it is the highest statistics on trauma, it is understandably how it would present as mental health issues.

The statistic show that 70 per cent of psychiatric emergency room population samples are survivors of childhood sexual abuse; 44 psychiatric out-patients have histories of childhood sexual abuse; and 40 per cent of psychiatric in-patients have confirmed histories of childhood sexual abuse.

I believe that more questions need to be asked when young women or young men present in their doctor's office or in emergency room situations.

The result of our work is that 59 per cent of our clients reduce or stop using alcohol or drugs to deal with the trauma. We look at compulsive coping behaviours, better understood as addiction, and we look at it on the broader perspective of gambling, caretaking, rescuing, drugs, alcohol, and all sorts of these issues that they use to modulate their emotions. So our trauma model looks at both of those issues.

Our outcome indicators check how successful the program is for them. Fifty-nine per cent have stopped using substances or compulsive coping behaviours, and 25 per cent have reduced using them. In most cases, the women do not need further work with their psychiatrists or medication.

We find that what happens with medication, although it may be necessary, it really disconnects someone from feeling their emotions. In our method, we believe that you must connect your body to your emotions; medication often inhibits or stops that function.

So part of how we work is to step back and look at the bigger picture of why people are presenting with mental health issues and looking at the total impact of trauma.

Throughout one year, we provide services to over 300 women. Our program focuses on individual counselling, couple work, and group work. We run groups throughout the year on specific topic areas.

When we look at the mental health issues, we also look at the impact, and the trauma and the addictions.

Ms. Madeline Boscoe, Institute of Gender and Health: Hello, everybody, it is good to see some familiar faces. I thank you for the opportunity to be here today and bring a hello and regrets from Miriam Stewart, scientific director of the Gender and Health Institute. I am here on behalf of the institute, and I have some of my own remarks, so it is a bit of a hodgepodge.

In my other part-time work, I manage a woman's health promotion and counselling program for a community health centre. I cannot help but bring those experiences and thoughts into this conversation today.

I want to thank both the Gender and Health Institute's work and the work of the Centres of Excellence in Women's Health in helping me prepare my remarks.

For most of us working in this field, we are glad that this committee is doing this important work. It is critically important that a national body such as this committee should put a focus on the issue of mental health and mental illness in this country. The state of the system is in disarray and it is not getting better, it is getting worse. I am not sure if the tensions surrounding our society are the greatest contributors to the problem, but I will have some recommendations today.

I speak on behalf of most of us in the field that your report is a fabulous compilation of substance and data, and we commended you and we are very, very grateful. It is a huge piece of work, I realize.

We particularly agree with your recommendations around referencing the social determinants of health, the need for a population health approach, the issue around policy, not just treatment, and the role of engaging clients in the discussion of care, the structure of care is wonderful. I have been harping about this for 20 years as part of the women's movement, but I think it is true and it is really nice to see it on paper.

Now, the Gender and Health Institute's mandate within the CIHR is to illuminate, support, and understand the intersections of sex and gender in health with the idea that this adds value in terms of both our research policies and programs. From our very first needs assessment process, the issues of understanding what is going on in mental health and mental illness was a number one priority, as we heard from both our research community and our community of interest.

The fact that we did not have gender analysis data to develop some of the programs and services, Ms. Palmer's centre is ground-breaking in trying to advance and develop services, understanding that none of these things is gender neutral, either from a cause factor or a care factor.

We are in the early stages of 92 projects that explore the issues of gender. I am unable to report any data today other than to say the teams are working around issues of poverty and its effect on depression and the impacts of gender violence.

I will highlight a few of the bits of information that we have garnered, and I will leave them with your researcher so you can have those references later on.

Canada has a rich community of researchers and providers who are very interested in the gender aspects of care in mental health, both in prevention and promotion. We are happy to provide those names and data to you in an ongoing basis.

We do strongly believe that without the absence of an analysis of gender, we make mistakes, in terms of care, services and prevention. We are trying to add value and create knowledge applicable to all of those settings.

