CHAPTER 3:
VISION AND PRINCIPLES

Given that a model tends to shape our perception of circumstances, it substantially influences how and what services we seek to construct, be they in mental health or in physical health.[56]

After two and a half years of studying the mental health and addiction “system” in Canada, it is still striking to the Committee how many key questions about that system cannot be easily answered. They range from factual matters (e.g., how much is spent annually in each jurisdiction on mental health services and supports?) to fundamental philosophical, medical and scientific issues relating to the nature of mental illnesses.

The Committee has heard many different points of view on the whole range of questions, all argued with passion, integrity and eloquence. The previous two chapters bear witness to the richness of this testimony.

In recent years, much progress has been made in developing new medications and new treatment methods for many mental illnesses. As well, people living with mental illness and their families have increasingly been making their voices heard and have rightly insisted on actively participating in making the decisions that affect them. Still, there is a very long way to go. This is why, in the background reports released in November 2004, the Committee clearly affirmed that maintenance of the status quo with regard to mental health, mental illness and addiction in Canada is not an acceptable option.

In the Committee’s view, what is needed is a genuine system that puts people living with mental illness at its centre, with a clear focus on their ability to recover. This chapter explains what the Committee means by recovery and lays the foundation for what follows in the report.

3.1        INTRODUCTION

3.1.1     The Limitations of this Report With Regard to Substance Use Issues

The Committee believes it is necessary at the outset to acknowledge something that will become quickly evident to the reader of this report. The Committee has not been able to devote as much attention to substance use issues as it intended when it embarked on its study of “mental health, mental illness and addiction.” This report therefore focuses primarily on mental health issues.

There are, of course, many areas of overlap between mental health and substance use issues, not least of which involve people living with both mental health and substance use disorders. It is quite common for people to suffer from both. Research has shown that 30% of people diagnosed with a mental illness will also have a substance use disorder in their lifetime and 37% of people with an alcohol use disorder (53% who have a drug use disorder other than alcohol) also live with a mental illness.[57] 

The relationship between services for mental illness (such as treatment for depression, anxiety disorders and schizophrenic disorders) and services for substance use disorders (including treatment for problematic alcohol use, withdrawal management services, methadone maintenance for opiate addiction and needle exchange programs) has been the subject of much discussion and debate across Canada. In previous decades, services for the two types of disorder were administered separately; they developed divergent treatment philosophies, used different terminology and constituted different ‘cultures’ that  were often in conflict.

The ‘culture clash’ between mental health services and addiction services has created substantial problems for clients, particularly those with concurrent disorders. As a result of conflicting approaches to treatment, clients have often received confusing and inconsistent information and advice. It has been common for them to be excluded from mental health services if they admitted to substance use problems. Similarly, clients were often excluded from addiction treatment programs if they admitted to the use of antidepressant medications.

Because of the importance of substance use issues in general, and of this overlap in particular, the Committee has devoted a Chapter of this report to substance use issues, and has attempted to address areas of common concern at various points throughout the report. Moreover, there is an important recommendation in Chapter 16 that the federal government inject an additional $50 million per year in concurrent disorder programs.

Despite this, however, the Committee is acutely aware of the limitations of this report with respect to substance use issues. This report only scratches the surface of many substance use issues that deserve a much fuller treatment. There are also many places where the Committee has been unable to examine fully the similarities and differences in approach in the mental health and substance use fields. It would clearly not be appropriate for the Committee to assume that conclusions it has reached after carefully considering the mental health evidence necessarily apply with respect to substance use issues. Some may apply, but the Committee has attempted to avoid any unwarranted assumptions in this regard.

3.1.2     Some questions of “language”

The language used to speak about an issue, and the models employed to understand it, have a significant bearing on the kinds of policy proposals favoured or endorsed subsequently. Nowhere does this ring more true than with respect to mental health, mental illness and addiction.

