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

Issue 22 - Evidence - June 14, 2005


ST. JOHN'S, Tuesday, June 14, 2005

The Standing Senate Committee on Social Affairs, Science and Technology, met this day at 1:03 p.m. to examine issues concerning mental health and mental illness.

Senator Michael Kirby (Chairman) in the chair.

[English]

The Chairman: We have a session this afternoon, one tomorrow morning and one tomorrow afternoon. To everybody in the audience and our witnesses, by the time we leave Charlottetown on Thursday night, we will have been to every province and territory, I think, with the exception of Iqaluit. This country is very big when you decide to hold hearings from coast to coast. We have learned a lot, and had a chance to meet with a lot of interesting people. We want to thank all of you for coming.

We have learned an amazing amount, particularly, interestingly enough, in the smaller provinces. I think this situation is, in large part, because the smaller provinces have less resources and they are more willing to try experimental things in a community spirit because they have to pull together to make things happen. Many best practices that we will refer to in our final report will be best practices that occur in the smaller provinces. It reminds me of the fact that in our previous report on the hospital-doctor system, we described what we called the post-acute home care program. This program was essentially that if someone needs home care after an operation or care can be done at home rather than the hospital, home care is significantly cheaper at $400 a day, roughly, than hospital care at $1,400 a day. The interesting thing that we discovered while we were going through our work that ultimately led to that recommendation was the program had been in existence in New Brunswick for 20 years. I think the fact that it was in New Brunswick meant that nobody else looked at it. As we have discovered, lots of really neat service delivery things are happening on the ground in pockets of this country that do not get out to other parts of the country. Ultimately, one thing we have to do is to get these best practices known to everybody.

This is why we are delighted to hear from both of you. From the Consumers Health Awareness Network of Newfoundland and Labrador, CHANNAL, we have Joan Edwards-Karmazyn, who is the manager. Then we have Ian Shortall, who is the manager with the BRIDGES Program, which is run by the Health Care Corporation of St. John's. You have not changed over to the Eastern Regional Health Authority yet because you literally just changed, right?

Mr. Ian Shortall, Division Manager, BRIDGES Program, Health Care Corporation of St. John's: Within weeks.

The Chairman: That is what I thought. I wanted to make sure I had the name correct. Thank you both for coming.

I will ask Joan to begin her presentation, then Ian, and then we will ask you questions together after you have both finished.

Ms. Joan Edwards-Karmazyn, Manager, Consumers Health Awareness Network Newfoundland and Labrador, CHANNAL: Greetings from St. John's. I hope you are enjoying your stay here.

I will begin by titling my paper, "A Psychiatric Peer Support Recovery Based Self-Help Perspective." That is the experience I speak of. I have also attached my biography, as well as a brochure for CHANNAL. I am a consumer, a psychiatric survivor, a family member, and a professional. I have worked in the field for 30 years and I have been a consumer and family member much longer. I will begin by reading my report.

Honourable members of the Senate, on behalf of CHANNAL, I would like to extend our appreciation for your invitation to speak with you today. I will use my time here to tell you of the organization I represent, and to address the emerging issues we have identified and the options we have utilized in providing peer support for each other within our program and community.

CHANNAL is now in celebration of its sixteenth year and it exists to provide a self-help psychiatric peer support network serving mental health consumer-survivors within Newfoundland and Labrador. CHANNAL receives funding from the Community Programs and Wellness Branch of Health and Community Services of Newfoundland and Labrador. It is under the sponsorship of their flow-through agency, the Canadian Mental Health Association, Newfoundland and Labrador Division. CHANNAL enjoys a healthy working relationship with their sponsor, and at this time is in the process of becoming an independent organization with the blessing and guidance of CMHA. It is expected that this will become a reality within the next two to three years. The work of building a strong infrastructure and developing our own governance is now underway.

CHANNAL offers peer support self-help groups within six regions of Newfoundland and Labrador. Each region is facilitated by a regional coordinator who reports to CHANNAL's Independence Development Manager. The regional coordinators are volunteer leaders who receive a small stipend for their large volume of work provided or produced. The only paid staff of CHANNAL at this point in time is the Independence Development Manager. I will speak more on this situation further along in my presentation.

The goals of CHANNAL are to build and strengthen self-help initiatives among individuals who live with mental health issues and difficulties; to increase peer consumer-survivor participation in mental health reform; to educate the public on issues relevant to consumers who use mental health services; to offer advocacy; to offer social and emotional support through self-help; to offer skill-building opportunities; and to offer a forum for consumer-survivor concerns. Why self-help? People involved with their peers within self-help groups take on a proactive approach towards managing their problems and finding solutions. The focus is on wellness and not illness, on ability and not disability, on becoming at ease with one's limitations and not remaining diseased within one's limitations, on focusing on the beginning of the recovery process and not on remaining stagnant within one's misery. It is about gaining the energy to have choice once again and setting about to plant the seeds of choice to enable the consumer-survivor once more to feel alive.

Often the question is asked, "What can CHANNAL do for me?" The answers are many. CHANNAL provides a voice that is connected within the community, beginning within the self-help group itself; to the voice that is heard through CHANNAL's associations and affiliations with our community partners, regionally, provincially and nationally; to the offering of support to one another while increasing members' personal independence, and eventually the discouragement of over-dependence on the mental health system; to the forum of communication that acts as a means to exchange ideas; to the opportunity to educate the public about mental health issues; and to the member networking that can truly help when we need it and is as close as the nearest phone call or email away.

Common elements of best practice in self-help programs are practiced throughout CHANNAL. Support is focused on peer support and mutual aid. Psychiatric consumer-survivors have decision-making powers over program design, evaluation and development. The program is guided by a value system that places importance on experiential expertise. Programs are respectful and inclusive. Emphasis is on commonalities rather than on differences. The program instills a sense of ownership, is consumer-focused, consumer-centered and consumer-driven. The program provides opportunities for leadership and supports leadership development through training. The program is recovery- and capacity-focused, and challenges low expectations. Information and education empowers decision-making. Programs help consumers to set and achieve personal goals. Programs are designed by participants and responsive to changing needs. Programs emphasize strengths and health versus illness and disability orientation. Expectations are clearly communicated and understood. There is a sense of belonging, mastery, independence and generosity. There is full and meaningful participation. There is community integration, avoiding ghettos. Programs are resourceful and creative with limited resources. There are diverse visions for mental health care — thinking outside of the box.

The values of psychiatric peer support programs are as follows: respect for all viewpoints, inclusion and acceptance, faith and trust in others, and a sense of belonging; representation, engagement and collaboration; empathy and compassion; hope; education; recognition of trauma and health; spirituality; determinant of health; concept of recovery, people can get better; making it a human issue; "We have to name it, to claim it, to tame it"; recognition of the value of our experiential knowledge; going beyond the biomedical definition and social components; value abilities, creativity, skills of persons with mental illness and not the diagnosis — value the person as a whole; and proactive, responsive and self-determined.

I wanted to add another value that came out of the World Health Assembly, if you would like to write this down: Nothing about us without us. We need to be at the table.

The emerging issues of psychiatric consumer-survivors within Newfoundland and Labrador — Suggestions for consideration in reference to the third report that was filed by the Senate: The emerging issues that I present here are taken from direct feedback from our CHANNAL constituents. I have chosen to put them into the three categories that were suggested on the earlier questionnaire sent out from this Senate committee. The three areas are health services, support services and discrimination. As well, these issues are presented in the context of the work that is currently being done by mental health stakeholders in the province in terms of the Provincial Mental Health Strategy. They speak to the high need for increased mental health community supports within Newfoundland and Labrador, and in particular, in the outlying rural areas of this province. This Provincial Mental Health Strategy highlights that in order to meet the needs of individuals with mental health issues, this framework has to consider and involve psychiatric consumer-survivors and family members — family is not necessarily family of origin, family is also friend or community, self-help support groups, generic community services and activities such as churches, social and recreation groups, as well as income, housing, education and employment groups. It also emphasizes that a mental health and addictions plan for Newfoundland and Labrador needs to be found and implemented. We are at that place where we are looking at that with this Mental Health Strategy.

Although the provincial plan highlights one aspect of the community resource model, the mental health system, there is a clear indication that the system has to be integrated and partnerships formed with the entities mentioned, as this integration will serve to enhance the recovery of persons living with mental illness.

William Anthony at the Center for Psychiatric Rehabilitation at Boston University — out of Boston's Psycho-social Rehabilitation Model — defined recovery in 1993 as follows:

Recovery... is a way of living a satisfying, hopeful and contributing life, even with limitations caused by illness. Recovery involves the development of new meaning and purpose in one's life as one grows beyond the catastrophic effects of mental illness.

Now I will speak to the three components — health services, supports and discrimination.

Health Services: The members of CHANNAL expressed a need for added case managers, community support workers including trained peer support workers, more doctors, more health care clinics, increased early psychosis intervention programs, increased education and prevention workshops for teens to reduce bullying and suicides and added short stay assessment units similar to the short stay unit in St. John's — the shot in the arm that we need here in Newfoundland and Labrador, and addresses the link to mental illness and addictions and the need for an increased program for mental health and addiction services and more generic community-based health care.

Support services: The members of CHANNAL expressed a need for more affordable housing; fewer barriers to receiving educational and vocational services; and increased wage earning allowances while receiving social income supports. Members state that they are caught in the system due to the needed benefits for medication allowances. Therefore, one is hesitant to stop income allowances as stopping income allowances has a direct impact on also having medication benefits stopped. People are afraid to come off their benefits because the income they would make out in the real work world would not allow them to afford the $1,500 a month for medication alone.

CHANNAL expressed a need for Capacity-building, that is skill-building within CHANNAL by means of peer support skills training. There is a need for such within the funding to put in place a staff complement of peer support workers that earn equal pay for equal work. To this end, the idea of voluntary leadership will be recognized still for what it is — volunteers assisting paid peer support workers within the program. A program is operating in Ontario, and I know it can happen here, but it requires more funding and a lot of training. Currently, our volunteer leaders, which include our regional coordinators, are contracted to work eight hours per week. However, in reality, they work an average of a 40-hour week. These hours are built up by the nature of the need that exists, particularly in the areas of outreach, lobbying, facilitating and administration. Government needs to recognize that they have created a voluntary workforce that now needs to move into a paid workforce, and that funding into the community needs to address this issue.

Discrimination: Continue to develop and deliver reduce-stigma campaigns targeted towards the public as well as health care providers, front-line workers including police, fire and ambulance workers, and also government and private sector workers. Recognize that the justice system needs to continue to deliver the Mental Health Court pilot project and Community Support Services project here in this province that has started.

In conclusion, I will address lifting the stigma of mental illness, and I will quote Ralph Nader.

To go through life as a non-citizen would be to feel that there's nothing you can do, that nobody's listening, that you don't matter. But to be a citizen is to enjoy the deep satisfaction of seeing the prevention of pain, misery and injustice.

Many people living with a mental illness are treated as non-citizens and are the victims of stigmatizing and discriminatory terms used within society to describe psychiatric consumer-survivors. A consumer is a person, by the way, who is consuming, or using the system, as a consumer would consume a bag of potato chips. However, we are classified as psychiatric survivors. A survivor is a person who has been through the mental health system, perhaps is continuing with the mental health system, but is surviving and has started the road to recovery. That is our definition.

The mental health care system has been changing from institutional to a community-based system where treatment and support is provided close to home. This treatment and support includes help to find appropriate housing, to obtain gainful employment and to access social supports that are important to one's well-being. With support from the community, psychiatric consumer-survivors can lead meaningful lives with jobs, homes, social supports and the opportunity to contribute to their community. One of our other sayings is, "We need a home, we need a friend, we need a job." It is the hierarchy of need for any human being. Today I thank you for letting me present.

The Chairman: Joan, thank you very much for that. There are lots of things we would like to discuss. We will turn next to Ian's participation.

Mr. Shortall: Thank you. Good afternoon again, Senator Kirby. Also, I would like to welcome you and your delegates to our province.

I have been a social worker working with children and youth for the last 19 years. In the last six years, I have been the Division Manager of a program called Brief Rapid Intervention Directed at Gaps in Existing Services, BRIDGES, which I will tell you about shortly.

In the spring of 1998, the Mental Health Program began to explore and review whether existing mental health resources should be reorganized to improve the service continuum for the older adolescent. By older adolescent, we refer to adolescents 16 to 20 years of age. A proposal had been submitted to the Department of Health on behalf of the Mental Health Program, with endorsement from the Health Care Corporation — that was the name of our organization at the time — now known as Eastern Health, with support from the senior management team. Particular emphasis was placed on the need for a separate inpatient unit for adolescents in the age range of 16 to 20 years. However, the capital funding required to build the recommended eight-to ten-bed unit at the time was never achieved.

A second aspect of that continuum, as outlined in the proposal, was the need to, one, improve emergency department services; and two, to strengthen linkages with the community. It was further suggested that if current emergency room services were to be reorganized, the result could mean, for clients of the Mental Health Program, more effective intervention and appropriate admissions, as well as timely follow-up in the community. These services are something that certainly in this region and other parts of the province have been severely lacking for many years.

The Mental Health Program has a mandate to provide psychiatric and mental health services to the older adolescent population. All too often, the interventions required to either resolve a crisis or prevent an admission into a hospital were rarely, if ever, available when most needed by the young person.

The waiting lists for adolescent mental health services in the St. John's region tend to vary significantly. The wait can range anywhere from 3 to 12 months, and most recently, I checked this for the purposes of this discussion today, it averages about 11 months. This time, of course, depends on the type of service required and the kind of guidance needed. There were only 4.5 full-time equivalent positions allocated for adolescent mental health services, and that includes an age range from 13 to 21 years. Furthermore, an adolescent-specific outpatient program that includes psychiatric services with an adolescent focus does not exist anywhere in this region. All our services tend to be fragmented, and there was no model of service that included a full teen complement.

The BRIDGES program was created as a pilot project of the Mental Health Program. The time frame for this pilot project was June, 2001 to June, 2002. The service was designed to be responsive to and directly linked to the Mental Health Program, and that included the areas of the inpatient service as well as to the psychiatric ER.

The objectives were to offer rapid and developmentally appropriate outpatient service to the older adolescent who is experiencing an acute psychiatric or mental health crisis or illness.

The second objective was to provide support and follow-up to clients from the inpatient and outpatient areas of the Mental Health Program. This support and follow-up included referrals from psychiatrists and the psychiatry division of the emergency department.

A third objective was to assist young persons, with the support of their family, in overcoming their crisis situation.

The final objective was to provide case management to youth diagnosed with an acute mental illness that required multi-agency support and collaboration. Until that point, case management services in this region, as well as in many others, were available only to adolescents who were 18 or older.

The services from the program include a rapid response, within 72 hours of the initial referral for mental health outpatient intervention, for individuals and families who were deemed to be appropriate to require brief intervention. The interventions included anywhere from one to six sessions, depending on the need and depending on whether the client decided to continue with that service. Progress is regularly reviewed at team meetings. Psychiatric consultation is available to clients taking part in the program at the request of team members. Right now, all we have is three hours a week in the community program where we can access psychiatric consultation, so it is not nearly enough. Finally, brokerage services are provided to help link clients to existing resources in the community.

The clinical team is comprised of two social workers, one psychologist, one nurse intake coordinator who is also a case manager, and one .5 full-time equivalent occupational therapist.

Since 2001, the program has received over 1,400 referrals, the majority of which have come from St. John's and other areas of the Avalon Peninsula. Interestingly, about 50 per cent of these referrals have come from family physicians that actually send an accompanied sort of DSM IV diagnosis. That was not something that we necessarily predicted, but —

The Chairman: What is a DSM IV diagnosis?

Mr. Shortall: That is the standardized diagnosis for mental illnesses. Diagnostic statistical manual, I think it is called.

Common problems or diagnoses that have brought a young person to our program are typical of what you would expect in any other mental health setting, and these things include depression, eating disorders, addictions issues, suicidal behaviours and self-harming behaviours, anxiety problems and psychosis.

The BRIDGES program has provided many benefits to our community, such as improved transition from hospital-based care to follow-up in the community; rapid and short-term counseling while the person is in crisis, as opposed to months later when the problem is nearly resolved or has become more chronic; and an opportunity for family physicians, parents and community professionals to collaborate with a specialized team of experts.