We are grateful for the mention of gender in your report, and would suggest and would be happy to illuminate that further if you are interested.

Women are more likely to experience depression and anxiety, but we need to explore the areas of socialization and ask questions about the links between depression, anxiety and poverty. We need to do much more work in this area.

Men are more likely to have their mental illness defined as an addiction or a behaviour disorder such as physical aggression or antisocial behaviour of one kind or another. We need to understand that and look at our labelling and think differently about men's health care.

Poverty, violence, and social exclusion are all contributing factors and the sequela of mental health issues; it is a cause and effect process. I am sure you have heard from other providers as you have gone across the country talking about this, but there is a substantial, an ever increasing body of research, both here in Canada and internationally, that links these areas of social exclusion, poverty, and violence of many, many kinds and its effect on mental health and well-being.

Now, this is particularly an issue for women as poverty and violence continues to be "feminized" both here in Canada and throughout the world. It is an issue for all women including elderly women, Aboriginal women, and new immigrants.

It is a huge international issue. Here in Canada, we see people come to our shores for respite from violence and chaos, and as we think we are good world citizens, we have a duty to advance and speak to those causative factors.

Here in North America, for example, there are gender differences in accessing care. Women, as we heard, are much more likely to attend out-patient mental health facilities and seek counselling care of one kind or another, whereas, men with psychiatric conditions are much less likely to get support for welfare, long-term disability. The unfortunate fact is that the state or society sees men's mental health issues as a behaviour problem rather than a mental health problem.

On the other hand, if you look at sex differences between adolescents, young boys tend to get into care faster than young women because they act out and therefore get attention. Young girls experience depression and commit more self-inflicted activities.

I am sure you have heard a lot about the sex differences in violence, but this huge issue needs a public health prevention approach as well as care and therapy. Women are much more likely, of course, to experience higher rates of sexual abuse, an intimate partner void, and sexual assault. Men are much more likely, unfortunately, to be perpetrators of violence on other men, women children, and on themselves. This violence relates to hyper-masculinity and sex-role stereotyping and supported behaviours. This encourages young men to experience early risk taking behaviours of one kind or another that society views as normal. In fact, young men who try to resist some of this sexual stereotyping are often re-victimized, linked into homophobic issues and attitudes in our society. So again, these are more little pictures rather than substantive processes.

I took very seriously your questions in your report about suggestions of one kind or another and I always like to offer those responses. First of all, the call for a national strategy is absolutely important. I think this is the lens by which we develop action plans to create synthesis, a consensus and go forward. I do think the provinces are struggling. I think the idea of a designated fund with signed —off indicators at the federal-provincial level on deliverables is important. The CIHI mental health indicators are quite narrow. It is difficult for the provinces because their investments have been difficult, at best, and they have been trying to do this within the existing description of medicare, which tends to mean psychiatrists and it tends to mean drugs.

I think the report would benefit from the further understanding of a gendered analysis of health problems. I have given you a few examples but we need more understanding, particularly at the community level, of anxiety, depression, and eating disorder issues. We are overwhelmed with problems is those areas.

Even though the eating disorder issue is most often a young women's issue, we receive requests from teachers to talk to young boys affected with the disorder. We speak to young girls in Grade 6 and follow through to puberty but even boys need counselling in that area. Boys, not even at puberty are taking hyper-protein drinks and in some cases using testosterone to help them adopt these super masculine bodies. This is a very troubling manifestation of eating disorders.

I suggest that you expand the population health approach to include a focus on prevention and to ask what kind of commitment we are prepared to make for our youth.

We can be proud of many publications of the mental health documents. When I think about mental health promotion, I think about creating healthy work environments and healthy cities. I think about and making cities safe for people to network and build in and in the creation of social support networks. I think of helping people understand how to deal with conflict in ways that are not physical, which seems to be the way our media teaches this new generation how to cope.

I think it is also important that we talk about reducing health disparities because often the relationship between income and mental health seems to be so close.