This report is about mental health, mental illness and addiction. How, then, should this report refer to the people most directly affected by mental illnesses and addictions? As the Committee noted in its interim report, there is no single, easy choice:

Traditionally, individuals with mental illness and addiction being cared for by physicians are called patients.  Other health professionals often refer to such individuals as clients or service users.  The individuals may describe themselves by a number of terms, commonly consumers and survivors.  Consumers usually refer to individuals with direct experience of significant mental health problems or mental illnesses who have used the resources available from the mental health system. 

In its initial reports, the Committee chose to use the term “people living with mental illness” as its broadest reference. It also used the term “patient/client” where relevant. It is important to clarify further how these various terms will be used throughout this report.

In addition to “people living with mental illness” as a generic term, the Committee will also employ the phrase “people with direct experience of mental illness.” Other terms will be used as appropriate. The term “patient,” for example, can be used when referring to people who are actually receiving medical treatment. Used as a general term, however, it conveys an impression that is overly medical; the Committee heard repeatedly, and compellingly, that more than medicine is involved when dealing with mental illnesses.

An anonymous participant in the Committee’s second e-consultation put it this way:

In making your final recommendations, I hope the Senate Committee will acknowledge that mental health care is more than psychiatry and clinic services. Though those things are extremely important, they can only be helpful as part of a broader community support system which adequately addresses the needs of mental health consumers. —Anonymous

For her part, Jocelyn Green, Director of Stella Burry Community Services in St. John’s, pointed to the potentially beneficial impact of a broader approach:

The formal mental health system is still too hierarchal and pathology-based.  Yes, obviously, there are severe, legitimate mental illnesses that need treatment and medication, but I think we often fail to factor in the systemic roots of many mental health problems, such as poverty, abuse, discrimination, the lack of child care and affordable housing.  I think if a lot of those issues were addressed, certainly a lot of the people that are coming through our formal systems would not need to be there.  —Jocelyn Green[58]

The term “consumer” poses similar difficulties. The Committee will use it to refer to people who are using available mental health supports and services. It will not be used, however, to refer to all those living with mental illness. One reason is that the majority of those with a mental disorder or substance use disorder, as shown in a recent national survey conducted by Statistics Canada,[59] do not access mental health services or supports. Clearly, calling all people living with mental illness “consumers” is inaccurate; the same limitation applies to the term “client.”

The Committee is also sensitive to the fact that the term “consumer” has a variety of meanings and is not liked by many to whom the designation might apply. As one respondent to the Committee’s e-consultation wrote:

I do not like the word “Consumer” — I find that stigmatizing. Other people who have illnesses are not defined in this manner. It gives the impression that because of our illness we overuse services. The word makes me think of a fire consuming that which sustains it. It has a very negative connotation and I think it should be dropped. People with personal experience with mental illness is quite adequate… just like people with personal experience with cancer or any other number of known diseases.   —Anonymous

Others pointed to the many commercial overtones of the term. For all these reasons, the Committee believes that it is not the best term to use to refer in the broadest way to all those who are living with mental illnesses. In this report, therefore, the Committee will use the term consumer only to refer to those who are in fact using available mental health supports and services, or when speaking about groups and individuals who refer to themselves as consumers.

3.1.3     The Mental and Physical Dimensions of Illness

People living with mental illness and addiction have faced, and continue to face, stigma and many forms of discrimination that compound the effects of their illnesses. As the Committee previously noted, this systematic discrimination is one explanation for the fact that  mental illness, in general, is not often treated with the same degree of seriousness as physical illness.[60]  This situation must be redressed.

The Committee senses that there is, in fact, a broad consensus in favour of equity of treatment among Canadians. Most would agree that having providers and others treat mental illness with the same seriousness as physical illness is part of the fundamental entitlement of people living with mental illness to the same rights and privileges as all other Canadians. Achieving equity of treatment would mark an important step in combating the stigma associated with mental illness and addiction and the discrimination against people living with them.