Only a small proportion, though, of youth in need of a service actually ever receive it. Those that do receive help cannot be provided with sufficient treatment time for the more complex treatment issues. A range of programs is not available in most parts of this province that will adequately treat these kinds of disorders. Currently in this region, services are so overextended that long waiting lists have become the norm. There are regions in this province where accessible services for children and youth simply do not exist at all. Where services are available, in places such as central Newfoundland and on the west coast of our province, there are usually long waiting lists. Our rural communities also face the unique challenges of out-migration, which makes it even more difficult to maintain a central base of child and youth mental health services.

I will speak briefly now to some of the strengths that I notice in the report.

First, the roundtable discussion on adolescent disorders references the impact on parents of adolescents living with mental disorders. Unless a parent seeks help from children's protection services, parents are not eligible for any kind of home support. The committee has taken note that in certain conditions, services will require that they be delivered in homes and schools and at flexible times in the day. We strongly support that recommendation.

Second, there is a recognition that children and youth services are grossly underserviced, uncoordinated and fragmented across the country. The same holds true in Newfoundland and Labrador. An inter-ministerial strategy involving all government departments would be an excellent first step to reorganizing and enhancing children and adolescent mental health services. The model of coordination is a perfect example of an approach that demonstrates the benefits of interagency collaboration towards improving mental health and educational outcomes of individual children.

Third, the notion that one size does not fit all is an extremely important principle to remember. Mental health programs in this province, like many others, are primarily focused on adult populations. The delivery of mental health services to children, youth and families is drastically different and requires specialized training. Adult assessment tools do not work, and adult treatment methods do not work. We also know that adult treatment settings do not work. We have had the experience in this province for some time where a 16-year old can be admitted to a psychiatric hospital and we know that it is not necessarily an appropriate setting. However, for some time we have not had any other place to have that person treated, other than in an adult system. Children do not move at the pace of adults, and we must ensure that we no longer create the types of service models that are adult in focus and that are inappropriate for children and youth.

I would like to add some other suggestions. Number one, primary prevention: Early intervention programs offer important interventions to at-risk youth. The determinants of mental health are based on factors such as poverty, the family environment and support of the community in the child's life. Many children and youth we see would not require as extensive mental health intervention if these determinants were different. The focus on prevention of mental health problems needs strengthening. Populations that should be targeted for primary prevention approaches include children of parents with mental health issues and addictions, children of socially disadvantaged circumstances, children in care and those on child protection caseloads, families at risk for poor parenting, and children and youth at risk for anxiety or coping problems.

The second area where we see the need for improvements is in the area of crisis intervention. In various parts of our province, it can be particularly difficult, especially for smaller centres, where there are few adequately trained staff and where inpatient beds do not exist to stabilize those children and youth who cannot be managed in our communities. We need to establish more mobile crisis response services in each region of our province. This response will be designed to fit the particular geography of that province, of that area and the resource realities in those areas.

We need to provide on-call crisis workers who are affiliated with the Janeway. That is our provincial child health centre. These workers should provide intervention to the St. John's region and consultation to other regions of the province. In terms of acute care, this summer there will be only three hospital beds open for youth for the entire province, and at least two of these beds will likely be filled by adolescents with eating disorders.

An effective acute care system should consider all areas of the child's life. Services that are specifically designed to provide mental health services must be linked with a range of services that can support the child through an acute episode of illness. A full range of services would include things like day treatment programs, flexible school programs where you have components of day treatment and the regular classroom where children who have behavioral disturbances could be integrated and given the support they need in the classroom. Right now, nothing like that exists. We have one separate school classroom that is not necessarily directly linked to a mental health service, but has to go outside and request those services.

We need dedicated beds that are specifically for older adolescents. That is something that is actually in the developmental stages now in our province, which we have advocated for a long time.

We need to use more technology, telepsychiatry, which is something that we tried a few years ago with good results, but have not been able to sustain the funding to carry that forward. We hope now with the new Provincial Mental Health Strategy that it will be something we can do.

Home-based and outreach services: Children and youth who require health services often have need for support and assistance in many areas of their lives. An effective system would address the needs of the "whole" person. The approach to address such needs requires both home-based and outreach services: things like community recreation programs that are available to children who are socially disadvantaged that are easy to access; an intake point that avoids the system gridlock — we find that many times people are caught in the administrative gridlock of deciding who is appropriate for what service and we need to better coordinate that as a collective group; communications systems that enable service providers to access information; and better coordinated plans of care that encourage communication between the specialized services, schools and families.

For residential service options, we need support of living arrangements that include provisions for home support and case management services; residential treatment centres for particular populations of people who are difficult to serve; supportive housing for youth with mental illnesses — we have nothing set up specifically for youth who are in crisis who have mental illnesses, apart from hospital admissions, it is done on an ad hoc basis, and usually in times of emergency; and addiction services that are specifically designed for youth.

Finally, we need more specialized services. Tomorrow, you will hear more about another program called the Early Psychosis Program that is very specialized and that is geared primarily toward youth, but can involve other age groups. We need to develop more regional specialized services so that each area of the province has more access to satellite kinds of services.

We need to increase opportunities for access to psychiatric consultation. This is something that is desperately needed, particularly in the area of children and youth; that children or youth should not have to wait as long as they do for a psychiatric assessment. Sometimes it requires only a consultation, and the work then is done by a mental health professional, together with the family, but right now, that is difficult often to access unless there is an absolute emergency situation.

We need to be flexible about our beds in hospitals so that we do accommodate people with mental health problems in other areas, in general hospitals.

Finally, our program is based on a strength model. By that I mean that we try to work with people from the beginning by getting input from the youth around what they are there for, even if the referral source has said to us, this is the reason why they think they need help. We have been clear that we solicit their input right from the beginning, and we do that in a number of ways: with questionnaires and with what we call session rating scales so that after every session the youth gets a chance to give feedback to the client, so it is much more of a reciprocal relationship.

The Chairman: Ian, I was struck by when you described your services team — two social workers, a psychologist and so on — that team does not include a psychiatrist, correct?

Mr. Shortall: Initially, it did, and then that psychiatrist moved from the region. Of course, we have difficulty at times replacing psychiatrists and bringing them into the province. Another psychiatrist was recruited, but part of that person's responsibilities involves working in one of the hospital settings, and right now, we have access to the psychiatrist for three hours, one afternoon a week, for clients who are seen by other members of our team. Formerly, we had access to a psychiatrist.

The Chairman: Do you have access to a larger number of clinical psychologists and social workers who do counselling and that kind of thing? I would have thought they were easier to get time with than psychiatrists.

Mr. Shortall: Yes, it depends. From program to program it varies. In this region, we probably have more children and youth services than the other region, but the numbers are low.

The Chairman: By this region, you mean the eastern region?

Mr. Shortall: The eastern region, and primarily the services are in St. John's. For example, there is a program similar to mine that sees children from the ages of around 2 to 21, and in that program there may be a full complement of about 13 psychologists and social workers. Of course, this region alone has around 180,000 people, so that program frequently has a waiting list.

The Chairman: Can you help us on the use of both words and ages? You talked about children, you talked about youth, you talked about adolescents and you talked about adults. The only reason I ask is in the report we will have to specify a term and an age. We have found across the country that in some places a child is 16 and under, for children's services, and some places children are under 19. In other places, there is a middle group; there are children, which we would think of as maybe under 12 or 13, and then there is a youth or adolescent — I would like to know which word is better — and then adult. Finally, in other places there are provinces where, if you are under 16 you are a child; if you are over 18 — 19 or over — you are an adult; and if you are 17 or 18, you are not covered because you are neither a child nor an adult.

Mr. Shortall: Yes.

The Chairman: Hard to figure, but this age group falls absolutely outside everybody's system. I have two questions for you. Are there age brackets in Newfoundland that say which program you go to? Secondly, what age do we use to define children, and do we distinguish between youth, adolescents and so on?

Mr. Shortall: That is a much more difficult question than it may seem. In other parts of the country, it is much more obvious in terms of where they delineate age groups. In this province, certainly, from a legal perspective, the Child Youth and Family Services Act sees and recognizes children up to the age of 18. Between 17 and 18, of course, you do not necessarily have to report cases of abuse or anything, but under that age, 16 and under, you do. In our health system, only in the last month or so there have been announcements that the child health program has expanded to the age of 18. Prior to that, services for anyone over the age of 16 were seen in the adult system. When BRIDGES was developed, we saw that gap between the transition from children's services to the adult system, and so we designed a program for adolescents from 16 to 20.

Now though, psychiatric services are going to look at children up to the age of 16, at least on an emergency basis, and work is underway to try to recruit a psychiatrist who will see children up to the ages of 18. Our services are disorganized in that respect around age groupings. Any child right now who is seen in a psychiatric setting typically is seen by an adult psychiatrist.

The Chairman: Do you prefer youth or adolescent? You used the two.

Mr. Shortall: I am sorry, I prefer youth.

The Chairman: You referred in your document to a round table on adolescent disorders.

Mr. Shortall: In the report.

The Chairman: Yes, I would love to see that if you have one. You may not have one here, but maybe you can send us one. We will give you a card.

Mr. Shortall: Sure.

The Chairman: Joan, you gave us the best description of peer support that we have had anywhere across the country.

Ms. Edwards-Karmazyn: Thank you.

The Chairman: It is really useful to us. I know terminology matters, but in the last report we had a number of people arguing we did not use terms right. Do you use self-help and peer support interchangeably? Do they mean the same thing?

Ms. Edwards-Karmazyn: They can. The self-help model is based on recovery. Although we do not practice 12-step, that is a self-help recovery model. There are components and tenets of the self-help model that we would encompass in our peer support and self-help: Peers helping other peers. People who facilitate and run self-help groups within CHANNAL would be peers first; they would be identified as consumer-survivors and peers. I would say peer support is what people receive, either one on one or in a group setting, and self-help is the model that provides this peer support.

The Chairman: Do you train a peer support worker? In other words, if I am a consumer and you then want me to participate in a peer support group, is my only criterion that I am a consumer with that particular mental illness, or do I need additional training?

Ms. Edwards-Karmazyn: I am glad you asked that question. For peer support, as it exists right now within CHANNAL, training is non-existent. I come from a background where I have trained peer support workers using the third level of coaching life skills model, which I provide certificates for, so we do have a credential for training peer support workers. At the same time, we do not have the availability to do that at this point in time. When one offers their volunteer services to become a self-help facilitator within a group, then the training at this point in time is minimal. To be a self-help facilitator, you must identify first as a consumer, but secondly, you must want to come forth as a volunteer, and this is where we are lacking. We need training.

The Chairman: Somewhere along the line, I think it was in Halifax, we learned of an interesting program that was offered somewhere in the United States, Georgia, I think it was, and just as interesting, it was on exactly this topic. This individual consumer had gone down and taken a —

Ms. Edwards-Karmazyn: That would be Roy Muise.

The Chairman: Roy Muise.

Ms. Edwards-Karmazyn: Yes, he is a colleague of mine. I am familiar with the program.

The Chairman: Certainly, as Roy described it, it was terrific. Would you agree with that?

Ms. Edwards-Karmazyn: Absolutely, but I think we have the resources here in Canada to put —

The Chairman: Right, so my question is, if you think it is a good program, would it make sense for us to recommend the creation of a similar program in Canada?

Ms. Edwards-Karmazyn: Absolutely, hands down.

The Chairman: Would it help people in your business a lot?

Ms. Edwards-Karmazyn: Yes. I sit on the board of directors for the National Network for Mental Health, and Roy had the opportunity when we were building the Canadian Coalition of Alternative Mental Health Resources to present the peer support program out of Georgia, I believe. It was certainly given endorsement at that level, as well. Certainly, it could be packaged Canadian-style and put into play.

Senator Trenholme Counsell: Thank you both for being here.

You used the words "new Provincial Mental Health Strategy." I came late so excuse me, and if I ask something that has been covered before I got here, just tell me. After you said those words, I looked to see whether it was included in this document, and I did not see it. Could you tell us more about the new Provincial Mental Health Strategy that you mentioned.

Mr. Shortall: In about the last year and a half, almost two years now, a Provincial Mental Health Strategy was struck that involved a comprehensive review with extensive consultation throughout the province of mental health services, not just for children and youth, but for people with a number of mental health needs. There were a number of different think-tank sessions, one involving children and youth, which spoke to the fact that we are under-resourced throughout the province. Within that report, there were a number of recommendations of what is needed, some of which I included in this report.

Senator Trenholme Counsell: Does that new strategy give you hope? Will it address a lot of the things you have here, or how do you regard it?

Mr. Shortall: Certainly, I feel very positive about the recommendations of the report. I think the strategy focuses on what is needed within this province. Some of those ideas are being rolled out now. For instance, one thing that was referenced there was an early psychosis program that would be a provincial focus. Recently, we managed to begin a satellite program with our colleagues in the western region, with Western Health, and they have a position for a coordinator, and we have had dialogue with that group. We hope to expand in other parts of the province and give our program here in St. John's more of a provincial focus, as opposed to focused within the eastern region. That is one example of something that has been rolled out and recommended from the strategy.

Senator Trenholme Counsell: Mr. Chair, will we hear about that strategy, or will we get any report on it?

The Chairman: I think we are tomorrow. In any event, we have copies coming.

Ms. Edwards-Karmazyn: On page 6 of my report, I speak to the highlights of that mental health strategy in reference to the community development work that has been recommended in the context of my paper. However, that is a brief look.

Senator Trenholme Counsell: In terms of the mental health strategy, there must be a lot to it. It would be valuable for us to see it.

Ms. Edwards-Karmazyn: Yes.

Senator Trenholme Counsell: Thank you.

I wanted to say with pride, you mention the need for a mobile crisis unit, and I read last week that New Brunswick is the first in Canada to have a mobile crisis unit beginning this year. I believe that is what they are saying. We are bragging about that. There will be two units throughout the province, and very rapid response, as promised. I would think it would be equally applicable in your province, and I urge you to use our example.

I wanted to ask you about early childhood initiatives. On page 5, you talk about "should be targeted," et cetera. Do you have some sort of early childhood initiatives, early childhood intervention or a family intervention that is province-wide? In our province, those five points, especially, that you have highlighted are exactly the kind of things that are indications of potential vulnerability in children.

Mr. Shortall: I will try to speak to that because I have not worked as closely in that area in more recent years, so I am probably not the person to specifically address some of that. There are programs within the city that certainly address the needs of younger children.

Senator Trenholme Counsell: I was wondering about province-wide assessment of newborns or early —

Mr. Shortall: No.

Senator Trenholme Counsell: There is none in Newfoundland?

Mr. Shortall: Province-wide assessments: Can you be more specific?

Senator Trenholme Counsell: I am speaking about vulnerabilities in young children. Some provinces assess all children shortly after birth for a needs vulnerability, if you will, and then a program of intervention is begun, which involves, of course, primarily the families.

Mr. Shortall: Public Health will assess children at early stages and offer support to families at times, and obviously will refer where it is indicated.

Senator Trenholme Counsell: Does it assess all children or referrals only?

Mr. Shortall: It assesses all children as part of their vaccinations and their pre-kindergarten assessment period. Until that time, when they are very young, I am not sure if there is anything specifically in place at identifying high risk, apart from when they are in the hospital settings, and it is identified at that level.

Senator Trenholme Counsell: I wanted to ask you about technology and telepsychiatry because I have had the impression that Newfoundland has been a leader in telemedicine. I know telepsychiatry works well with young people. It is less threatening sometimes than sitting across a desk from somebody with a lab coat on, suit and tie or whatever it happens to be. You said it started, but then it did not continue. Is that correct, that you are not using it to a great extent?

Mr. Shortall: Years ago, I think it may have been around the early 1990s, a psychiatrist within our system had done a study and looked at, if memory serves me correctly, the differences in terms of accuracy and diagnoses in diagnosing a child through telepsychiatry as opposed to face to face. The study looked at a number of variables around that, and found in the end that the two types were equally accurate in terms of identifying treatment needs for children. There was support at the time, and now, of course, within this new mental health strategy —

Senator Trenholme Counsell: Is it included?

Mr. Shortall: It is included as part of the strategy. We hope to use that in the early psychosis program, as well.

Senator Trenholme Counsell: Good.