I think that most of us feel there is a role for paraprofessionals such as social workers, health educators and community workers. I also feel that interventions do not have to operate solely within the drug and drug management process.

Many of us are concerned that the Romanow report is narrow concerning primary care and mental health being. That report focuses on drug monitoring activity, illegal drug cessation and ignores physical activity, nutrition, tobacco cessation, social support and sheltered housing.

I am not a counsellor and I believe Humpty Dumpty is a true story. I think you can fall off the wall and get put back together, but you do not always get put back together in a way that does not mean you do not need help in a regular way. We have abandoned those folks to the street, as I am sure you are aware.

We really are grateful for your recommendation about research. It is difficult to help people do policy and allocate scarce resources in the absence of good research.

One of the gaps we have identified at the Gender and Health Institute is in the area of funding innovation and supporting innovation. The kinds of activities that we are talking about, using other kinds of care providers, projects like street programs for the homeless folks, sheltered housing, supportive housing, the Laurel Centre, most of these things happen outside most of the research environment and, therefore, they are not evaluated and supported very well.

Here in Canada, we do not have an innovation fund that allows research and trial runs. We are very good on the side of clinical trials; if you have a drug or you want to do surgery, then we can fund innovation. However, we do not have a fund that allows the social support programs field to develop. We believe that population health studies, clinical trials, and the study of the pros and cons of different kinds of psychiatrists is essential to good research on the subject of mental health. We want to get out a little farther and help create some research that is going to help us on innovation. We ran into a problem having a researcher and no staff to do the innovation, so it is a bit of a catch 22.

I would like to highlight the next mental health report, due in the fall. The Institute of Gender and Health and the CIHR contributed two chapters to the report, one on gender analysis, and one on Aboriginal mental health. I think you will that report very useful as you go forward in your deliberations.

The Deputy Chairman: There are very significant differences in patterns between male and female. I suspect that we will have to target the youngsters in slightly different ways to cope with these differences.

Is your data consistent with the rest of the country or is your situation unique?

Mr. Fransoo: It is hard to say with certainty, but as the study included a million people, it is very unlikely that other provinces are radically different. There will of course be regional variations, perhaps in the prevalence of rates, but, I suspect the associations across genders and with income are very likely patterns that would hold across the country.

The Deputy Chairman: I would suspect so also because your numbers are far greater than most of the statistical studies.

Have you discussed different approaches to male and female mental illness in youngsters?

Mr. Fransoo: Well, I do not know of anything really pointed. The likely exception is Ms. Marni Brownell, who has done extensive work on ADD and ADHD and use of psycho stimulant medications. That is another illness with a huge gender bias and is more commonly diagnosed in young boys. Among those diagnosed, young boys are considerably more likely to get psycho-stimulant medication. We see the incidence rate of ADD and ADHD rising slowly over time. What that means is the prevalence will continue to rise as time goes, as this is not generally something that is lost until children reach 20 or 25, in some cases. In some cases, it never goes away.

One of the other questions about the male/female difference issue is the male hesitance to attend to health care. You know, one of the ways that we think this has reared its head in the statistics we have, though this is not something our data can address directly, is the difference between the people in the no disorders group and the cumulative disorders group. That difference was in a number of cases actually higher for males than for females. People in our working group speculated this might be because if males are more hesitant to attend health care providers and to discuss mental illness issues with their doctors or health care providers, their diagnosis is delayed. That delay can mean that the disease is more severe and its ramifications are more intense in terms of their need for physician help and hospital care.

Much as the prevalence is obviously higher in females, there may be need to find specific ways to get at males to get these issues on the table and to address them earlier on, before they are at end stage or in more serious situations.

The Deputy Chairman: Ms. Palmer, are you aware of this discrepancy. Has it affected your thinking at all, this discrepancy between male and female?

Ms. Palmer: We work with the female population.

The Deputy Chairman: Only females?

Ms. Palmer: Yes, only females.

The Deputy Chairman: So you are already there, you do not do comparatives?