But it is important to clarify what “treating mental illness like physical illness” really means. There is nothing approaching universal agreement on how mental and physical factors influence the state of our mental health. Indeed, there are many different ways in which social, environmental, psychological, and biological factors are thought to interact in the development of mental disorders, although most people seem to agree that mental illnesses almost always entail some combination of these factors.

However, different emphases placed on the role of these four factors can and do lead to very different approaches to mental health policy. For example, someone who believes that the key to “curing” mental illness is an understanding of the underlying functions of the brain, would be much more likely to support spending scarce research dollars on neurophysiology than on studies of the impact on individuals of the social determinants of mental health.

In the Committee’s view, it is essential to recognize that in treating mental illness comparably to physical illness it is not necessary to treat them as if they were identical to one another. Mental and physical illness are both like and unlike each other. There are key similarities and key differences, many points of overlap, but also features that are unique to each.

In particular, the Committee believes it is extremely important to stress the significance of what are called the social determinants of health in understanding mental illness and in fostering recovery from it. The Committee was repeatedly told that factors such as income, access to adequate housing and employment, and participation in a social network of family and friends, play a much greater role in promoting mental health and recovery from mental illness than is the case with physical illness. As well, it is important to see that the direction of causality goes both ways, from the mental (psychological, emotional, etc.) to the physical (neurobiological) as well as from the physical to the mental.

What the Committee means, then, by treating mental illness like physical illness is best understood to mean that both types of illness must be treated with equal seriousness, by providers, by all Canadians — and particularly by governments. People who are living with mental illness and addiction must be accorded respect and consideration equal to those given to people affected by physical illnesses. The Committee has sought to make this one of the guiding principles that underpin this entire report.

3.2       RECOVERY

This report focuses on facilitating the recovery of people living with mental illness and addiction. Widely documented in the field of addictions, the idea of recovery has been applied only relatively recently (over the past decade) to mental illness. The goal of recovery for people living with mental illness has nonetheless gained considerable acceptance in that time.

The Committee noted previously that:

Recovery is not the same thing as being cured.  For many individuals, it is a way of living a satisfying, hopeful, and productive life even with limitations caused by the illness; for others, recovery means the reduction or complete remission of symptoms related to mental illness.[61]

The Committee believes that recovery must be placed at the centre of mental health reform. Studies have shown that even people with the most severe mental illnesses who have been decades under institutional care, can and do recover.^[62] Long-term studies of the impact of serious mental illness have demonstrated that a significant number of affected people are able to regain full function.^[63]  Research carried out by the National Empowerment Centre, based on in-depth interviews with people diagnosed with schizophrenia, bipolar or schizoaffective disorders, confirms the capacity for recovery.^[64]

Although the term recovery also has a number of drawbacks, the Committee nonetheless believes it is the most appropriate one for all the reasons outlined in this section. The Committee is aware that not everyone living with a mental illness will be able to recover, but, as explained below, it believes recovery to be the primary goal around which the mental health delivery system should be organized.[65]

Advocacy groups have been central in promoting the focus on recovery. In this regard, a participant in the Committee’s e-consultations commented:

Surprisingly when considering the history of psychiatric treatment recovery can be seen as a radical concept. The demand to see the human potential of consumers and the expectation that help will lead to recovery was spawned by the consumer and family movement.  —Anonymous 

Kim Baldwin, Director of Mental Health and Addictions Services for the St. John's region, also noted that:

“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.[66]

Numerous witnesses testified about the significance of this shift of focus, including Jean‑Pierre Galipeault, owner of the Empowerment Connection in Dartmouth, Nova Scotia, who gave the Committee a sense of the far-reaching implications of adopting a recovery framework:

There are different definitions of recovery, but my business, The Empowerment Connection, defines recovery as, “[o]ccurring when a person's psychiatric diagnosis or emotional and psychological trauma is no longer the central focus in that person's life, but simply becomes a part of who that person is.”  We must remember that people also have to face the task of recovering from the effects of external and internalized stigma, learned helplessness, institutionalization, poverty, homelessness and the wounds of a broken spirit.[67]