Mr. Shortall: We hope to use it particularly in areas such as Labrador where it is much further away, and difficult to transfer people from one region to another.

Senator Trenholme Counsell: We hear about certain cities in the country and about the problems on the streets. I come from a very small village in New Brunswick, so I know a lot about small villages, their problems, and too often, their decline. In St. John's or in Corner Brook, your cities, do you see an increasing number of young people with psychiatric problems as a result of the changes in the society of Newfoundland and the village, the outport, all the factors that affect life in Newfoundland, or are you not? I hope you are not, I hope the answer is no.

Mr. Shortall: A study done a couple of years ago through the Canadian Mental Health Association talks about what is happening with our youth in the province. One area they talked about, of course, was mental health in terms of the impacts of the changes in the rural parts of our province. As I mentioned, there is an awful lot of out-migration. Families have had to leave communities because of the fisheries closing. In that report there was talk of an increase in the prevalence of depression in youth, particularly youth who may have wanted to stay in their home community, and pictured themselves staying there but could not because of the economy in those communities.

Senator Trenholme Counsell: Do you have a problem with street youth in St. John's?

Mr. Shortall: We have a volunteer sector. There is a program called "Choices for Youth." It is based in the downtown core of our city. They have a brand-new building, and within that facility there is a shelter for young men between the ages of 16 to 29, who are in need of emergency shelter or housing. In that group, they also have a number of staff who work within the Health and Community Services or within the Choices for Youth program who help and assist youth with housing issues.

On top of that, recently they formed a group of volunteers, mostly comprised of social workers or anyone who has a mental health background or some counseling training, to go out one night a week and do the work of a street worker. By that, they may just give information to youth who are hanging out in the streets. They may try to engage a young person who has been hanging about in areas where they may be at risk, and then encourage them or give them information so they can seek help or come back to the office that is located downtown to find out more about resources and options that they have. That program is really in its infancy stages. It has been in operation only about two months.

Senator Trenholme Counsell: Joan, I wanted to ask you about paying volunteers. I worried as I listened to that, but we have not heard much of a dialogue, exchange or talk about it. Do you mean paying people who become peer support workers, or what do you mean by that? I think all of us around the table are advocates for volunteerism, and we have to be very strong advocates, as the numbers of volunteers are declining, and the need is increasing. What do you mean here by paying volunteers?

Ms. Edwards-Karmazyn: Within CHANNAL, our volunteers, our volunteer leaders, and our regional coordinators receive a stipend for work that would enable them to do outreach. It would be travel dollars. It would be over and above. A lot of our volunteers receive a disability income.

Senator Trenholme Counsell: Okay, so they are people —

Ms. Edwards-Karmazyn: They receive a little bit of money within the cap of what they are allowed to make before it is clawed back dollar for dollar. That is in reference to our volunteers receiving an honorarium or a stipend for what they do.

Senator Trenholme Counsell: You are not talking about, I will say perfectly healthy people who decide they want to volunteer for mental health groups. You are talking about people who have come up through, have recovered and want to help others?

Ms. Edwards-Karmazyn: That is correct: volunteer leaders that are psychiatric consumer-survivors as well, and who now volunteer their leadership skills and time. Some of them come with inherent leadership skills and amazing amounts of experience. Also, behind those volunteer leaders, the regional coordinators also have group facilitators that are in their ranks, as well. Besides the six volunteer leaders we may have within any one region, we might have up to four dozen or five dozen volunteers that help that regional coordinator run the program.

Senator Cordy: Thank you. You have both given us some wonderful information.

Joan, I love your sayings. "We have to name it, to claim it, to tame it," and "Nothing about us, without us." If you wanted to summarize your whole presentation, I think that would do it.

You just talked about people volunteering in peer mediation or peer support, and we are talking about people who may not have the resources to buy a bus pass and those kinds of things. How difficult is it to get funding for those kinds of things; to buy a bus pass for somebody, or to provide gas money? If you have a program where you hire a person, then you can say, "The salary is so much a week," but for those kinds of things that are so important you are not paying the volunteer, in fact. You provide the resources so the volunteer can get from point A to point B.

Ms. Edwards-Karmazyn: When we provide an honorarium or a stipend for our volunteers, it is clearly up to them how they will spend that. We do not indicate that this is for travel, for example. It may be for a pack of cigarettes, and we know that. However, it is their choice to use it, but we often find that it will enhance for perhaps buying a bus pass or enabling them to get around. Within the program itself, our travel dollars are tagged to the equitable distribution within each region. It is not an equal distribution. For example, in St. John's, the travel dollars would be linked to, say, the bus service or the taxi service that is needed, and this is in conjunction with a person maybe doing outreach, lobbying efforts or advocacy. We define advocacy as "big A, little a advocacy." Big A advocacy is advocating on behalf of a group within, say, outreach to another program; little a advocacy is helping somebody get to the hospital if they need that service.

In terms of our volunteers and what they need travel-wise, we find in the outlying regions that the barrier exists for travel: big land, big geography. Yet people are spread among the outports, for example, on the southwest of Labrador, Labrador City, and we may have 15 people using that group, but they live in the outlying areas. We are now looking at a creative way of providing teleconferencing perhaps once every three weeks or so for group teleconferencing so people do not have to travel in the winter for face-to-face self-help. That is one creative way of looking at it. Another way is to encourage car pooling, but then we run into the insurance on that. We have to look at the implications of people car pooling, what type of insurance they need and how we can supplement that by not necessarily saying, "You must car pool, but if you choose to car pool, here is the travel money to do that and you may charge back to our program." A lot of our budget is earmarked to travel because of the lay of the land of our province.

Senator Cordy: One thing you talked about in your best practices was recovering capacity-focused challenges, low expectations. Within the training of health care workers, have we changed the way we train health care professionals so they realize that the self-help programs are extremely important, that community-based programs are extremely important, and that consumers of the mental health system not only can become self-sufficient but can move back into the workforce and become taxpayers once again?

Ms. Edwards-Karmazyn: Yes, in terms of training clinicians and health care workers, et cetera, an amazing program has been launched in Newfoundland and Labrador called the "Changing Minds Project." The Canadian Mental Health Association, along with other community partners, have developed this amazing program and it came out of the inquiry into Fred Powell and Norman Reid. We had two deaths happen by way of police, and the intervention caused the inquiry to unfold. From that, the Changing Minds Project developed to train front-line workers including mental health workers, ambulance, police, fire, initial service providers such as principals of high schools. That is beginning to launch now. I think the September annual general meeting for the Canadian Mental Health Association, which is in Edmonton this year, will look at rolling that Changing Minds Project out.

In terms of teaching, yes, we are saying self-help. In telling our stories, recovery begins to happen in the modeling of wellness of where we are along the continuum of our health. I sit before you today as a well person, but in the past I have been a very ill person. Telling those stories is good medicine. It helps us.

Senator Cordy: It is also good for reducing stigma among the population when we can put a human face to those who have been consumers of the system.

Ian, I am curious. You talked about the wait time that can be 3 months to 12 months, and is currently about 11 months. What happens to the kids who wait for 11 months?

Mr. Shortall: Different programs make an attempt to prioritize waiting lists. Of course, there is a strategy within our own organization right now to begin looking at wait list issues, in particular, with a focus on mental health. Within the BRIDGES program, we do not have a waiting list and we have been able to manage without a waiting list for four years, since our inception. The reason for that is, we have a very narrow scope. We see young people between the ages of 16 and 20. Our mandate is that these people have a mental health crisis or a mental illness that is significant enough to impair their functioning. We get around 30 to 40 new referrals a month, and the idea of BRIDGES is that it be a brief, rapid service because, otherwise, it will bottleneck.

We have only three full-time equivalent clinicians and one person who works as a case manager. One thing that helped us is that for young people, say, who present with issues that involve difficulty in functioning within their community or in the school, we have been fortunate to have the resources of an occupational therapist who can work with that young person in conjunction with the other members of the team. We have had some wonderful outcomes with young people with some complex needs. However, if they do not fall within our program, they could go to another program, and we have only two or three resources within our region that would service young people with a mental health problem.

When I talk to my colleagues in other areas, one of their chief complaints is not having the same access to psychiatric services that a program such as mine would have. They talk about the difficulty in penetrating that system and making a case for a young person in need prior to bringing them to the emergency room, or calling the police because it has become an urgent situation where there is risk.

Senator Cordy: You get about 30 referrals a month, and in your services, you have rapid mental health outpatient intervention. How does it work? You get a referral from a school, or how does the referral come, first of all? Second, with your rapid outpatient intervention, within 72 hours they receive a counseling session? Would you explain how that works?

Mr. Shortall: Initially, we thought it would be within 72 hours. We found that when a referral comes to our program, it is faxed to our program.

Senator Cordy: Who would refer it?

Mr. Shortall: It could be a school guidance counsellor. About 50 per cent of our referrals are from family doctors. They have become well aware of the program. We have done an extensive communication strategy some time ago, and so they continue to be our primary referral source. We also have referrals from social workers from the children's protection services and from other mental health professionals in the community, but we have said that we prefer that the young person be seen first by someone who would have at least determined that they need a service.

We have not — and this has been deliberate — advertised ourselves as a self-referral service simply because we know we would not be able to absorb the volume of referrals we receive. As soon as someone is referred, it goes to a clinic team meeting every morning of the week. For 15 minutes, the team gets together, reviews those referrals, and either assigns them or requests further information. The turnaround time is intended to be very quick. In cases where we have to turn people away, we look for other resources for that person. On that list of 30 or 40, if there are five or seven who can wait, then we have been forced to do that.

When we initially started out and we were not known, we accepted every person who came in the door. As time went on, we have had to more rigorous. We are not comfortable doing that because it is a judgment and you hope that when you make a decision, the person who you say will have to wait and be referred to another program is not someone who needs it more than another person. It is a systemic issue. We need the resources of our other people who provide the service, as well.

Senator Cordy: You said that you can broker services and refer them to other agencies. If, for example, you referred them to a psychologist who is not covered under medicare, who would pay for the psychologist? Would the individual pay?

Mr. Shortall: Certain programs will be covered under their parent's employee assistance program, EAP, for example, and they have that option. Most of our services here, the majority of people work in public service agencies. A small number of individuals work in the private field, whether they are social workers or psychologists. Those two disciplines tend to be the ones that provide private practice in this province. In total, you are probably talking about 40 individuals, if my memory serves me. You can get access quickly to services that are private, for children and youth. There is a real difference: If someone can afford to pay, then they probably will get that service. It will not be by a specialized team, necessarily, in an agency that has all the resources that an agency like mine may have for backup.

Senator Cordy: If you referred to services, you would refer to services that are covered by medicare?

Mr. Shortall: Sometimes, or sometimes we refer to one of the other agencies, especially if we think a person can wait. Typically, even though our program is one to six sessions, we allow for a limited amount of time beyond those six sessions because youth do not like to be transferred to another counsellor after they have started seeing someone. That is well researched in the literature. It is true of most people. When you engage in a relationship with someone you trust, you are reluctant to carry on with a new person.

Senator Cordy: Joan made reference to the need for a holistic approach to dealing with mental health issues, and she referred to family, whether it is your biological family or your community family. When you look at the child, you have to look at the situation around the child, and I wonder about kids who are caught up in the legal system. In Nova Scotia, the federal government had a pilot project a couple of years ago where they hired two people in Nova Scotia to deal with young offenders. Their job was to look at the families of the young offenders because often there are problems within the family, whether it is parenting, whether the child has addictions or any number of things. Are you involved at all in youth who are involved in the justice system?

Mr. Shortall: We are. Primarily, our mandate is youth with mental illness, but sometimes, obviously, we have youth who have mental illness who also have had involvement with the justice system. There are other programs, as well. One program that has been around for some time, I forget the exactly title of it, is within the youth justice system. It is an intensive program whereby a social worker may have a small caseload of about ten, and their efforts are around working with the youth and the family. Some of it is case management, some of it is counseling and support, but that area tends to be inundated with referrals. Often it is difficult for someone to get in there and the worst situations or cases tend to be prioritized. However, I would say a small percentage of the people who are referred to us, probably 20 per cent, would have had some involvement with the justice system.

Within the Choices for Youth program, they have youth corrections workers, so we have done more work in the last year with that particular program, and collaborated around individual cases where we have supported each other. However, there is recognition that we need to do more of that.

Senator Cordy: Joan, you talked about the hesitation of people to stop allowance or payments from Community Services or whatever, because it has a direct impact on having a medical plan. Are we doing a better job of coordinating within provincial governments? I will not even go into coordination between municipal and federal governments, but between provincial governments so that you can work at a minimum wage job, but still continue to get help with medications? Or is it, if you are not on social assistance, then you are cut off completely from receiving medications?

Ms. Edwards-Karmazyn: I am not familiar with the process for social support services here in Newfoundland and Labrador. I can speak to Ontario, where programs enable that to happen. They enable a person to have a combined income as well as income disability support. I think Newfoundland and Labrador, with all due respect, is 20 years behind in a lot of services that are being delivered. I come from a perspective of Ontario, where I worked for a number of years in the mental health field. There are vast gaps and differences from one province to the other, as we all know. In Newfoundland and Labrador right now, when I speak to a person about receiving an extra little bit of money to do what they are doing within CHANNAL, and if they are on income support, everyone I speak to comes up with a different dollar figure of how much they can receive. Their workers tell them, "You can make $100 more a month," and then somebody else says, "I make $200 more a month." I think it is case by case. I do not think there is any real sliding scale or anything in existence. I have yet to hear of one. I feel it depends on whether it is an income that is combined with Canadian Pension Commission, CPC, and disability. It is subject to what the individual is receiving, so there is no clear cut amount. People are petrified to go off their income assistance, because when they stop and think about it, in the real world if they were out working, they would have to make upwards of $50,000 a year to be able to stay on their medication. I know of one individual whose medication totals $1,500 a month, and that in itself is shocking, not that the person is taking that medication at that expense, but the fact that they are caught between the rock and hard place. Yet, at the same time, they want to work, but know that their skills base does not allow them to make the money to be able to support their medication.

Ms. Deborah Jackman, as an individual: I feel that I need to add something to what Joan said. I believe that in Newfoundland there was a change recently that if you get a minimum-wage job, you are allowed to get six months.

The Chairman: What happens after six months?

Ms. Jackman: You are on your own. That is what causes people to stay on social assistance.

Senator Cochrane: First, I might begin with you, Joan. On page 1 of your brief, you mention that CHANNAL enjoys a healthy working relationship with their sponsor, but at the same time is in the process of becoming an independent organization. What would an independent organization do that you are not doing now?

Ms. Edwards-Karmazyn: To give you a little background regarding that statement, prior to my coming on board as their independence development manager, CHANNAL had had a conference, a planning session, and had arrived at that time, after 15 years of being under sponsorship, of wanting to look at becoming independent. I think CHANNAL was created 15 years ago with the intent of divesting programs within two to three years. However, that did not happen. The growth, infrastructure and governance did not take place. Along with CMHA's involvement and endorsement, the encouragement is now in place to go further along the road of independence to operate similar to other psychiatric consumer-survivor programs that operate across Canada directly funded from government with their own operating government number. They want to be able to do that. In the interest of independence, they have been given the blessing of CMHA, so we have a healthy working relationship and an endorsement to strive to do this. I think clearly the message has been sent to us in the movement that yes, this is possible. We have seen it happen with other models that are operating. A program that I had operated in Ontario in the Muskoka and Parry Sound region for a number of years is totally independent of the agency that they initially started with. It is on the road to recovery, again, but not just recovery of the individual. The whole message is yes, you are adults and you are able to do it; go for it and do it.

Senator Cochrane: Within this area that you are part of now, no other group is doing this?

Ms. Edwards-Karmazyn: I do not believe there is another group that is a self-help, peer-support-run group, such as CHANNAL. CHANNAL, again, is in its sixteenth year. To my knowledge, there is not another group or organization. The Canadian Mental Health Association has sponsored CHANNAL for the length of time it has been involved. To my knowledge, I do not believe there are others. There may be groups within hospital settings and day treatment settings and whatnot who end up eventually referring to CHANNAL at some point, but no, I do not see another group existent at this point in time.