Ms. Palmer: No, but during the course of couple counselling we find that because the female accesses help so much sooner than the male that couple counselling can be difficult. The woman is at a better stage in terms of being able to name her needs, identify her feelings, and name the issues in her relationship. The man, on the other hand is at the beginning stages and this gap in their ability to name and discuss their problems makes counselling difficult.

The Deputy Chairman: Are the general measures to screen young people and then to treat and support them different in your centre from the average setting that treats both males and females?

Ms. Palmer: At our agency, our mandate is to deal with sexually abused women who are also experiencing addiction and compulsive coping issues. That is our screening criteria. If they meet those criteria, they come in for help.

The Deputy Chairman: Ms. Boscoe, how do these finding affect your work?

Ms. Boscoe: I will go back to your original question. My instinct is that the findings would be similar across the country.

It is also the way name issues. I am going to go back to young men who have tried to resist typical sexual issues such as drinking and driving, or taking some of the risks that young men take. There is a cost for them to resist those issues while at the same time it puts them at a different kind of risk.

We must have better primary health and mental health promotion to stop that process so that we do not end up with it just being on an individual.

I think we are finding that the link between your brain, your heart, and your blood pressure is an extremely close and intimate relationship. We see that men have a physiological reaction and the relationship between depression and heart disease. We are reaffirming what we have always known; we cannot differentiate those processes. Unfortunately, we have created a medical system that believes there is a difference between the two. We have providers who are comfortable with the blood pressure process but not so comfortable on the feeling process. Women tend to engage more easily and we demand it more because we are socialized to expect it. Where I think it is much more complex for men, and young men to get into that process.

I notice grade 6 kids worrying about body image, we do exercises in reading magazines critically, and they do collages and things. It is a tighter loop for young girls to understand that influence and push back a bit. I think it is still riskier for these young boys. We talk a lot about girls responding to peer pressure, but the peer pressure for men is much more sophisticated and subtle, but just as active.

Senator Pépin: You mentioned that women use the services twice as often as men do. I have the feeling that women are much more open, and if we have a problem, we will go for help. You also mentioned that the woman calls for her husband. Do you see it that way or is it different?

Mr. Fransoo: No, it is different. I hope I did not miscommunicate because it seems that I have. We did not deem that women use services twice as often as men, not at all. It is only a very little bit higher. The people who have mental illness visit doctors twice as often as people who do not, and that is true for both sexes.

The difference between men and women is very small compared to the difference between those who have no mental illness and they say who have mental illness, but the comparison between sexes is relatively close.

I am sorry if I did not make that clear.

Senator Pépin: You also mentioned that one young girl out of three who has tried suicide.

Mr. Fransoo: That is not in a general population.

Senator Pépin: You said in a part of Manitoba.

Mr. Fransoo: In the north, right. It is among those living in the lowest income areas and who have had a previous diagnosis for mental illness. It is really a demonstration of things that influence the likelihood of attempting suicide. In the north of Manitoba where there is a large low-income population, the younger women are more likely to commit suicide. However, the strongest factor is whether they have a mental illness. That factor is a very strong predictor in terms of differentiating who is going to attempt and who is not.

If you have, in a sense, all of those strikes against you, you have somewhere around 30 per cent or 32 per cent likelihood of attempting suicide. But that is not for all women in Manitoba.

Senator Pépin: Please tell me that average age of these girls.

Mr. Fransoo: These girls are within the age range of 10-19 years. We had to group a very large age range because, thankfully, the number of events here is relatively small. We work under suppression rules for things that happen very rarely, we do not report.

Senator Pépin: Ms. Palmer you mentioned that your centre is looking after women who have been sexually aggressed, I thought maybe they tried suicide because they were unable to ask for help.

Ms. Palmer: Yes, exactly.

Senator Pépin: You said that one young woman out of three, and regarding boys what is the ratio?

Ms. Palmer: One out of seven.

Senator Johnson: One out of seven. This is new, I mean, for the boys that you know we are coming off like this because we always speak about girls. I mean we rarely speak about young men. I think that it is wonderful the centre you have because it is rare that you have a centre that is looking after women who are being sexually aggressed.