The histories of people diagnosed with a mental illness are extremely varied; a wide variety of treatments, services and supports can assist recovery.  For most consumers of mental health services it is their family physician who is the first, and often only, port of call.[68] Having access to psychiatrists, psychologists, nurses and other health professionals can also make an invaluable contribution to the well-being of people living with mental illness. At the same time, witnesses also pointed to the need for other kinds of services and supports to be available, as Raymond Cheng (a consumer and peer advisor) noted:

…what people need sometimes is a safe and comfortable place, open at hours they want, accessible to their needs, and having a feeling of community and sharing food, talking to one another, laughing together, and helping one another.[69]

Recovery has increasingly been embraced within the broader mental health sector,^[70] as well as in government circles. For example, as the Committee noted in its review of mental health policies and programs in other countries, the goal of fostering recovery was placed at the centre of a recent national mental health report in the United States.[71] In practical terms, one of the attractions of a recovery orientation is that it may help create a framework within which services can be meaningfully measured and evaluated.^[72]

3.2.1     The Need for a Recovery-Oriented System

Two models of recovery have been developed: the Psychosocial Rehabilitation Model and the Empowerment Model. The first arose within the professional community, while the second has largely come from the consumer advocacy movement. Although the two models are similar in some respects, there are also important differences. Often used interchangeably by planners, depending on how they are applied the philosophical differences between the models can result in the development of different approaches in service delivery. The two models are described in more detail in the appendix to this chapter.

Drawing on these two models,^[73] the Committee has concluded that a policy approach based on the idea of recovery must acknowledge the following:

§         Each person’s path to recovery is unique;

§         Recovery is a process, not an end point;

§         Recovery is an active process, in which the individual takes responsibility for the outcome, with success depending primarily on collaboration among helping friends, family, the community, and professional supports.

Recovery is about hope. As we noted earlier, recovery does not necessarily equate with cure. It can mean different things to different people.  Very broadly, it suggests that the goal of mental health policy should be to enable people to live the most satisfying, hopeful, and productive life consistent with the limitations caused by their illness. For some, recovery will equate to the reduction or complete remission of symptoms related to mental illness.

In the past, much of mental health planning has not focused sufficiently on the outcomes achieved by people using the services provided within the mental health system.  Recovery provides a focus for re-orienting the design and delivery of mental health programs, services and supports. Importantly, it allows us to define the role of the system: it is to facilitate the ability of people living with mental illness to deal actively with the limits imposed by their conditions.

As Darrell Burnham, Executive Director of the Coast Mental Health Foundation, told the Committee:

The path to recovery is not clearly drawn in a map.  We see it as a very person-centred approach; that people will have their own way back into society.  The system needs to foster that and facilitate that rather than deliver a specific program that may prejudge that path.[74]

Working toward a recovery-focused system is a complex undertaking. It involves coordinated action by governments at all levels, and at each level there are multiple ministries, agencies or departments, each usually having only minimal awareness of what the others are doing. It involves tens of thousands of providers working both inside and outside the formal mental health care system, some paid within the public system and others not, as well as hundreds of thousands of unpaid caregivers, using whatever resources they can find to help their friends and loved ones, volunteering their time and energy when they can.

There is always the danger that the idea of recovery will be embraced rhetorically but not translated into policy and action.[75] In the next three sections of this chapter, a bridge is suggested between the notion of recovery and the specific proposals for reform contained in the remaining chapters of this report. In the Committee’s view, a recovery-oriented system must rest upon three pillars:

§         Choice: Access to a wide range of publicly funded services and supports that offer people living with mental illness the opportunity to choose those that will benefit them most;

§         Community: Making these services and supports available in the communities where people live, and orienting them toward supporting people living in the community;

§         Integration: Integrating all types of services and supports across the many levels of government and across both the public/private divide and the professional/non-professional dichotomy.