Senator Cochrane: Let me go now to Ian. I, too, came from an education background. Like Senator Cordy, I am interested in the school system. What could be done within the school system now that would help identify some of these children, and maybe give them help before the problem gets too serious? Are teachers being educated in regards to diagnosing — diagnosing is not the word but being able to tap into — a problem that this child has, and before the problem gets serious, maybe consult a doctor or someone, even within the school board to get help as soon as possible?

Mr. Shortall: In this province, we have what they call now the Individual Support Services Planning process, ISSP. It was a program that was developed through a number of government departments, the Department of Justice, the Department of Health and the Department of Education. Its purpose was to identify children who may have problems in terms of how they perform in their school years that were related to a number of other variables and factors. Some of these children would be identified by the school, and the premise was that anyone could call an ISSP on a child, whether it is a parent or a social worker who is working out in the community with the family; anyone could do that. Typically, often the school initiates that because often the school is the one who identifies the child because the child may be posing problems in the school setting. I worked in Ontario for five years in a program, and we actually had a day treatment program based out of a school, as well as a separate school system for youth who are identified as having difficulties. These kids were not able to be managed in our school systems.

Apart from identifying children or identifying children who have issues, there is also the impact of the children who are in settings where a child is out of control in a classroom and other children who are witnessing this behaviour. These children may themselves be traumatized by the interventions to try to get that child under control. I have heard stories of children having to leave classrooms because one child is out of control, and this may be a classroom of Grade 2 students where there are no resources in the classroom to manage that particular child, whether it is a student aide or whether it is consultation with the appropriate people. Guidance counsellors in our schools often are affiliated with more than one school. A guidance counsellor may need to know more than just 500 children in the school. They may have two schools they manage and, therefore, they visit the school regularly.

What I would advocate for, and where we have seen some success, is having social workers in schools. We have a social worker in a few schools in this region, not many, maybe two or three schools, who is employed by Health and Community Services. The social worker works part of the time in some cases in the school system, but not on a full-time basis. They tend to follow children where there are high risk families. I think we need more of that. I think we need to see more intervention at the school. Children spend most of their time in school, particularly young children. Teachers are overburdened and not properly resourced to deal with some of the behaviours they are seeing in children. Classroom sizes are way too large for younger children. On average, in a primary school in this city, you are looking at a minimum of around 28 to 30 children in a classroom, and that is children with all different kinds of needs: maybe children who are hungry coming to school that day who may not have had a meal, et cetera.

Senator Cochrane: Right, I know where you are coming from because there are such large classes and it is very hard, but we do have classes within our schools that are set aside for certain children who have disabilities of that sort.

I am also wondering about, on page 5, youth treated as adults.

Mr. Shortall: Yes.

Senator Cochrane: You mention, "The delivery of mental health services to children, youth and families is drastically different and requires specialized training." I know that. "Adult assessment tools do not work." Did you say that sometimes when there is no place for these children that they are put into adult institutions?

Mr. Shortall: Yes, sometimes if a young person is deemed to be at risk due to a mental illness and they need to be hospitalized, if they are over the age of 16, right now as our system exists they are seen in an adult setting, in a hospital where there could be other adults. We have only a few options in our city, and it is worse in other parts of the province. In our program, we will increase that age to 18, so we will have a designated number of beds in a pediatric general hospital that are specifically for people with mental health needs. That is something that is just now evolving. However, for many years we had young people over the age of 16 who were seen in a general hospital setting on an adult ward. If the person is deemed as being out of control or difficult to manage, they can be seen in our adult system at a provincial psychiatric hospital because that may be the only place where they can be safely managed, in a secure facility or a secure unit. However, that is usually seen as a last resort. In some cases, people do well there, but they have the option of looking at what is best. We are moving towards that so we have more choices; making the service fit the needs of the youth as opposed to trying to make the person fit into the program.

Senator Cochrane: You said that there are only three beds for the summer that are available to mental health?

Mr. Shortall: In the eastern region, yes.

Senator Cochrane: In the eastern region?

Mr. Shortall: Yes: There is a program in Corner Brook where they have, I think, a number of adolescent and youth beds in a hospital.

Senator Cochrane: How many would you say we need for the summer?

Mr. Shortall: In the report I mentioned to you earlier, back a few years ago it was identified that we needed about eight to ten beds at any given time. Recently when we looked at our statistics, we were able to downsize that to approximately — I would need to check this for sure — four beds at any given time.

Senator Cochrane: Do you say the system is improving then?

Mr. Shortall: I think the system is improving. We are not there yet.

Senator Cochrane: Right.

Mr. Shortall: If you have two youth who present with an eating disorder, which is complex, their length of stay in hospital may be longer due to medical kinds of complications, and these may be one or two beds open for the summer for the province. It is not just this region sometimes. That is the tertiary hospital, the provincial hospital. It is better than what we had before because now at least we can go to the age of 18 in a more appropriate setting.

Senator Cochrane: When is this age 18 age coming into effect?

Mr. Shortall: I am sorry?

Senator Cochrane: You were talking about age 16 and they have to be treated. Now you are going to the age of 18.

Mr. Shortall: The facility is not completed. The physical structure needs to be modified. The majority of children seen in this facility in that under 16 age group were younger, so they are trying to accommodate it and build it in such a way that it has a separate area for the older youth, and there is not as much mixing with the younger children in that same facility.

Senator Cochrane: Are you integrated or do you have a relationship with other organizations within the mental health system where you can compare different progress, ideas and things? Maybe Joan can answer as well. Do you integrate your services with other services that are of the same nature?

Mr. Shortall: Absolutely. Even though we are the largest city or town in the province, it is still a small tight community, especially when you talk about children and youth because there are so few resources.

There is reference in the report about services being fragmented. They are, but sometimes with children and youth you need to look at other departments and other programs because if you are looking at needs from a holistic approach, then it does involve other stakeholders. We have gotten much better at doing that, and there are structures in place where we have reasons to come together and talk about some of the barriers around our services.

Senator Cochrane: And the good points.

Mr. Shortall: Absolutely.

Senator Cochrane: Remedies, right?

Ms. Edwards-Karmazyn: Shall I answer that question?

The Chairman: Go ahead.

Ms. Edwards-Karmazyn: The short answer is yes. The short answer is no. We have integration happening. We have CHANNAL volunteers and members who are involved with community partners, and that does not necessarily mean community partners of mental health. It could be across the spectrum of health care. Yes, it is happening, but we could certainly use a lot more of it.

Senator Gill: I have also been involved with education, teaching and in charge of schools on Indian reserves and off Indian reserves. When I had a so-called problem with a young person, I would usually look carefully at the family behaviour and things like that.

I am concerned about adolescents. I have been through that with my kids and with my grandchildren. By the way, I have 13 grandchildren, and they have all made their way through their adolescence. We know that it is not easy for those kids to find their way in life and to work on their personalities. It is difficult to know if a kid is normal. Society has standards, and when you do not behave according to the standards, people find that difficult to relate to. This is my concern. How do we know if an adolescent has psychiatric problems or if he or she is just experiencing a normal adolescent crisis? I am talking about young people who live in isolated areas of our country, as compared to grand cities like Montreal, Toronto and the like. Could you explain that to me?

Mr. Shortall: I am a parent of children who have not reached adolescence yet, so when they do I may come to you. If you have 13 grandchildren now who are reaching adolescence, maybe I will need to come to you. That is a good question.

You mentioned family involvement, and of course families are involved in our program. As a team, we meet with families to get their perspective as well as that of the child or the adolescent around what it is that they are noticing in terms of the concerns they bring forward. This is done in the context of a room where people observe what is happening. It is not a room with a two-way mirror. It is an open room, which we experimented with when we first started out as a program. The family comes for an hour to talk about what concern they have and then they will have a chance to hear out loud what the team members think about that concern or what is brought forward. The team will try to normalize some of those behaviours in the context of what is normal for any adolescent so there is an educational piece that the family will hear that maybe another team member may have even struggled with, with their own child. We are no different in that way, none of us. Then the team reflects back to the family what was observed and what things they are doing well that they should continue to do. We talk about the problem of the youth as if it is sometimes a problem external to that person: that it is not the person, it is the problem that is concerning the family, particularly in cases where there is a lot of concern around behavioral kinds of things. We will write a letter to the family of the youth, commenting on what we have done. The purpose is to empower the family and the young person because when you come to see someone, sometimes you can feel as if you do not know anything and you are coming for help. In fact, we run from the premise that the families themselves have far more knowledge about their child than we ever could know. That is the premise that we work from.

Some things are outside the boundaries of, I will not say normal but that may lead us to be more concerned about the well-being of that person. There are ways of asking questions that delineate some of that. However, even when you do that, it is always important we do not get so wrapped up all the time in what the diagnosis is of a person. People are more than just a diagnosis, children, youth and adults. However, we try to focus on the strengths that help them overcome those issues and help the family see, as well, beyond the problem that is presented. We have purposely trained our staff to think that way, and we have done it in different ways. We have modeled that by constantly having a feedback loop from the parents and the families that is both written and verbal back to the team. We are open in terms of even saying at times when we do not know what the answer is. We will say, "We do not know, you need to help us here." I think that kind of engagement is a way of normalizing certain things. However, we will draw attention and highlight things when we think it is concerning.

Senator Gill: Joan, I like your approach, talking about the peer support. I grew up on a reserve. I went to school in the non-Native system, but occasionally I needed to go back to my family, back to my grandfather. I even become emotional talking about that. I needed some reference in my life, and this is the way that I got it. People need an explanation of what is going on and why we see big changes. Sometimes, I feel that we do not do that enough with kids and adolescents, and even with some adults who have problems. It does not mean that we are not adding other values living in today's world. We have to do that, but we have to be in control, and to be in control, we have to know where we come from and who we are. I like your peer support program, but I wonder how it works in particular with immigrants and Aboriginals.

Ms. Edwards-Karmazyn: In terms of cross-cultural, new immigrants and Aboriginal folks, within CHANNAL I imagine the peer support would certainly recognize that as an initial possible barrier. At the same time I think the individuals, the people who are working at CHANNAL, the volunteer leaders, are astute enough and mindful enough, and through our discussions and our quasi-training that we receive right now, to understand that we can transcend culture, we can overcome, and it is the communication of the heart. I like to refer to it as the alternative medicine that people will receive. Again, I go back to what I relate to in the telling of our stories. Human beings are human beings. Of course, culture will make a difference, an impact in respect to domains of life and how that life unfolded for them. However, coming into the doors of CHANNAL, I am honestly able to say that I trust that the people who run CHANNAL are able to transcend culture. That is the best way I can describe that for you.

The Chairman: Thank you both for coming today. We appreciate your testimony.

The Chairman: Senators, our next three presenters are Kim Baldwin, the Director of Mental Health and Addictions Services for the St. John's region, Ron Fitzpatrick, who is here as an individual, and Geri Dalton, who is a nurse practitioner in the Short Stay Unit at the Waterford. We will begin with Ms. Dalton.

Ms. Geri Dalton, Nurse Practitioner, Short Stay Unit, Waterford Hospital: Good afternoon. I am pleased to have been invited to speak about the Short Stay Unit Assessment Unit and my role as nurse practitioner in that area. I will offer my perspectives on the reform of the mental health system.

I have been working in the mental health field for 24 years, and have functioned in a variety of positions: staff nurse, nurse administrator, nurse educator and, most recently, nurse practitioner. I am a primary health care nurse practitioner. I graduated from the Centre for Nursing Studies in 1999 and I have been employed with the mental health program of the previous Health Care Corporation of St. John's in the acute admission area as one of three nurse practitioners hired since 1999 to work in that area. Presently, I am the nurse practitioner working in Short Stay Unit-Psychiatric Assessment Unit at the Waterford Hospital. It is a new service, which opened in February of 2002. It is actually two separate services, but it is staffed by the same interdisciplinary team who work for both areas.

The Short Stay Unit, SSU, was developed to better serve those patients who required a brief period of stabilization plus intensive needs assessment, and to ensure rapid reconnection with the community. It is a seven-bed, inpatient unit with a length of stay of 72 hours or three working days. The admission criteria states that the patient admitted to the area must have a psychiatric diagnosis, and that they cannot be managed safely in a less restrictive environment. However, their suitability is based on the expectation that they can be discharged within 72 hours.

The Psychiatric Assessment Unit, PAU, provides 24-hour psychiatric care to the public, including clients brought in by law enforcement officers and who are detained under the Mental Health Act of the province. It is now designated as a safe setting for individuals picked up under the Mental Health Act, and who are detained until a psychiatric assessment can be completed. This work was previously done behind bars. People picked up under our Mental Health Act previously went to St. John's city lock-up and were held there until they were assessed. Essentially, we have taken people out of our city lock-ups and brought them to our treatment centre.

The unique feature of this particular service is that there are three holding beds or crisis intervention beds associated with the service, which allows us to provide an assessment of somebody who may come in and may not require admission, but we are not comfortable sending them home right away. We may want to keep them overnight, see if a collateral history is needed from somebody or have an opportunity to hook them up with services in the morning. They do not have to be admitted to hospital. Previously, the only option we had was to admit them to an inpatient psychiatric unit, whereas now, we can have the person stay in a holding bed overnight. They are monitored by staff and they are reassessed in the morning as to what their needs are. They may well go home. That is a new feature with three beds dedicated in that area.

That is an overview of the service and the Psychiatric Assessment Unit, and I am sure you will have questions for me on it.

In terms of my role as a nurse practitioner in the mental health system, as far as I know, there are three primary health care nurse practitioners working in mental health in this province. I do not think there are any other nurse practitioners working in mental health. I am a primary health care nurse practitioner, but I work in the mental health setting. That does not mean that nurse practitioners working in communities are not providing mental health services, but in a specialized area, I think there are only three of us. Two of us were hired and placed on acute-care inpatient units in the provincial psychiatric facility at Waterford and one was on the inpatient unit on the Health Sciences Centre. We work collaboratively with the psychiatrist, the GP and the other members of an interdisciplinary team to develop a treatment plan, to facilitate patient access to services, and to determine and implement appropriate health promotion or disease prevention strategies. We monitor the client's condition during hospitalization, we identify any family or client needs and provide education or counselling regarding health issues to ensure that the patient's participation and understanding of the prescribed treatments is good.

In my area as a nurse practitioner, my daily work involves performing comprehensive health assessments and physical examinations, ordering appropriate treatments and interpreting diagnostic tests, establishing and diagnosing those conditions and prescribing or treating those that are within my scope of practice. I see clients who have conditions that are outside my scope of practice, then I work in a consultative relationship with other health providers or I refer the person to a more appropriate provider. As well, I manage clients with stable chronic conditions.

To date, my practice has been institution-based and has focused significantly on diagnosis and treatment of acute mental illness. Because I see people in their most acute phase on an inpatient psychiatric unit, it is not a natural environment and it is not necessarily the best time to intervene in terms of health promotion, or illness prevention, rehabilitation or recovery strategies. I think we would be better utilized in these areas if we were in community-based services. It certainly presents challenges.

I am seeking this committee's support for the integration of a nurse practitioner role into the delivery of services at the community level, whether it is through primary health care clinics or primary mental health service delivery in the province. This role can only strengthen the team of providers working with individuals, families and communities to improve the health for all.

In regard to reform of the mental health system in Newfoundland, I will speak briefly. The Government of Newfoundland has undertaken the process of developing a mental health services plan developed for this province. This process has involved a lot of consultation along the lines outlined by this committee in its reports. Along with consultation, there has been debate, review of literature, review of reports and inquiries to help develop a plan that is comprehensive and responsive for the province. I am excited about it. I have been in this field for 24 years and reform has been a long time coming. I am hoping that we will see even more happening in the area, but the plan is here and now my biggest concern is that it is fully implemented and properly funded to ensure that it meets the needs of the people of this province.

In that plan, there is talk about the influence of income, housing, families and the formalized system. They have tried to look at the entire picture and at ways of addressing concerns and, in particular, at how it can be done in regions, rural versus urban, and what services are needed.