While I was a member of parliament, I did a study on violence against children. That pointed to the number of sexual aggressions. I thought that because of education that things had improved, but I have the feeling that it is getting worse.

Ms. Palmer: It is quite frightening sometimes. I would like to believe that it is improving too, but my work with young women indicates that it is not improving.

Violence against women and children is a huge social/political issue.

Senator Pépin: Yes, and it does not occur only in the rural areas, because your centre is in the city.

Ms. Palmer: You are correct, Senator Pepin.

Senator Pépin: Madeline, you spoke about the importance of prevention and we talk about the sensitization of the community.

Ms. Boscoe: Mental health has a skill component to it. We talk about early recognition and diagnosis and the screening processes. When we go into schools, we talk about safe street safety, and being safe in your body, and being safe at home, and developing skills and negotiating conflict in a way that is healthy. We point out that the answer to problems is not always fisticuffs. We very much support the community anti-bullying programs and programs that help build social support.

It is funny to imagine it, but programs such as community kitchens, community gardens, Habitat for Humanity, things that bring people out of their homes and into relationships and into mutual support are all on that prevention pile because they are very people focused.

I believe in a healthy economic policy. When you look at some of the depression and some of these other issues, it is hard to know which came first, the chicken or the egg. Certainly, if you have a mental illness and you are on long-term disability, unless you have a family that is somehow supporting you, you are beyond poor. You are poor to the point where you have no housing. We are talking about a substantive life involvement that is very difficult for these people.

The debates around minimum wage and trying to get minimum wage crawling up, at least here in Manitoba, close to the poverty level is a prevention process, because living in poverty creates a kind of social exclusion and depression intention that then feeds your mental health.

Just as an aside, Dr. Stewart and I are on a research project looking at low-income women and smoking. We were talking about issues in their lives. Two to one, in one of our focus groups, those women are moved three times with their kids in the last year because they could not find safe housing. I would be more than smoking if I had to do that, I have got to tell you.

When I think about prevention, I think about it in the spirit of Jake Epp, I think about it in the spirit of Mr. Lalonde, and I am old enough to remember them. We think about prevention in the true noble nature of our society and our democracy. Safe and good housing contributes to good mental health and bringing the minimum wage up to a liveable level reduces stress. These conditions are interrelated and investments in both the care side and the prevention side would take us a long way. I do not mean drugs and psychiatrists. A framework with a noble vision excites me and I would volunteer to be on the writing committee.

The Deputy Chairman: When we get into details, we forget that the major determinant of health is wealth, and we keep forgetting that.

Mr. Fransoo: I will add that the report keeps the focus on policy and systemic issues. One of the things we celebrate in Canadian health research and epidemiology is we think ahead of the view south of the border, which is much more individualistic looking at behaviours and diet and exercise and all those kind of things. They can be important influences in health as well, but we think the societal and systemic issues have far more important effects on the population's health level.

We are happy in Canada that we are better at avoiding the blaming victim game, but it is important that we are aware that we are good at that so we keep it at the forefront in our minds.

One of the sort of individual versions that is to be healthy do not smoke if you can and do not drink, you know, eat a good diet and exercise a lot. The more policy or group level approach is do not be poor, and if you have to be poor do not be poor for long, and do not live in substandard housing, and do not have a low income or minimum wage job, and those kinds of things. It just gets your thinking in the different sort of area that we can take for granted a lot because in Canada, we do have more of these conversations where we think of these systemic issues. It is not universal in the world and it is important that we are aware of it so we keep it on the top of our heads.

Senator Johnson: Mr. Fransoo, in chapter 4, you discuss the burden of Manitoba's health care system, and I wonder if the word "burden" is perhaps the incorrect terminology. This is the nature of the illness, and a burden because the treatment is inadequate. We are aware that this illness manifests itself in many physical problems.

Mr. Fransoo: It is a commonly used term in the epidemiology world. It was surprising to us that among one million Manitobans, there is on average five million physician visits each year. One in 10 of those visits are for mental illness problems.