3.3       CHOICE

In general, the range of choices that have been available to consumers of mental health services has been severely limited. The system has lacked both the resource capacity and the flexibility to provide personalized services that engage individuals in their own recovery, whether they are seeking treatment in an acute inpatient ward or living in their communities.

This is how Darrell Downton, Co-Chair of the Mental Health and Addictions Advisory Committee of the Five Hills Health Region in Saskatchewan, put it in his testimony to the Committee:

The limited options available to people with mental illness and addictions confirm to them that they are not eligible to receive the care and support they deserve.  Their recovery is limited by the options available.[76]

Viewed from the perspective of fostering recovery, choice is both a means to an end — a more responsive service — and also an end in itself. This is because being able to make choices is a manifestation of the rights and responsibilities of adulthood, and of full citizenship. The availability and exercise of choice is itself a potential contributor to the recovery process.

The Committee believes that it is people living with mental illness themselves who should be, to the maximum extent possible, the final arbiters of the services that are made available within the overall mental health system and of the ways in which they are delivered.  In this sense, it is legitimate to speak in terms of encouraging a consumer-driven, or consumer choice, approach.

This is the best way both to encourage the elaboration and implementation of practical solutions to the problems encountered by people living with mental illness and addiction, and to promote the mental well-being of the population as a whole.  No single body, least of all a governmental one, should be so arrogant as to believe it can prescribe a universal treatment model for all people living with mental illnesses and addictions.

Furthermore, no single treatment model should be allowed to dominate the policy horizon, either in theory or in practice.  Many people will find successful treatments or care that are derived from a purely “medical” model, while others will look to their particular community or cultural traditions for ways of achieving the best mental health possible. 

Moreover, because of the complexity of mental illnesses and their intimate connection with each individual’s unique circumstances and environment, many will find that they will need to draw on treatments, supports and ways of caring that combine elements drawn from multiple approaches.

Allowing people a range of choices that can be based in a variety of traditions is not merely the expression of a philosophical preference — it has important national policy implications.  It points to the need to address the fact that an institutionalized bias is built into the way public funding for health care services works in Canada: under the Canada Health Act, only services that are provided by physicians or in hospitals are required to be publicly funded.[77]

While other services may be funded by individual provinces or even at the community level, access to them will vary widely. Current funding arrangements mean, therefore, that many services needed by people living with mental illness and addiction are available only to those who can pay for them out of their own pockets, or who have private insurance plans that cover them.

The services provided by psychologists are one example that the Committee heard repeatedly. As one e-consultation respondent argued:

The biomedical model does not address underlying issues like abuse. I believe the origin of my illness is from childhood incest. Childhood sexual abuse has devastating consequences to a person's life. A huge percentage of people diagnosed with Borderline Personality Disorder have suffered sexual abuse. I can not afford to pay a psychologist $150 an hour to treat me. The most important thing I need is therapy.  —Anonymous

This was echoed by another respondent:

Ever since the “revolution” in drug treatment for psychiatric disorders, psychiatrists have gradually dropped their role as psychotherapists. Psychotherapy is only covered by my provincial health plan if provided by a psychiatrist (as a medical doctor). I have taken far more medication than I would have liked at an exorbitant cost to my health and to my provincial health plan, when I could have done with much less medication and had a far quicker recovery had I been able to afford psychotherapy. If the provincial plan had paid for my psychotherapy I believe that they would have saved money and my overall mental and physical health would be better as a result.
—Anonymous

Providing people living with mental illness with access to a full range of services and supports in addition to those provided by physicians and hospitals, and enabling them to select freely the ones they prefer, requires that an adequate range of services be made available and that people have available the funds to pay for them.

The Committee is aware that creating the conditions to sustain an environment that allows people living with mental illness to choose those services that benefit them most will not be easy. There will always be hard policy decisions to be made about how public resources can best be used. Moreover, no one can expect that all options will ever be freely available for everyone who desires them.