Immediate attention is needed for revision to our provincial Mental Health Act. Our Mental Health Act is 35 years old and it is grossly outdated. It was developed in an era when patient and consumer rights were not a predominant issue, and options for treatment were incredibly limited. What concerns me is the Mental Health Act is the only legislation, apart from the criminal code, that allows for the detention of somebody against their will. Our act also provides for the treatment of individuals against their will if they are deemed to be suffering from a mental illness and unable to make decisions for themselves. It is serious legislation that is seriously outdated and in need of revamping. In Newfoundland, there are 500 incidents per year of persons being admitted to psychiatric services under the Mental Health Act, and there are another 500 people detained and assessed, and not admitted. The act is used extensively in terms of managing mental health issues in the province and it needs to reflect the times. Until recently, the detention was primarily lock-ups and as I said, in St. John's, the Short Stay Unit has changed that practice, but in rural areas, they still use lock-ups in many cases because there is no safe place or safe rooms in regional facilities.

Recently, in some of our remote areas, the requirement for a physician's signature to transport someone to a psychiatric facility when no physician is immediately available has resulted in delays in receiving adequate treatment and unnecessary distress for individuals and families. Inclusion of other caregivers, such as nurse practitioners, as those able to assess and certify individuals detained under the Mental Health Act could alleviate some of these concerns and situations.

In addition, the appeal process associated with the Mental Health Act is extremely poor. There is one review board for the province, and the response to applications made is extremely slow. I would say in 90 per cent, or maybe even higher, of the cases of people applying for review, they are decertified and have gone home before their application has even been considered. There is something fundamentally wrong with this process.

There needs to be a redesign and implementation of a new act which respects the autonomy and decision-making ability of individuals, and is based on current evidence and clinical practice standards. I suggest that perhaps there should be national Mental Health Act legislation rather than leaving the responsibility for updating this powerful and important piece of legislation to provincial agendas.

Finally, on a personal note based on my own observations, I have been concerned about the recent implementation by our province of restrictive policies regarding access to atypical anti-psychotic medications. Pharmacological intervention is the keystone treatment for many mental illnesses, and access to medication is essential. Persons with mental illnesses should not have their recovery jeopardized. Their quality of life cannot be measured in dollars and cents. New drugs with improved side-effect profiles must be made available to our mentally ill persons. This availability will support early intervention and prevent the declined functioning often seen with sub-optimal treatment and, hence, help reduce the isolation, stigmatization and discrimination clients often experience.

In closing, our Canadian mental health system has long needed a champion and an advocate for reform and I would like to thank this committee for taking on that role. Your work is most encouraging.

Ms. Kim Baldwin, Director of Mental Health and Addictions, Health and Community Services — St. John's Region: Good afternoon. First, I want to thank you for the opportunity to address your committee this afternoon. When I was initially contacted to appear today, it was with respect to talking about new developments in the addictions area, specifically methadone maintenance treatment, but I would be remiss as director of a community-based mental health and addictions program not to highlight some of the strengths and challenges we currently face in this province.

I have worked in the addictions field for approximately 20 years and more recently have assumed responsibility for community mental health services. Our organization, over the last five or six years, looked at integrating the Mental Health and Addictions program under one structure, and that was in an effort to respond more appropriately to the issues of co-occurring mental health issues and addictions. However, we also recognize that there are distinct differences that need to be maintained and respected, so we have been able to maintain two distinct programs that intersect as well.

The range of programs that we are responsible for fall along a continuum. Within mental health, we have everything from crisis intervention to community-based mental health counselling, vocational counselling and transitional housing. Within the addictions area, we are responsible for addictions education and prevention, detoxification, addictions counselling and support. We are also in the process of developing some much-needed day treatment programs, along with a methadone maintenance program.

Over the last number of years, we have made efforts to better connect our mental health and addictions programs and we have made some inroads internally. However, we recognize that historically there has been a strong disconnect between the community sector and the institutional sector. Unfortunately, this has resulted in gaps in services. Over probably the last couple of years, we have acknowledged that gap and we have actually embarked on a process of joint planning where the community boards and the institutional boards have worked together to plan collectively for services in the region. This collaboration will only be enhanced by the process of health care restructuring we are currently undergoing in this province, and the creation of integrated health authorities where all mental health and addiction services will be housed under one organization.

Geri Dalton made reference to the provincial mental health and addiction strategy entitled, Working Together for Mental Health. This document, as Geri indicated, was the result of a series of consultations around the province, an extensive review of the literature and an extensive review of the services currently available. The strategy is intended to cover the full continuum from prevention and promotion to recovery.

The last couple of years in this province have seen a great deal of attention focused on mental health and addictions issues. From a personal perspective, this attention has been long overdue. In the context of larger health issues, mental health and addictions tend not to have that same kind of profile. In the addictions area, where I have been working primarily, funding for programs has remained fairly constant over a number of years despite increasing demands for services and new responsibilities placed on those services.

In the last year or so, we have seen mental health and addictions established as more of a priority. This area has been highlighted in some of the recent provincial budget announcements, along with the development of the provincial Mental Health and Addiction Services plan, and the recently announced or released OxyContin Task Force report.

The OxyContin Task Force was set up by government in response to some of the demands and growing concerns that we were experiencing in the community as highlighted by community advocates, law enforcements and health professionals. It was a collaborative effort involving the Department of Justice, the Department of Education and the Department of Health. We looked at developping a comprehensive strategy for responding to addictions issues, particularly OxyContin and other related narcotics, as they were the concern at that time. The final report of that task force was released in August of 2004 and it is very encouraging that to date, approximately 80 per cent of the 50 recommendations in that report have been either initiated or implemented. That is a good start.

Within the task force report, it was recommended that in addressing the complexity of addictions issues, a multifaceted approach is needed that involves education, treatment, harm reduction and enforcement strategies. The approach also crosses a range of sectors, so it requires a range of stakeholders to be involved in coming up with a collective solution.

In this province, community-based mental health and addiction services are relatively small. I have four counterparts across the province and out of necessity, we have developed a strong and effective linkage where we can share information, identify emerging trends and collectively work towards developing policies and programs with respect to community-based services.

Along with some of the strengths that we have been able to develop, we have our share of challenges in this province. We have limited resources and, unfortunately, that has caused us to be more reactive as opposed to proactive. We tend to focus on treating the problem instead of looking at prevention, education and promotion.

We tend to view addictions and mental health as falling along a continuum and along that continuum, different interventions are required at different stages. Within the addictions area, for example, we treat issues ranging anywhere from experimental use to problem use to dependent use. As well, mental well-being has been recognized as a major component of optimal health and an improved quality of life for an individual. We have been trying to put more emphasis on wellness and promoting optimal mental health. One of our challenges is to be responsive, but also to recognize and address the needs to put more emphasis on promotion, prevention and early intervention.

Another challenge is evidence-based practice and in the past, we have tried to develop programs and policies that are based on research and evaluation. This practice can be particularly challenging when you have an immediate issue in the community where there has been a lot of public pressure to respond in a timely and effective manner. We must strive to balance being responsive to needs with proper care based on effective practice.

Level of resources is another challenge that we currently face in this province within the areas of both mental health and addictions. While we are grateful that the provincial budget announced that additional funding will actually come into those two areas, we see this only as a good start. Although our province has a small population, we are large in geography and providing an adequate number of services to some of the more remote areas has been difficult. Recruitment and retention of specialized, qualified staff has been a major issue for us. We recognize the need to develop a human resource plan where we can identify competencies, look at training and look at opportunities to retain staff. As well, the need to retain staff has caused us to look at innovative ways of providing services to more remote communities.

Wait lists are another challenge and, again, because of the level of resources that we have, we have a range of wait times for our services. Depending on the part of the province or the particular part of the city in which you live, you could have significant wait times. These could range anywhere from a couple of weeks to several months. We know that when people are faced with having to wait for service, they tend not to follow through and connect with that service when it is finally offered. We have seen that, particularly with some of the addictions clients that we have dealt with.

Stigma is another challenge we face. Even though virtually every individual in this province has been affected either directly or indirectly by mental health or substance abuse issues, there still remains a stigma with respect to those two areas. It has an impact on individuals reaching out and seeking treatment. There is also a concern that it may actually have an impact on policy directions and resource allocation. It is hard to advocate for a methadone maintenance program when there are such high demands for cancer care and cardiac care.

I wanted to comment as well on the range of issues that we are addressing, and I am looking right now from an addictions perspective. Again, when I use the term "addictions," it is almost a misnomer because it tends to focus on one end of the spectrum when actually our services deal with the full spectrum of use.

Over the last year or two, there has been a lot of emphasis and focus in this province on the drug OxyContin. Although those concerns have been warranted, the focus on any particular substance at any given time tends to overshadow some of the broader substance abuse issues that we face in the province. Emerging trends in Newfoundland include increased rates of cannabis use among our youth. We just had the results released of a student drug use survey, and that was one drug in which we have seen substantial increases. We are starting to see increased demands for gambling counselling. As well, we cannot lose sight of the fact that in the recent surveys, Newfoundland and Labrador had one of the highest rates of heavy drinking in all the country. It always strikes me that whenever we try to put some focus on the rate of heavy drinking in this province, it is not considered newsworthy. That is a concern.

We have been working towards better integrating the mental health and addiction services in this province. We have adopted the approach that we need to look at systems integration as opposed to complete program integration. We tend to view addictions and mental health as equal and interactive partners, that there is a point of intersection, but there are also distinct components of each. We look forward to working with the Mental Health and Addiction Services plan to better integrate some of those services.

In closing, this is an exciting, yet challenging time for Mental Health and Addiction Services within the province and within the country. Again, Geri has emphasized the point that a mental health plan has been long overdue and we are anxious to move forward with that. We have seen some progress, as I indicated, with the OxyContin Task Force report and some of the recommendations towards addressing addictions needs in this province. I think the work of this committee has resulted in the start of some plan to develop a national framework for substance use, as well as media attention lately on drugs such as OxyContin or crystal meth in the Western provinces. I think all of that helps raise the profile of mental health and addictions in the province and in the country.

Thus, as we move forward, we need to continue building on this momentum. We need to look at being innovative. Strong partnerships are definitely needed both across systems and within the community. We need to look at evidence-based decision making and focusing on an upstream approach as much as possible if we are ever to make significant changes.

Mr. Ron Fitzpatrick, as an individual: Honourable senators, when you asked me to come here today, you probably had me noted under the heading of Metro Community Chaplaincy, but this weekend past, we revamped our organization and we are now called Turnings. We will have a media blitz shortly.

For the last several years, I have worked with offenders and ex-offenders. My job in a nutshell is to meet offenders in a prison and find out what they need when they get out in society and do whatever we can in our organization to get them out of a life of crime; no more victims and no more re-offending, with the safety of the community being paramount. I am on the board of the Addictions Treatment and Services Association, ATSA. I am also on the board of the AIDS committee, the Regional Coalition Against Violence, the steering committee for Restorative Justice and on the Methadone Maintenance Treatment Advisory Committee for treatment in a new clinic we are opening soon. I am also executive director with this new organization called Turnings, which was, until a few days ago, Metro Community Chaplaincy.

I am delighted to be here. I consider it an honour. I have read your interim reports and the other two reports, and I feel that almost 99.9 per cent of the bases have been covered. I only had a chance, actually this morning, to write up a few things here, which I would like to read, if I could. It is only about six minutes. I have a different spin on mental illness and addictions, so if you will bear with me, I would appreciate it.

Many individuals with a mental illness problem can become productive citizens if they receive the appropriate health care and supports they need. Too often, people with mental illness have simply been neglected in the community and are often left to begging and charity. As a result of this neglect, they fall through the cracks in the health care system right into the criminal justice system that we all know is ill-equipped and unprepared to care for them properly.

That comes out of your notes I read, but I wanted to put it in because it really focuses in on what I have to say.

Police lock-ups, local jails and penitentiaries are all too readily available and frequently used to control these people when, in reality, the health care system has failed them.

When it comes to health care for individuals with mental illness, our government shows itself to be penny-wise and pound foolish. Our government is continually cutting back on health care and social services, and considers this action to be a positive and responsible move. However, in my personal opinion, I consider their cutbacks to be unacceptable. The fruits of these cutbacks can be seen and realized in the operating budget of the criminal justice system where everybody suffers, including Canadian taxpayers.

It is all too obvious here in Newfoundland that too many individuals with mental illness get caught up in a pattern of recidivism. Too often, I have watched individuals with mental illness appear before a judge in our provincial courts and be sentenced to time in prison when, in my opinion, they should have been placed in a psychiatric facility. I have often sat in courtrooms and listened and watched while Crown prosecutors inform the presiding judge about their criminal activity and the prosecutor did so as if the offender had simply thrown all caution to the wind and, blatantly and without remorse, broke the law.

I have witnessed individuals with mental illness being refused help at our local hospitals. The psychiatric nurse and the attending physician appeared concerned about the physical and mental state of the individual at first. However, the minute they mentioned that they had a severe IV drug addiction, their attitude changed.

On a couple of occasions, I have had to assist individuals who had been beaten up and had their social assistance money and some of their household items stolen from them, but because of fear, they would not press charges or pursue the matter any further. It was too stressful for them. Some individuals with mental illness are easy prey to those who would take advantage of them.

I have watched families fall apart and family caregivers get ill and others get addicted to prescription drugs as a result of the destructive behaviour of a loved one who had a mental illness that was compounded by a severe drug addiction.

It has been my experience that some people with a mental illness are easily led and are extremely vulnerable. In some cases, I have noticed that they do not tell their doctor the truth when they are questioned, and so they do not receive the proper treatments they need for a full recovery.

Over the past few years, I have visited many patients and most of these individuals had some form of a mental illness and were either placed in an acute care unit or in a forensic unit. The majority of these individuals have been in trouble with the law and were depressed, suicidal or ill with bipolar disease or with some other psychiatric disorder. Whatever the cause, they were out of sorts, probably due to an overdose of medication or because they had stopped taking their medications altogether.

It blows my mind how some of these individuals can come into a psychiatric hospital, are assigned to a designated psychiatrist, are treated at the hospital for a couple of months and then released. They check out, prescription in hand, only to relapse a few months later. They come back to the same hospital, are treated by the same doctor for the same problem and a couple of months later, they are released again and the cycle continues. The only time I have seen a break in this cycle is when one of them dies or is arrested and sent to prison.

On more than one occasion, I found myself asking certain questions; for instance, how can a psychiatrist stipulate that this individual is now fit to plead innocent or guilty in a court of law and is properly certified as ready to stand trial? How can this judge sentence this person when it is clearly obvious to every normal person seated in the courtroom that the accused is low functioning and probably has some form of mental illness and should be placed in a psychiatric facility for proper care and healing? In my opinion, there is always too much focus placed on the crime, and little or no consideration given to the mental condition of the individual who has broken the law.

We are all aware that people with mental illness are discriminated against and, most often, are not treated the same as people who do not suffer from a mental illness. However, I have observed in several court cases that these individuals are treated as people who are in total control of their faculties. The very time that they deserve special consideration, they are ironically treated as equal and, believe me, through no fault of their own.

It is obvious to me at times that front-line health care workers and their counterparts in the criminal justice system have little or no compassion for those suffering with a mental illness, and it is even more obvious when the illness is compounded by a drug addiction.

In my humble opinion, our government needs to better monitor the quality of care provided by their employees in the health care system and the criminal justice system. These employees, including doctors and judges, must be held accountable for the manner in which they dispatch their duties. If they fall short of the mark, they should be held accountable and dismissed from their duties, and not merely tolerated. It has been my experience that some doctors and judges consider it an act of total arrogance to question them about any aspect of their work. Over the past few years, I have, on the one hand, seen doctors over prescribe medications while, on the other hand, I have watched while individuals with various mental health disorders suffer needlessly because the resident physician withholds medication.

Our government must put in place measures that will ensure that every Canadian citizen gets the best health care that can be provided. Our top officials must make sure that nobody ever suffers at the hands of a doctor, judge or any employee in the health care or criminal justice system. Rules and regulations must be put in place for treating people with mental illness and addictions problems, and no individual working within the system should be allowed to function as though they were not accountable to anyone for their actions.

Senator Trenholme Counsell: These presentations have been very interesting. I think it is the first time I have heard the word "excitement" used by two presenters during our hearings, so I think that means that there is good news and good faith in Newfoundland and Labrador, which does not surprise us. With all the problems, hope is very much alive.

Ron, before I go to the good news, I want to suggest one thing to you, because you are obviously observing some things about physicians that worry you. I expect it is the same here as it is in other provinces, that you can make a complaint to the College of Physicians and Surgeons and then it is looked into very carefully. I think that is a reasonable thing to suggest to you, that if you feel a certain physician is acting irresponsibly, then it is your right to make a complaint to the college.