Senator Johnson: Why should that surprise you?

Mr. Fransoo: The high number of 500,000 visits surprises me.

Senator Johnson: That is what is going on in the world.

Mr. Fransoo: There is also a concern, especially in rural areas, that the physician does not name the mental illness.

Senator Johnson: I return to that stigma issue after each discussion.

Mr. Fransoo: We thought the number would be smaller because even physicians sweep these items under the carpet.

Senator Johnson: I am not trying to be negative towards you in any way. I just think that even the language we use in this kind of thing is part of the problem.

Unveiling the stigma is the last frontier and hopefully this study will help open up that frontier. People must have adequate treatment and that is difficult if they live in Fisher Branch and have depression. If they go to their doctor with a migraine or irritable bowl et cetera, the doctor might link those maladies to mental health illness. You call them cumulative disorders, or depression, or whatever.

Ms. Boscoe: It is also difficult to always rely on health service utilization data in this area because many clinicians deliberately do not bill or talk about these things because of privacy rights. Certainly, in the management, we did not get a chance to talk about the electronic billing record. I cannot for the life of me believe that we should imagine this is a robust electronic record. We will not find this type of information because both the providers and the public do not want mental illness noted in the medical files.

The Deputy Chairman: Ms. Boscoe, I think it is possible, provided the patient owns the record, because they can build firewalls into their card. The patient should carry the medical record, they should own it, and it should be like their bankcard. They should release information that they choose to release.

I have been involved in this nightmare for 30 years, and the problem is that institutions, doctors, and so forth want to own the record when they have no right to own it; it belongs to the patient.

Ms. Boscoe: I have given up that battle, so I am glad you are still fighting.

The Deputy Chairman: I am going to have to thank you and move on.

Ms. Boscoe: Thank you very much for the opportunity to see you.

Ms. Barbara Chatelain, As an individual: I am a consumer of mental health services, thanks for allowing me to speak on behalf of people with mental illness. I am just going to read quickly what I have, it is very quick.

The Deputy Chairman: Do not rush. We will give you time.

Ms. Chatelain: I am here to propose two subjects that I believe would help people with mental illness get well and keep well. I myself have a mental illness with recovery well on its way. Having overcome struggle, some extreme, I feel I have a platform to speak from for our well-being, for this group of people. With no emotional support from my family, surviving a suicide attempt, a drinking problem, and a mother who died by her own hand when I was 11 years old, I have overcome. We are on the outside looking into society with fear on every side of us. Every effort that gets the person with mental illness out into that society is beneficial, perhaps crucial to their quality of life.

I have recently obtained a volunteer position at an art studio for artists with mental illness, as a receptionist. It is called Art Beat Studio. It is not funded at all by the government. This is the first job I have had in six years and I cannot get a bus pass to go to this job, which has potential for a paid position.

Proposal number one is that everyone in this type of disability gets a bus pass to help us get out into society. Sometimes just sitting on the bus amongst people helps the loneliness that can take our breath away.

The second proposal is for a crisis home like they have in England. This is where a normal family takes in a person with mental illness. The whole family receives a small amount of training to support and just share with the participant. The majority of people with mental illness do not have a supportive family, or because of generational illness, do not have a chance or a clue as how to be in our society.

Because of God, myself, classes, books, doctors, volunteers, and ongoing therapy, I have overcome a lot, but the crisis house and the bus pass would have sped this process up extremely.

People with mental illness, after they are on the other side of it, I call it "fighting the dragon," may make the greatest contribution because of the appreciation of just being able to finally work and socialize and contribute something to our society. Thank you.

The Deputy Chairman: Thank you very much for coming. You are very courageous. Thank you.

Ms. Chatelain: Thank you for listening.

Sister Johanna Jonker, as an individual: I am the social justice coordinator for the Archdiocese of Winnipeg. Last year I was promised major monies if I could find a project worth supporting. After a lot of research, I came to the conclusion, and I interviewed a lot of different CEO's or people running agencies, the major concern was the lack of support for people with mental illness. This is a very unprofessional assessment of the situation; I am a teacher by trade and spent 40 years in the classroom.