On the one hand, this means that policy decisions about which services and supports should be widely available and accessible to those who would choose them must be made on the basis of the best available evidence as to their effectiveness. Given the multiple dimensions implicated in mental health issues (social, environmental, medical, biological), it is necessary to apply a methodological pluralism to the selection and evaluation of the evidence of effectiveness itself. Relevant findings derived from the medical sciences, social sciences, and from people with direct experience of mental illness must all count in weighing such evidence.

On the other hand, the need to collectively set the priorities for public spending points to another dimension of fostering choice. Consumers of mental health services and supports must be given the opportunity to participate actively in the process of collective decision-making. Their collective voice must be heard at the policy table, just as they should be allowed to make  individual choices about which services and supports are right for them.

3.4       COMMUNITY

An orientation to providing access to community-based services and supports is the second pillar needed to support the creation of a recovery-oriented system. The evidence is clear that the shift begun many years ago away from institutionalized models of care was the right one, even if it was not always sufficiently resourced in practice.

Many witnesses stressed the importance of this community-based orientation:

In all the literature I have read about recovery, every person who discloses on this topic says that connection to the recovery community is the most important fact of ongoing recovery. Otherwise, relapse is particularly inevitable — sending the person back into a poorly functioning state.  —Patricia Commins[78]

Others pointed to the range of resources required in the community to support and sustain the recovery process. Geoff Chaulk, Executive Director of the Newfoundland and Labrador division of the Canadian Mental Health Association, told the Committee:

The community resource-based model with the person at the centre of the system also addresses the essential elements for successful community living and recovery, including adequate housing and income, work, social connections and mental health services and supports.[79]

Since mental health and addiction problems cut across so many facets of community life, much more than health care and other publicly funded social services will be required to respond properly. A wide variety of forms of community action make meaningful contributions to people affected by mental illness and addiction; without them, publicly funded services would be left to struggle with an overwhelming challenge. In addition, by making the community the focus for service provision, people can stay close to their personal support networks.

But Dr. Paul Garfinkel, CEO of the Centre for Addiction and Mental Health, cautioned that:

…community care is not cheap care. Community care requires specialized resources with knowledgeable people who provide care and treatment. We have a treatment program for psychosis involving 100 people with schizophrenia.  Our team goes out to the homes in Toronto and keeps these people at home, very successfully. It is an excellent treatment program. It involves 100 people who, for sure, would have been in hospital. However, it is expensive. You need a doctor. You need a nurse. You need a social worker. You need a whole team.[80]

The significance of basing mental health services and supports in the community holds for people living with all types of mental illnesses, from the mildest to the most severe. But the mechanisms through which the needed services and supports are best delivered will vary according to the severity of people’s illnesses as well as their individual capacities to cope with the limitations imposed on them by their illnesses.

For people living with serious mental illness, there is strong evidence that with the proper supports in place they can not only live in the community but also lead fulfilling and productive lives.

A recent report by the Community Mental Health Evaluation Initiative in Ontario, for example, concluded that programs such as Intensive Case Management or Assertive Community Treatment that are designed to assist people living with serious mental illness to remain in the community were “helping clients decrease their reliance on institutional care and improve their quality of life.”[81]

The same report referred to data from a study done in Ottawa that indicate that:

…on average, it costs about $68 per day to provide community-based services to a person with mental illness. To treat the same person in hospital, however, would cost $481 per day.[82]

Of course, hospital services will always be an essential component in the continuum of care. Nonetheless, another study, from the Eastern Townships region of Quebec, showed that, by providing appropriate community-based facilities, it was possible for a region of close to 300,000 people to meet the long-term needs of people living with serious mental illness in a region that has never had a specialized psychiatric institution.[83]

An orientation towards the community will mean something different for people experiencing mild to moderate mental health problems. For most of them, contact with the mental health system will occur through a primary health care provider (group or solo), who may or may not connect them subsequently with a specialized mental health service of some kind.