Mr. Fitzpatrick: Yes, I realize that and I have done that in the past because, in the organization I work for, we consider ourselves to be the voice of those who cannot speak for themselves. I can assure you that I have also brought it the Newfoundland and Labrador Medical Board, as I said, and it is not uncommon to get a letter in the mail from a lawyer of one of these doctors and be informed that,

We were called by the Newfoundland and Labrador Medical Board. You are complaining about this doctor. His character is impeccable. You are staining his character and he has every right in the Supreme Court to make sure that his character is not defamed. You can either desist from your complaint or we will see you in court.

Most of us or all of us, it is to be hoped, who work with individuals with mental illness and drug addictions care very deeply that they are treated properly, but, logically, I do not have a penny to spare. I cannot be in court every day fighting doctors who make a lot more money than I do.

Senator Trenholme Counsell: No, no.

Mr. Fitzpatrick: It is to be hoped that this new board, of which you are probably aware, that is being set up in Newfoundland and Labrador now, where at least three or four members on the board are outside the medical profession, will see that this does not happen again. One of the things I asked for, and I will continue to ask for the first chance I have to meet with the Minister of Justice, is freedom for people like myself who are the voice of these people to be able to fight for them without fear of being taken to court. When they came up with it, they made sure that they said no other doctor making a complaint will find himself in court. It has been the practice in Newfoundland that most doctors, like members in any powerful organizations, even if they do not agree with their colleagues, especially when it comes to prescribing drugs, are ruled by the unwritten law of no exposure. That is why I should say in my speech here, "should not be tolerated", because, personally, I am sick of seeing it every day. I am accountable for everything I do and when my actions do not suit my employer, I am gone. However, some of these doctors and judges think they are above the law and I think when you deliberate and make your decisions, you should put some of these people in their place and give some of them a flick.

Senator Trenholme Counsell: I guess one of the most difficult things is to reach that decision where a person is declared fit to stand trial.

Mr. Fitzpatrick: Yes.

Senator Trenholme Counsell: You are weighing the public interest versus the interests of the individual, and it is very challenging.

Mr. Fitzpatrick: Yes, I know that.

Senator Trenholme Counsell: I have a question for each of you. Kim, you spoke eloquently and comprehensively about the integration of mental health and addictions. I wanted to ask you whether you also feel a greater sense of integration with the entire Health and Wellness or whatever your department is now called in Newfoundland. Do you feel that you are all coming together better, out of the silos into a family of health care professionals?

Ms. Baldwin: Certainly: I think as a program within Health and Community Services, we have pretty much adopted a population health perspective with a focus on the determinants of health. Obviously, the program needs to look at the whole continuum of services both within the Mental Health and Addictions, but also how that fits with the broader continuum of services of health care and community-based services. Our community health and our community-based services became integrated about 10 years ago and we now have the opportunity to integrate with the institutional sector and the long-term sector, so we should have a full range of services now.

Senator Trenholme Counsell: I would like to ask you how many community health centres you have in Newfoundland, and if your mental health services are integrated with those community health centres.

Ms. Baldwin: Do you mean mental health centres?

Senator Trenholme Counsell: I was wondering about community health centres in the new concept of bringing different health care professionals together under one roof, and whether or not mental health is included in that.

Ms. Baldwin: It is changing now, but we have five regions of the province that have community health services, and some of those have satellite offices as well.

Senator Trenholme Counsell: I know that your specialty, Kim, of course, is mental health and addictions, but in terms of the province, maybe you know, Geri, whether there are community health centres because some of your nurse practitioner colleagues would certainly work in them, I would think.

Ms. Dalton: Yes, as far as I know, there are no formalized, primary health care centres right now. There is a primary health care reform in progress in this province and there is a centre being developed for the St. John's area. It is in the works. Most of my colleagues are working in clinics in remote areas, with or without a physician on staff, and link with the other health professionals from Health Community Services for access, but the intent is to move to primary health care centres and the delivery of primary health care services from those centres with multidisciplinary staff. The mental health plan for the province integrates the delivery of primary mental health services into those centres.

Senator Trenholme Counsell: Yes, it is good news.

Ms. Baldwin: To add to what Geri said, in each of the five regions I mentioned with Community Health Services, there is a pilot for a primary health site.

Ms. Dalton: Right, yes.

Ms. Baldwin: We have had the makings of a couple in the St. John's area, one in Shea Heights and one in Ferryland, which is on the southern shore, where we have had a mental health addictions worker as part of the team, and those have proven to be very effective in creating some of those linkages.

In addition, Geri has mentioned that this province is also in the process of primary health care reform and just as we are developing a mental health and addictions strategy, we are also developing a provincial wellness strategy with a lot of emphasis on wellness as opposed to illness.

Ms. Dalton: That is right.

Senator Trenholme Counsell: I want to ask one question, Geri, about nurse practitioners. I can assure you that I will use my voice wherever and however I can to support nurse practitioners because in 1969, I sent my nurse in my medical office in Toronto for the nurse practitioner's course at McMaster University, and I am a strong advocate, although I realize some of the challenges. I want to ask you two things. First of all, PHC, that is "primary health care nurse practitioner"?

Ms. Dalton: Primary health care nurse practitioner.

Senator Trenholme Counsell: This is wonderful. I have to memorize this. There is a Canadian Nurse Practitioner Initiative.

Ms. Dalton: Yes, the nurse practitioners in this province have a voice in that initiative and we have a special interest group for nurse practitioners. We have certainly been involved in the activities concerning the initiatives that are under way there.

Senator Trenholme Counsell: Is that initiative going well?

Ms. Dalton: Yes, it is going very well.

Senator Trenholme Counsell: I want to ask you this because this goes to the heart of what we are talking about here. In your case, you had worked about 18 years in mental health before you became a nurse practitioner so it was, I would imagine, an easy transition and a perfectly sensible one for you to come out of that program and be a primary health care nurse specialist in mental health. The other day, Senator Cook and I talked about the difference between doing a master's degree in nursing, mental health and doing the nurse practitioner course. I know a lot about what you learn as a nurse practitioner, but let us say you were someone directly out of their Bachelor of Nursing degree or maybe you have worked for a few years in whatever kind of clinical setting and took the nurse practitioner program. Are you able to specialize within that nurse practitioner program in mental health or do you need more after that?

Ms. Dalton: When I graduated from the program, I was in the second class of nurse practitioners to graduate in this province, so the only stream offered here in Newfoundland at that time was the primary health care nurse practitioner stream. Memorial University actually has developed a specialist stream and one of the specialties that you can take is mental health, a mental health specialty as a nurse practitioner specialist.

Senator Trenholme Counsell: Mr. Chairman, I think you would agree that this is something we should take special interest in as a committee and maybe become a champion for because I see it as being so important across the land and maybe something to show the world.

The Chairman: Absolutely, yes.

Senator Trenholme Counsell: Thank you very much and good luck to all of you. Those were special presentations and you are playing special roles. Keep that word "excitement" in there.

Senator Cochrane: What is your profession, Mr. Fitzpatrick?

Mr. Fitzpatrick: I work for a charitable organization now called Turnings. It used to be called, like I said, St. John's Metro Community Chaplaincy. That is an organization that is a registered charity. It is funded by the Department of Justice in Ottawa out of the Chaplaincy Division. Our job, like I mentioned, is to work with offenders and ex-offenders and try to get them out of a life of crime, back into the mainstream community and improve the safety of our communities. I work mostly with high-profile sex offenders, violent rapists, pedophiles, individuals who commit violent crime and arsonists. One thing I wanted to speak to you about before you dismiss us here today, if I could, is about arsonists, because you were looking for certain things that were not in your portfolio here and there is a big issue with arsonists. About 70 per cent of my clients right now are drug addicts, mostly opiates.

Senator Cochrane: Do you want to talk about the arsonist issue now?

Mr. Fitzpatrick: Yes, I would like to mention a couple of things.

When I read your interim report, it was like the task force report that we did here on our OxyContin epidemic, and, of course, that was a fantastic board that put that together, a great group of people. They made recommendations to our government at that time and if all the recommendations were followed, you would certainly have a great handle on the problem. Certainly, you know what is in your interim report, so if most of that was followed, you would have a great handle on everything.

However, with arsonists, the government will have to step in right now because when an arsonist comes out of prison, whether you are aware of it or not, usually, they are placed on a long-term service order, LTSO, because they are a threat to the community. Usually, they are put in a correctional services facility, what we would call a halfway house, where they are supervised. However, sooner or later, the minute that long-term service order is up, they have to come out into the community. When they come out into the community, there is nobody in the community that can take them in because there is not an insurance company in Newfoundland who will insure anybody who has an arsonist living in their house. If you take anybody in, they are going to lose their insurance, so nobody is going to do that. That leaves that arsonist with no recourse but to commit another crime and end up back in the penitentiary because they cannot live on the streets. Definitely, in Newfoundland, they would freeze to death. The ones I know, the three or four that I have been working with, for instance, are low functioning and have several forms of mental illness.

That is a problem you have to deal with because these guys are accidents waiting to happen, or bombs waiting to go off. That is not only in Newfoundland. If we have them here, you have them right from here to Vancouver.

So, not to give you a problem without a solution, one thing you may be interested in doing is making changes in the insurance industry such that there is a company that is prepared to insure people who take in these individuals.

The Chairman: As a supplementary question, because I do not know anything about the likelihood of an arsonist recommitting the same crime, is it a fairly high probability? In other words, is there something about an arsonist that means that if you have done arson once, you are likely to do it again?

Mr. Fitzpatrick: Oh, guaranteed, yes. These people, like most people with mental illness or drug addiction, need continuous support. The only jurisdiction the federal government has on them right now is to put them under an article called a long-term service order. Even then, they have rights and when that is up, they are on the streets and you are saying to them, "Mr. So-and-So, we have to let you go. We do not want to, but we have to, and there is not a Christian in Newfoundland who is going to take you in." What do you think this person is going to do? We have people here in Newfoundland, like you have all across Canada, who, in the wintertime, will throw a rock through one of the stores just to go to prison for the winter. If you have a guy who is low functioning and has three or four forms of mental illness, nobody will take him in. It is not because nobody would want to. I am sure that the Department of Human Resources, Labour and Employment, HRLE, would pay $5,000 a month for somebody to take him in to get him off the street, but if anyone takes him in, that person will lose their insurance and he may burn down their house.

I am giving you a heads-up. That is a problem that you will have to face. It has to be addressed and the bottom line is, you cannot procrastinate and put it off. That issue should be dealt with, and I am very concerned.

Senator Cochrane: Thank you for letting us know. That is important. This is why we are travelling across the country, to get an emphasis on items that need to be emphasized. We are happy to have you, trust me.

Ms. Baldwin: One initiative that I think is worth mentioning in this forum is a project of a local group called Stella Burry Community Services. They have certainly been working with the Department of Health and Community Services along with the former Health Care Corporation of St. John's, which was the institutional side, and Correctional Services of Canada to respond better to the individuals, such as the individual that Ron referred to. We found that by providing an amount of home support and intensive case management service, we have been able to maintain people in the community for longer periods of time.

The Chairman: We visited their facilities this morning.

Ms. Baldwin: Oh, good.

Senator Cochrane: Yes, that is exactly what we did. We also went to Mill Lane Enterprises and we also went to the Powell Centre, so we are a little bit ahead of you there, Kim. We are doing our homework. Anyway, Mr. Fitzpatrick, I am really glad that you are the voice of the people.

Mr. Fitzpatrick: God, do not let that get out. We consider ourselves to be representatives of those who are low functioning or suffering from an illness and are not prepared to speak for themselves.

Senator Cochrane: We need you. The people need you. You are on this board, which will be wonderful as well.

Mr. Fitzpatrick: Yes.

Senator Cochrane: How many members are on this board?

Mr. Fitzpatrick: We have a board of directors that is comprised of 12 individuals from many walks of life. We have retired school principals, a lawyer, social workers and a parole officer; that type of a make-up. We have 23 fully trained volunteers who work with us with these individuals.

Senator Cochrane: Wow, I think things are really turning around.

I wanted to ask Geri about an item here. You said the PAU provides 24-hour psychiatric assessment services to the public, including clients brought in by law enforcers under the Mental Health Act.

Ms. Dalton: Yes.

Senator Cochrane: I have had experiences as well. RCMP officers have told me that is what they do because they have no place to put them, so they have to send them to the various institutions. Who else sends these people to you for help?

Ms. Dalton: The PAU is in St. John's, and right now in St. John's, there are two points of entry for emergency psychiatric services. There is the PAU at the Waterford Hospital, to which you can come in off the street and ask to see someone if you are in crisis or there is a concern. The Health Science Emergency Department is considered the centralized emergency in the general hospital sector and they have a psychiatric nurse on 24 hours there and the residents from the program. Also, there is a city-wide, on-call psychiatrist every day who responds to those two areas.

Senator Cochrane: Is there a 1-800 number or anything like that?

Ms. Dalton: No, we have our own number for both the emergency and Health Sciences Centre, but there is a crisis line with whom we link frequently and who refer people to us. That is through Kim's department. I guess it is all of us now, is it not?

Senator Cochrane: Tell us about it. Is that just for St. John's?

Ms. Baldwin: We are going through a bit of an identity crisis, as you can tell. No, we actually have a mental health crisis line, which is a provincial service. It is a 1-800 number and we frequently get calls from across the province. It is a 24-hour service. We are looking at making changes to that line, trying to better integrate services with Geri's program and have a centralized crisis response service.

Senator Cochrane: If I was suicidal and I wanted to call this 1-800 number because I needed help, what would I receive on the other end?

Ms. Baldwin: You would connect with a professional on the other end, whether it is a mental health nurse or a social worker. They will try to work with you at identifying the level of risk that you may pose at that point. At some point, it may be necessary to invoke the Mental Health Act in terms of safety and at that point, they may have to contact the RCMP or the Royal Newfoundland Constabulary, depending on the area. Before it gets to that point, there is a lot of contracting and negotiation with the individual. Once the individual has been stabilized and has developed a contract with the staff, there are efforts to connect that person to local mental health services wherever they may reside.

Senator Cochrane: Is there some sort of follow-up?

Ms. Baldwin: Again, it is up to the individual if they chose to follow through with that, yes.

Senator Cochrane: What is your interpretation of "recovery"? Do you have a definition?

Ms. Baldwin: "Recovery" is a term we have used in the addictions field for a long time and have been getting to know it in terms of mental health as well. It is a concentration on wellness as opposed to focusing on the illness.

Senator Cochrane: Do you have anything positive to suggest? For example, would you recommend any preventative measures that you have encountered, and with which positive results have been achieved?

Ms. Baldwin: Prevention is an area we have struggled with. The demands have been so heavy on the treatment and intervention side, very few resources were left for prevention. We have staff, particular on the addictions side, whose primary focus is on working with young people. Coming out of the OxyContin Task Force report, we have developed a provincial committee that is comprised of representatives from the Department of Education, Department of Health, Department of Justice, youth serving agencies and young people themselves, in an effort to develop a strategy for preventing substance-use problems among our youth. That is still in its early stages, but again, it is the first time that we have had all those partners. Law enforcement is part of that as well. We recognize that different sectors approach prevention in different ways, so we needed to coordinate those services better. Also, we recognize in the mental health strategy the need to develop and do more about prevention and promotion of mental health.

Senator Cochrane: Does Mr. Fitzpatrick have something to add?

Mr. Fitzpatrick: Yes, I was telling you that 70 per cent of our clients have drug addiction problems. In the past year and a half, at least 35 individuals we were working with were stealing every day to get money for drugs. We got them into programs and we sent them to Addiction Services. We got them to sign themselves into hospitals and we went to the hospitals every day to see them. We got them set up in school programs, this kind of a thing, got them straightened out, gave them something to do and got some of the jobs. You know what I mean?

Senator Cochrane: Yes.

Mr. Fitzpatrick: These people would have been a cost to the taxpayers of Canada, especially in Newfoundland, of at least a minimum from the time they were arrested until they served one year in prison of $100,000 a year. We took 35 of them off the street. That is three and a half million dollars. I went to Tom Marshall, Minister of Justice and Attorney General. I have a letter in my office on file from the minister. I explained to him that the government should fund us so we could train more volunteers. Our volunteers are trained from Correctional Service of Canada in Ottawa and in our regional offices, where John Tonks is our regional director. Anyway, he said that the government does not put money up front. We are talking here about preventive measures.