The people with mental illness are the main consumers at our soup kitchens. They are the main people at drop-in centres. The estimate in our prison system is that it varies between 40 per cent and 75 per cent, and some arrests are simply because they disturb, and there is no other help for them except to lock them up. One-half of our homeless people, and they estimate them to be 1,500, are people with mental illness.

There are few resources available to people with mental illness. I have received a fair number of calls since making it known that the diocese was interested in becoming involved in some way with mental illness. There are people who are suffering and families who are burnt-out because they do not know how to access, help. I mean, it is just a terrible situation for parents. They must have a referral to see a psychiatrist. As you know, family doctors are scarce in Manitoba and as a result, people with mental illness problems have even greater difficulty in seeing a psychiatrist.

There are other kinds of help available to people with mental illness but the Manitoba Health Commission does not cover them. Therefore, psychologists and counsellors are out of the purview of people with a mental illness.

There are no alternatives except the medical model, and the medical model is expensive. It often pushes drugs because that appears to be the easiest way to treat the illness. I have had young men tell me that they will not go to the doctor because all they get is drugs that do not solve the problem.

Existing successful programs are underfunded. We have one PACT program, Program for Assertive Community Treatment, and we have an early psychosis prevention and intervention service. Neither of these programs can take new patients because they are full and cannot receive more funding in order to expand their services.

Some people in the field believe that there are plenty of community resources available. That is not borne out by the patients or people with a mental illness or their families, otherwise I would not be getting all the calls I get.

There is the whole Privacy Act problem where parents are often excluded from discussions about mental illness because the young man or woman is over 18 years and has the right to say parents cannot be involved. However, they suffer from the lack of ability to make good choices. We must look at this problem.

There are those who are trying to come back from a mental illness. There is a real lack of training and opportunity for employment, part-time employment, any employment that they are capable of performing.

There is real stigma, and part of it is just unawareness, people do not know what mental illness means or what implications it has and, therefore, they are afraid to say, hey, look, I have schizophrenia. If I am saying weird things it is because that is the voice I hear up here. So you look at them and they are made fun of and so on.

In addition, because of their fear of disclosure, there is a real delay for timely and appropriate treatment. They do not get diagnosed. There is a real lack of an integrated information system. The CMHA puts out a guide for services for the mental health system. Do you know that that guide has over 200 phone numbers? Moreover, how would you, as a mentally ill person or a person under stress, feel if you had to find a number out of those 200 listen, or when you get an automated system and they say press one, press two, press three, and you just get to a stage where you say, I am not that sick.

The other issue is having a team approach and having family or an advocate involved in the treatment program. You know, they need someone to speak up for them. One of the situations in which I was involved was with a young man who was suicidal. I brought him to the hospital and introduced myself, and the doctor was very unwilling to have me present at the interview. In the end, the doctor judged him not to be ill enough; he was not going to hurt himself or others. He was not a psychiatrist. He sent the young man home. I went with him and had him seen the following day, and he has been in the hospital now for two months.

One of the things that I thought was very interesting is that women access resources more easily than men do. My experience is the opposite. That is probably because I am a non-professional. People call me and tell me all kinds of things, but often finish the discussion when I ask them if they are getting some help. There is something about going to a psychiatrist, or a psychologist, or a counsellor that seems to affect people.

There is a saying that we can be judged by how we look after those who are the weakest in our society. I find it very worrisome, and I am glad that the church is now becoming involved because I think that we absolutely need to include these people in our society and in our churches because they have the right as human beings to be part of us.

Thank you. I am sorry that I am keeping you late, but I really did want the opportunity to say this.

The Deputy Chairman: We are all right, Sister. We will get there. Do not worry. Thank you very much.

Senator Pépin: It is very important because you are close; you work with them. I think that is very important.

Thank you for coming.

The committee adjourned.