For as little as $100,000, we probably could have trained 30 or 40 volunteers, and we may have taken 50 guys off the street, but the government is not prepared to do that. That is why I said in my statement that the government is penny-wise and pound foolish. They are prepared to spend millions of dollars a year when they could give an organization a couple of hundred thousand dollars and save money. That is where I was coming from. People need to have a reason to get out of bed in the morning.

Senator Cochrane: Your point is well taken.

Senator Cook: I would like to say hello to all of you. It is good for me to be home and to hear that we are not doing too badly here in this little province. I have been listening all afternoon to how we care for other people, consumers of mental health, and I want to ask you the question: Who cares for you? I look at Geri's brief and she was 24 years working in the system and five as a nurse practitioner in primary care. I will leave that one. You can think about that, why you did what you did and what it cost you and all the rest of it. I do not mean in dollars and cents.

You are each professionals in your own area. The complexities that exist, for example, in the drug addiction field, OxyContin and crystal meth, and the methadone program, which is part of the recovery, mean that continuing education has to be paramount. How much is available for continuing education in your professions? If there is nothing available, how do you cope with the unknown that is continually coming at you as the universe unfolds? Geri, you decided one day you were going to do something else because you were challenged. To do that, you had to embark on a process. I would like to hear about that because if we are going to build capacity in a workforce to care for the people that we identify, then I think governments have to offer something, whether it is seats at universities or schools of nursing, or somewhere for continuing education to take place. How do we build this capacity, especially here in my province where the retention of professionals is far more challenging than it is in mainstream Canada? Not everyone wants to subject themselves to this kind of weather, let alone everything else, but it is a great place to live. I would like to hear how you feel about that. Talk about you for a change.

Ms. Dalton: I guess I have always been involved throughout my career in professional development initiatives to ensure that I provide care that is appropriate and reflects the best practice for my profession. However, when I decided to do the nurse practitioner program, the mental health program was a new program here in the province and the mental health program decided that there was a place for people with that skill set in the program. They offered or obtained four seats, but not four paid seats. They simply obtained four seats for nurse practitioners to take part in that mental health program. When I applied for it, I was very interested and I guess I had been in administration for a while and decided that I wanted to get back into the clinical work. I will tell you, it was a big investment and it was not easy. I would say the program cost me $100,000 because I gave up a year of salary, I borrowed through a deferred salary payment arrangement about two-thirds of my salary, which I am still paying back, and when I returned to work, I took a job that was lower paying than what it was before I went into the program. It is not for the money that I am doing it, I can tell you.

Senator Cook: No.

Ms. Dalton: To attract people who have the drive, the interest and the commitment, there needs to be, as you said, support for people to pursue continuing education and these things.

Ms. Baldwin: I agree. Training is paramount for people working in the field, and ongoing development is important. Historically, we have not done well with supporting people to do the training that they need to stay abreast of the field. Again, it has been a balancing act in terms of providing the service and the supports needed to provide that service. We have been involved in some initiatives, working with the community centres on substance abuse and looking at workforce development in the addictions field. It has been one area that is showing some promise in terms of highlighting what is needed to maintain people in the field. Personally speaking, I know you have to have a real affinity for working in this field. It has its share of frustrations, particularly with addictions where you deal with relapse on an ongoing basis. As well, I have worked in a range of programs across the field, but the most difficult was working in the detox centre where you see people who could not get well. Eventually, we had a number of people who did not make it. That is emotionally draining.

In terms of how do we take care of ourselves, we need to incorporate the very things we are trying to impart regarding maintaining optimal mental health. We have good support systems. I have referenced a support system that we have developed across the province. We have recently expanded that to other parts of Atlantic Canada, so we have a group of addictions directors who are in constant contact and we can learn from each other. As well, we have good structures locally that we rely on. Those kinds of things are essential, and knowing your boundaries and being able to balance is important.

Mr. Fitzpatrick: I guess we all do the same things, but differently. I started about seven years ago. I used to work for Newfoundland Power, the hydro company here. I was a senior operator there in charge of a shift, supplying the province with power. I used to work 12-hours shifts. I had four days on and four off, so when I was off, I started volunteering with what was the Metro Community Chaplaincy at the time, working with offenders. I took a package from Newfoundland Power five years ago and I started volunteering 40 hours a week with Metro Chaplaincy for two and a half years. I also started doing different courses on suicide prevention and other topics. Anyway, a year and a half ago, they were looking for a chaplain, so I applied. I had the street experience and I got the job.

I find it stressful, but at our head office in Ottawa, we meet a couple of times a year with other chaplains, as Kim just said, and over coffee or whatever, we talk about what we are doing. We try to help each other out. Last year, I think we had nine chaplains burn out. Every year, eight or nine burn out. It is stressful.

I am fortunate. I have a stressful job, but I also love it and that makes a big difference. I am Roman Catholic. I have a parish priest that I can go to and drive him nuts when I get wound up. I also have a parole officer that I can turn to. I find that you need to unwind and I am like an Italian; I have to be going with the hands, yelling and bawling. If it is on my mind, it has to come out. I get to the priest and I just unwind. He lets me go, and that is what I find is good. Then I learned to pace myself. I know when I am doing too much.

We are so underfunded and so short-staffed and every day, our workload grows. We know we cannot do it all and we know we should pace ourselves, but we do all push ourselves to the limit. We are not complaining because if I was told I could not do this tomorrow, you would not be around me. I live for what I do.

Senator Cook: From what I gather this afternoon, everyone seems to be excited about this new provincial mental health strategy.

Mr. Fitzpatrick: Yes.

Senator Cook: If I heard correctly, there was no new infusion of funds; rather, it was a relocation of the present funding. Is that right: was there a piece of money or was it a reallocation of funds to do things differently?

Ms. Baldwin: To clarify, that is the mental health strategy you are referring to?

Senator Cook: Yes.

Ms. Baldwin: I think it is a combination. In the budget, there was an announcement of a million dollars for implementation of some of the plan. It is a longer term plan.

Senator Cook: It was a million dollars for implementation and once it is implemented, do you see it needing funding? In other words, is it a one-time shot of a million dollars?

Ms. Baldwin: No. It will be ongoing funding.

Senator Cook: It will have to be a sustainable fund?

Ms. Baldwin: Yes, that is right.

Mr. Fitzpatrick: We were talking about methadone. I am a member of the committee and I certainly favour of methadone treatment, but it is important to be aware, in case you do not know, that when the government opens up a methadone maintenance treatment program, when people start taking methadone, it can be just as deadly or even deadlier as OxyContin, heroin or anything else when it is abused. If the government supplies a clinic and provides methadone maintenance treatment for opiate abusers, after a couple of months, all those people taking treatment are now chronically addicted to methadone. The government must have a commitment. You cannot put 100 or 200 people in a methadone maintenance treatment program, get them taking methadone daily and then say, "Okay, we are going to drop the funding." Then the streets are loaded up with 200 or 300 people who are chronically addicted to methadone, and you have created another drug epidemic. Once you start, you are basically committed to continue.

The Chairman: Has that happened anywhere that you know of?

Mr. Fitzpatrick: No, it has not because the programs work so well, and the federal government have seen it work so well. It has been documented and monitored in all the federal prisons across Canada and all the provincial prisons in British Columbia. It has proven to be cost saving, and there is no end to the benefits.

On that topic, and I purposely did a segue to get this in, we desperately need methadone maintenance treatment programs in our provincial prisons because if we do not, in Newfoundland, every time one of my clients or anybody else ends up in one of our penitentiaries with an opiate addiction, they are forced to go cold turkey. They are always seeking ways to sneak drugs into the prison because inmates are always looking for a fix. I have picked people up when they are released from prison and if I brought them to a certain address, like up the street here, I would not even have time to stop my car and they would be jumping out the door and gone, looking for a fix. Ninety nine per cent of them go right back on it the next day, as soon as they get out.

When they go to a provincial prison for stealing drugs, especially opiates, they need to get on a methadone maintenance treatment program. Then they need to take addictions counselling, which is provided there, and other supports to understand the reasons why they use drugs. Then, when they get out, they can enter our provincial methadone maintenance treatment program and become productive citizens again without ever getting back to a life of crime.

The Chairman: There are no programs in provincial jails?

Mr. Fitzpatrick: This is one of the things we are experiencing now. There is no continuity. If a guy comes out of federal prison after, say, a five-year term and he was on methadone maintenance treatment in the prison, he is released from prison, his warrant expires and he is as free as you or I. He needs to be in a methadone program because he has been on it these five years. If he does not get in it right away because of waiting lists, he can be back on the street using street drugs because that is his only alternative, and he ends up back in jail. If he is sentenced to our provincial prison for stealing drugs, he goes to prison and he may or may not get into a methadone maintenance program. There is no hard-and-fast rule that says if you were on a methadone maintenance program coming out of federal prison and you go to provincial prison, you will be given your methadone. There is nothing like that. It is entirely up to the doctor at the provincial prison whether he wants to treat you for it and the doctor can only treat you for it, as you know, if they have a licence prescribed by Health Canada.

Ms. Baldwin: I would like to expand on that, because that was a recommendation coming out of the OxyContin Task Force report.

Mr. Fitzpatrick: Yes.

Ms. Baldwin: It was recognized at the time that there was that gap in treatment service in the province. There were no community-based methadone programs, so it was difficult to have a program in a facility knowing people were coming out into the community. The recommendations were there to develop provincial guidelines, which included the provision of methadone treatment services in provincial facilities. There was also the recommendation to develop a community-based program, which we will offer within the next week, a limited service. As well, there was the recommendation to expand and have methadone services available in provincial facilities. It is a staged approach to implementing the service.

Senator Trenholme Counsell: I heard the term "lock-up" used two or three times this afternoon. One thing we believe as a senator task force representing the Parliament of Canada is that we can decrease stigma across the land. I think we should start by having our police officers, community people, health care workers and so on using the word "detention centre" rather than "lock up" because that has such a stigma to it. I am not accusing you people of anything. I know that is the term used, but if we can start little by little and get rid of that word, it will help all the people who find themselves in that kind of predicament overnight or for whatever length of time.

Senator Cordy: Kim, do we have enough national research in the area of mental health and addictions? How do we develop best practices unless we have the research to back it up?

Ms. Baldwin: Within the addictions area, a number of best practice documents have been published through Health Canada, and they pretty well become our bible when we are developing or planning services. We refer to them, we consult with other jurisdictions and then we use that information as we move forward. In terms of research, more attention has been focused on the need for more specialized research in mental health and addictions. I mentioned earlier the movement towards developing a national framework on substance abuse. Concurrent with that is the development of a national research agenda for substance use and abuse. Similarly, I think processes like that would be needed for broader mental health, yes.

The Chairman: Kim, thank you for giving us the distinction between program integration and system integration. We had been trying to figure out how to describe it — system integration, not program integration — and that definition was really good.

Ron, you look like you want the last word.

Mr. Fitzpatrick: No, I am not trying to get the last word. I am like Columbo. I am always saying, "Oh, by the way..." I just wanted to mention something.

I know you have it covered in your interim report, but it is something that I see all too often. It is overprescribing. The Morineau report calls it the "chemical straitjacket" or something.

The Chairman: Right.

Mr. Fitzpatrick: I am in court regularly with clients who are up on charges for stealing for drugs. I had an occasion to be with a guy about a month ago where the guard almost had to lift him from the room with the shackles on and sit him in the seat, then lift him out and bring him back. He was being sentenced and he was stunned as a bat and did not know where he was. Do you know what I am saying? He was zonked right out of it. I think there is far too much overprescribing.

Ms. Jackman: That is not funny. "Stoned as a bat." That is not funny.

The Chairman: Okay.

Mr. Fitzpatrick: Yes.

The Chairman: Thank you for that comment. Thank you very much for coming, all three of you.

Senators, we will hear now from some consumers.

May I thank all four of you for coming. I think when you registered, checked in or whatever the formal terminology is, you were advised that you get approximately five minutes to make a statement and we do not really get into a large number of questions with you. By the way, I know some of you have sat here all day, so thanks to all of you for coming.

Ms. Helen Forristall, as an individual: I have been itching to say something because I think it is important for you to see the face of mental illness. I do not like to admit it. I am ashamed and humiliated and I still have to work on that, but I am a mental illness consumer and I do take strong offence to stigma. I find that it is amazing how people treat you. Even when I came here today, for example, it was, "Are you a presenter?", because nobody really knows the face of mental illness and the implication was, "Or what are you? Are you an observer or what are you?" There was a comment made about how the health care workers take care of themselves and I admire that, but I did not choose this illness. This is not something that I chose and it is important to remind people of that, including this society and my family.

I want to make two points. There are severe consequences to admitting that you are mentally ill. That is one point. Two, when you admit it, there are long waiting lists that you have to endure alone.

My doctor told me I had a sick brain just as somebody else would have a sick heart and that is fine and well in a doctor's office, but in society, that does not work. People tell me to, "Snap out of it," and "Think happy thoughts." They recommend books and they lay this guilt trip on me, such as, "You are too young to be depressed," and, "You have nothing to be depressed about. Look what you have. You live in Newfoundland. You have a great life." Again, I did not choose this. If I had breast cancer, nobody would question me.

When I came to my employers and told them that I was depressed, they said, "Well, you will have to prove that." I said, "I intend to. I have a note from a psychiatrist that says so. If you would like to see my purse, I have lots of pills that I have to take and I have to suffer through."

I also have to suffer through the indignity of being looked down on and it bothers me a great deal, so it is difficult to sit here. I find myself hiding behind my hair when there is a picture being taken because I still deal with the shame every day.

I wanted to say that I left my job last year sobbing. I am a clerk with the government, but my job is that the most vulnerable members of the public tell me the most traumatic things in their lives, such as they have lost their spouse, they are permanently disabled and they cannot afford their drugs. I am the only person they find that has ever really listened to them. I do not have training. I am bilingual, I have an arts degree, but I am not a social worker and I did not know how to deal with this. I worked with the federal government.

I left my job, July 9. I have not been back. I am on the status of leave without pay, leave undetermined. I have to fill out questionnaires monthly to prove that I am still mentally ill. I had to beg my GP to have an appointment with a psychiatrist. I begged him, I pleaded with him and his response was, "Yes, well, he has 600 active patients. He is getting old and you do not really need this. Just keep on taking your drugs." I stood up and I said, "No, I want to see a psychiatrist." He said, "Fine." I have not gone back to that doctor.

I see a psychiatrist once every three weeks. I used to live in Ottawa. I saw a psychiatrist twice a week. There is a little bit of a difference here in Newfoundland, but I am from here.

I am in a program in Merchant House for which I had to wait six months to get an interview to be accepted into the program. I am glad to say I am in the program, but my counsellor has recommended that I go into group therapy, for which I am on two waiting lists. I am sixteenth on one list and she did not want to give me the number of the other list because it is much too long. She told me the program is supposed to last six months, but it ends up being two years or so because of the waiting lists.

I am going to go to my first CHANNAL meeting tonight and it has been very difficult. I have lost family and friends because they are afraid. The fear in this case is ignorance and I have to deal every day with suicidal thoughts, medication, therapy and psychiatrists. It is not an easy road. For those who choose the profession, I say God bless you, but again, I would do anything to have breast cancer over mental illness. I would do anything because I do not have to put up with the stigma. Thank you.

The Chairman: Thank you for that. I should tell you and the other people here that almost all the members of the committee, certainly well over the majority, have someone in their family who has or has had a significant mental illness.

Helen, we are familiar with what you described as the face of the survivor and are sympathetic to what you have gone through. Thank you for taking the time to come and talk to us. It is very helpful.

Mr. Harold Dunne, as an individual: Yes, sir, I know what she is talking about because I am bipolar and manic depressive myself. I worked in Ontario 29 years and I lost my health, all my finances and everything because of mental illness. I had a five-year-old son who died of cancer and nine years ago, my father died, my uncle died and my aunt died, and I have not worked since. I spent over a year in the Waterford Hospital; three admissions. One time, I was there for nine months. I have had electric shock treatment and attempted suicide twice, but that was a cry for help. I knew what I was doing and I got the help that I needed. I could not get it in Ontario. I had to come to Newfoundland to get help. That Waterford Hospital is a wonderful place. I am not ashamed of my illness because I needed the help and I got it.

I would like to ask you, if, like the lady said, a $1 million budget was given by Danny Williams to the province for mental health, then maybe you could go back to Ottawa and ask them if they could put a million dollars or a few more million dollars.

One thing nobody mentioned here today is suicides. In Labrador alone, as the man was saying from the reserve, there has been an awful lot of suicides of young people. This is not limited to Labrador, but happens in St. John's and all over the province from depression. There are also a lot of suicides in this province from those video lottery terminals and, as Mr. Fitzpatrick said, from overdoses with drugs and everything.

Four years ago, I was taken by the police from my apartment, brought to a hospital, left the hospital and taken to the prison, put in a cell, stripped down to my underwear and left waiting for a psychiatrist to come. Then I guess he came and saw the mess I was in. He assessed me and sent me to the Waterford Hospital. I am glad now that they have this new Short Stay Unit. I think it will make it a lot better for the other people that have to go through what I went through.

Ms. Deborah Jackman, as an individual: I am a psychiatric survivor, mental health consumer and one of the founding members of CHANNAL.

One of the points I want to make today is about volunteering and volunteerism. In terms of mental health, sometimes when we get back on our feet, depending on where we are in our healing, we might decide we want to get back into the workforce, so volunteering is a good way to do it. My fear is that volunteerism can be a way to reinforce stigmatization with mental health consumers. What I mean by that for persons with mental illness, the feeling seems to be, "Oh, give them disability," and in saying that, not all people with mental health issues and mental illness get a disability pension. That is a struggle I am having still. I worry that we are seen as people who are defined by our illness: "Give them something to do and that will do them a world of good;" a pat on the back, kind of thing. However, I am a functioning person and I would like to get paid for my work. In the meantime, "We are trying to put this into place," will not do. If I cannot get paid, at least help me out a bit. I am somebody who continues to recover from agoraphobia. I used to be totally housebound. I still have phobias, anxiety, panic disorder, post-traumatic stress disorder and depression, but I want to work. I cannot emphasize enough that sometimes with the stress on volunteering, while I recognize that it can be a good thing, I fear that sometimes the government tends to use that so that they do not have to pay people. That is my thinking.

The other point I wanted to make pertains to consumer involvement and input in table discussions like this. I am glad Joan was here today to speak as a professional and consumer, but you are hearing from the professionals at the table who work in these fields and you are still not hearing enough from the consumers. We are not asked to go to the table. We are last. I do not like the idea that I am last. We are the last people. We have been here all day and I want to be a part of this table. I do not want to sit back there and just bite my tongue and wait for my turn.

In 1991, I went to the first conference with Women in Dialogue regarding mental illness issues. It was the first time that consumers were invited to the table, and I was one of those people. Unfortunately, we were just token consumers. I would like to see our role expanded and that we not remain token consumers. It is really good to hear the professionals. These people run these organizations and programs, such as the Short Stay Unit, for example. It is good, but I worry that maybe you do not want to hear from us because of our tears and our pain. We have experienced these things. Obviously, you do want to hear and I am glad that you are here, but I worry that we are not asked enough to come to these sorts of places and sit at the table.

The other comment I wanted to make is with regard to the Short Stay Unit. There needs to be some discussion here between the practitioners and the users or consumers of that new system that is now in place. I have had some experience of that system and while I can attest to a lot of the positive things about it, there are some negative things, too, that I experienced. It is hard for me to sit and listen to somebody say that a program is doing well when I know that I, along with other consumers, have had bad experiences and one, in particular, was with a nurse practitioner. While there, I witnessed verbal abuse and poor treatment of another female patient where I had to come out of my room, step in the middle and tell this person that he could not treat this patient like that. He told me to stay out of it; it was none of my business. I told him that it was my business because I am affected by this and it has something to do with my safety. Thankfully, the good thing out of this was that it was taken seriously. I reported it and it was taken seriously. I do not know the outcome, but it was brought to his attention. I thank those people on the inside who believed me and listened because when I think about the words "mental health," "compassion" and "care," they go together, right? If you are working in the mental health system, you have to care. You have to show people respect and dignity. This is something that I find is still missing.

The Chairman: Thank you, Deborah. Let me just say a couple of things.

You are right. Today, we did not hear from consumers until the end of the day. But in many of the places we have been across the country, we have frequently actually begun the first couple of hours with consumers of with family members of consumer. In fact, we have heard more from consumers than any other sort of federal-type group and as I said, the majority of us have a consumer in our reasonably immediate family.

The other point I want to make, and this is where you and people like you have been so helpful to us, is that when we put a short questionnaire on our website last November, we estimated we might get 75 or 100 responses. We had nearly 600 when we finally took it off. Our report will very much put a human face on the issue. Because of the time that people spent responding to our questionnaire, we will be able to associate very much human vignettes with each of the issues with which we are dealing. So the consumers and their families and caregivers have been extraordinary in terms of the information at times. Having read a lot of them, I could not believe the amount of time people took to tell us their stories. Frankly, our report will be infinitely better because of it.

Ms. Jackman: The other thing I wanted to mention that I forgot was about the stipend. I wanted to say when, as Joan said, we are given a stipend, it is our business what we do with it.

The Chairman: Of course.

Ms. Jackman: Somehow, people think that people on social assistance have to justify where their money is being spent, and it is nobody's business. I wanted to add that when I get a stipend, it goes towards food because I am on social assistance and I cannot afford to live. That needs to be addressed, how many mental health consumers live in poverty, right?

The Chairman: Absolutely.

Mr. Robert J. Ryan, as an individual: Thank you for the privilege of appearing before you, particularly given my late notice. I have been retired for about a decade. I live on disability. That is a physical disability.

I spent a huge amount of time researching an extraordinary intersection, one in which you have been innately involved for some time now. This would be the intersection of psychiatry, psychopharmacology, the law and, in particular, within the law itself, constitutional law, human rights law, employment law and labour law. It is the law that I particularly want to address here today. I will give some history about it and I hope you will be patient with me.

Some 300 years ago, before the trial of the witches of Salem, Lord Coke wrote, "'Tis the worst form of injustice, 'tis the worst form of oppression, that which is given the colour of justice." That was 300 years ago. In 1910, the English Court of Appeal wrote a decision called Young v. Toynbee. A former law professor in the country, who would probably smile if she heard me speak these words, once reviewed Young v. Toynbee. The court case is cited as 1 KB, 1910, English Court of Appeal. I do not have the page number. My memory is a little off. That 1910 decision, according to that Canadian law professor, who has moved on, stands for the proposition that a solicitor who takes the case of a client with a serious psychiatric disability does so at the solicitor's peril. That case has cast a chilling spell over the legal profession for most of the last 100 years.

If we review the legal jurisprudence in this country over the last century, we will discovery a paucity of cases at the highest levels of provincial courts and even a worse paucity at the Supreme Court of Canada level of people who are plaintiffs or complainants who are persons in civil cases with serious mental disabilities. I separate serious mental disabilities from people with drug addictions. I am talking about persons who are afflicted with bipolar disorder, approximately 1.2 per cent of the population, notwithstanding the appearance by the pharmaceutical companies. They managed to discover another four per cent of the population recently when they did their own cooked-up surveys. I am talking about persons with schizophrenia, another one per cent of the population, and I am talking about persons with unipolar depression, making up nearly five per cent of the population.

We are talking about the most vulnerable people in society. We are talking about suicide rates for people with bipolar disorder, a.k.a. manic depression, that run from 15 to 20 per cent suicides, and that run 25 to 50 per cent attempted suicides. I was pleased to see Dr. Kay Jamieson on CNN the night before last. She wrote this book, An Unquiet Mind, in which she talks about suicide prevalence amongst people with bipolar disorder. The suicide prevalence amongst people with schizophrenia is in excess of 10 per cent, and we know that the suicide rates for people with unipolar depression is far in excess of what is considered to be normal. If we were talking about any other class of citizens in this country, we would say, "This is an epidemic. What are we not doing? What have we been doing wrong?" However, it is persons with serious mental disabilities.

What has been done other than what Michael Perlin refers to as the "hortatory law" — H-O-R-T-A-T-O-R-Y from the Latin word hora, by the hour. That hour occurred in 1982 when our Parliament passed the Charter of Rights and Freedoms and, under section 15(1), afforded special protection to persons with serious mental disabilities. In that hour, there was a semblance of concern and recognition that this vulnerable class of citizens, these members of a discrete and insular society, needed special protection. That lasted about an hour. In 1985, section 15 of the charter was proclaimed law, because, of course, the employers needed three years to get their acts together. What happened between 1985 and the present in terms of how many people have appeared who have been represented by lawyers in front of the Supreme Court of Canada or Court of Appeals in the various jurisdictions across this country, or even at human rights tribunals, alleging that they have been discriminated against on the basis of mental disability? You may need a microscope to measure them. It will be a very small number. Why are they not represented? Where are the lawyers?

A couple of years ago, I asked Michael Perlin, a law professor at New York University, the author of 13 books on mental disability law and 175 articles on mental disability law. I asked him to do some research for me in a couple of areas. I could not understand what was going on. Professor Perlin wrote this book. It is called, The Hidden Prejudice: Mental Disability on Trial. It is a brilliant book written in the year 2000. Hollow Promises, written by Susan Stefan, is another brilliant book that talks about the impact on people with mental disabilities from a United States perspective.

We are not 20 years behind in this province. We are a century behind. It is appalling what goes on in this province in terms of persons with mental disabilities. It is not simply a matter of being shunned and set to one side.

I appreciate the fact that you have come here today. We have had commissions of inquiry coming here since at least — and I refer, Senator Cook, to your book there. If you were to go to page 249 of the book in front of you, I will read to you, if I may. This is a book, Out of Mind, Out of Sight: A History of the Waterford Hospital.

In October 1948, at the invitation of the Commission Government, the Canadian National Committee for Mental Hygiene, under its director, Clarence M. Hicks, and its secretary, Marjorie Keyes, conducted a three-week survey of the Hospital for Mental/Nervous Diseases and The Colony's Mental Health Services.

Then on page 251, here are the recommendations they made after visiting The Colony for three weeks: "The use of jails should be discontinued."

Well, the use of jails was discontinued. We no longer use the lock-up. It only took 55 years. That was reported on Sunday, December 7, 2003, in the Evening Telegram, how we had finally got around to building this replacement for the lock up. We cannot afford another 55 years. There are too many lives at stakes, there are too many families being destroyed. There are too many people who want to make contributions to society who are not able to do it, not because they cannot. These persons with mental disabilities are persons. They are full persons. They enjoy personhood. They have the right to equality. They have the right to psychological integrity, the right to dignity and the right to inclusion. They have all the constitutional rights that everybody else has.

To give you an idea how scary this is when you bring it into perspective, I have been present when a high-ranking administrative official in this province's mental health care system said to me in front of somebody that I had brought into the hospital for treatment, "As long as this person has these outstanding legal issues, it is unlikely," he said, "that any psychiatrist in this jurisdiction will take him as a patient."

I want to talk about some things which we can do, perhaps, to slow down some things and change things. We have to do it at all levels of society; every strata. We have to start with children who are most influenced at the ages of four, five, six, seven. We have to teach children the importance of the other "R" besides reading, writing and arithmetic: respect. We need to start teaching children at the earliest ages about ethics, morality and human dignity. Children are ready to learn about that. They are ready to learn about inclusion and respect. They know it instinctively, better than us fools.

At the university level, there is only one university in this entire country, and that is St. Thomas University in Fredericton, that offers a degree program in the field of human rights. The university in this province, Memorial University, does not offer a single course exclusively dedicated to domestic human rights.

Oh, yes, you have your hands full. That is without getting into the influence of multinational pharmaceutical companies in determining what drugs we will use as chemical straitjackets and chemical sledgehammers on people that are not a whole lot different than sticking a spike in your eye socket and separating your frontal lobes, a problem for which not a single person in Newfoundland was ever compensated a single penny. I could show this committee somebody right now and you will see the star on the head. Lives were destroyed under the guise of medicine. Oh, yes, Lord Coke was right.

Ms. Jackman: I forgot to mention one thing. There was no talk today about mental illness and the connection to childhood trauma, poverty, neglect and those things. They were not brought to the table and I think that they are really important, too. Not all mental illnesses are just a disease. They can develop, as in my case, from environmental causes.

The Chairman: We actually spent a lot of time on that issue. In fact, we spent an eight-hour day just dealing with that issue and the importance of early intervention, childhood development and a lot of things.

Senator Trenholme Counsell: Thank you all for coming. It is very important and it is courageous. You are doing the right thing. I think this committee has made a big effort and I, too, apologize for you being last today.

Helen and Deborah, you both used the word "consumer." My colleagues know that I do not like that word.

Ms. Jackman: I do not like it either.

Senator Trenholme Counsell: Maybe I have to come around to it. I wanted to ask you about the word. I wanted to say to you, Helen, that someone with breast cancer would never use the word "consumer." The person would say, or I might one day have to say, "I am a breast cancer patient."

Mr. Dunne: Survivor.

Senator Trenholme Counsell: Or survivor.

Ms. Jackman: Yes.

Senator Trenholme Counsell: I wonder about the word. You both used it freely. Deborah used it several times and Helen used it at least once. Do you accept the word? Do you like it? Do you think it is the right word?

Ms. Jackman: I do not think it is the right word. I do not like it. When we started in 1989, we had the word "user" and it sounded too much like a user of the system. Then we came up with "consumer." We hemmed and hawed about it and we were left with "consumer."

Ms. Jackman: I do not like the word "consumer."

Senator Trenholme Counsell: Who came up with the word?

Ms. Jackman: From my understanding, a group in Alberta started up their own consumer project and it started there. And when we started doing this, it was within CHANNAL that we decided to call it "consumers". We could not really come up with anything else. What do we call ourselves, right? But I would like to see that changed, too.

Senator Trenholme Counsell: I am a family physician and I think we are talking about health and wellness, or not being healthy today or for our whole lives or whatever. Maybe you are not healthy for one day or maybe you have a problem that you will have to work with all your life. However, what is wrong with "patient"? Is there something wrong with it?

Ms. Forristall: "Mental health patient"? It is hard for me to bring myself to say it.

Senator Trenholme Counsell: Do you like the word "consumer", Helen?

Ms. Forristall: "Consumer" is better to me because it sounds better. A mental health patient brings up terrible images for me and I do not like it.

Ms. Jackman: Yes.

Senator Trenholme Counsell: We have a split here.

Ms. Jackman: No, I feel the same way as you do about "patient."

Senator Trenholme Counsell: Well, if you were to think up a word, and you must have thought about it a lot, what word would you suggest?

Ms. Jackman: When I think about myself, I consider myself a client.

Ms. Forristall: "Client"?

Ms. Jackman: How do you sum up a person seeking help from the mental health system? We are trying to find the word for that, right?

The Chairman: We are always interested in getting views on that because it is an issue that we have had.

Ms. Forristall: I would like to be known as a human being.

Ms. Jackman: Yes.

Mr. Dunne: Yes.

Senator Trenholme Counsell: When I think of "consumer," I think of Consumer Magazine, which is one that comes to mind, does it not?

Ms. Jackman: I know, yes.

Ms. Forristall: Yes.

Senator Trenholme Counsell: We talk about consumerism all the time, where you think of Wal-Mart, Frenchy's or Whole Brand Foods or whatever you think of.

Ms. Forristall: I would like to know what my ex-co-workers say because when they see me in the grocery store, they turn the other way, so, obviously, "mental health patient" really carries a stigma.

Ms. Jackman: Yes, yes, it does.

Ms. Forristall: I would like to be known as Helen and I would like to be known as a human being, yes.

Senator Trenholme Counsell: Do you think we could make such progress in society that to be a mental health patient will be the same as to be a diabetic patient or a breast cancer patient?

Ms. Forristall: I hope so.

Senator Trenholme Counsell: You do not think so?

Ms. Forristall: I do not think so, not in my lifetime.

Ms. Jackman: Attitudes have to change. The label or terminology itself is not so much the issue as it is that attitudes need changing.

The Chairman: Yes, exactly. We have to do something.

Thank you all for coming today. We very much appreciate it.

The committee adjourned.