Epidemiological data indicate that, each year, roughly 3% of the population will experience a serious mental illness, and that another 17% or so will experience mild to moderate illness. The full range of services must be available therefore to address the needs of both broad categories of people. Figure 1 provides a graphic representation of a system that places individuals at its centre, and of the types of treatments, supports and services that must be in place to meet the needs of all people who experience mental health problems.

The most appropriate balance among all the various elements will vary from community to community and will likely evolve as more becomes known about what types of intervention genuinely facilitate recovery among those living with the complete range of mental illnesses. However, the starting point for thinking about how to improve the mental health system should be the main types of mental health treatments, supports and services that are currently being deployed. This is what is captured in Figure 1.

3.5       INTEGRATION

The separation between services and supports that are delivered through the health care system and those that fall largely under other spheres of responsibility, as illustrated in Figure 1, points to the fact that many institutional and structural roadblocks stand in the way of realizing a “seamless” delivery of mental health supports and services.

On the one hand, within the health sector, mental health services must be integrated with physical health care services. Ways must be found to improve the diagnosis and treatment of many illnesses at the level of primary care, as well as ways to integrate better specialist care with primary care services.

On the other hand, the variety of mental health treatments and services funded by ministries of health must also be integrated with the broader range of services required by people living with mental illness that are the responsibility of the various governmental departments and agencies that deal with income support, housing, employment, etc. Moreover, it is essential that services and supports for people living with both mental illness and addiction be better integrated.

Finally, integration also requires that services and supports will be available to people throughout their lifespan, and that as people’s needs change as a result of aging or circumstances they will still be able to gain access to appropriate services and supports in a “seamless” fashion.

Many challenges must be met to achieve the integration of services and supports that many witnesses insisted was essential to improving access to required services and building a system that encourages recovery.  First amongst these is the recognition that integration can take place in many ways, and that it is important therefore to adapt strategies to achieve integration in ways that are appropriate to each community’s particular situation.

In this regard, a report prepared by researchers at the Centre for Addiction and Mental Health, Strategies for Mental Health Integration, points out the numerous dimensions to the problem of integrating mental health services. It cites research underlining the need to distinguish among three domains — governance, administration and service delivery.

Governance refers to the part of the system with accountability for system performance and the authority to set strategic direction and policy and to oversee general management and the use of resources. Administration is the domain that supports operations on a daily basis and includes the infrastructure for finance, information, human resources, etc. Service is that part of the organization that provides services and supports directly to consumers.

The report notes that the intensity of integration can vary from loosely connected alliances to highly integrated organizations, as can the degree of formality involved (ranging from informal or verbal agreements to formal policies, rules and procedures).[84]  The evidence summarized in the report suggests that it is difficult to draw definitive conclusions regarding the ideal way to achieve integration or system-building. It does not appear that integration is best pursued as a cost-saving measure, or that all approaches to system integration yield the desired results.

Nonetheless, a number of benefits were identified that can be derived from greater integration of mental health services, noting that several studies have demonstrated the positive effects of initiatives where:[85]

§         a system manager controls a pooled funding envelope;

§         performance targets are set and monitored;

§         organization of services in the network is centralized around a core (but not necessarily consolidated) agency;

§         the system manager has control over inpatient services and monitors admissions.

Figure 1

Source: Adapted from New Brunswick Department of Health and Wellness, Community Mental Health Centres: Programs and Services, p. 3, accessed at: http://www.gnb.ca/0055/cmhcs-e.asp

Types of mental health
Treaments, supports and services

         Individual situated within a complex set of social determinants of health

Others have also commented on the fundamental challenges involved in changing governance structures in the broader health care sector. Mintzberg and Glouberman, for example, have noted that:

Clinical activities cannot be coordinated by managerial interventions — not by outside bosses or coordinators, not by administrative systems, not by discussions of “quality” disconnected from the delivery of it, not by all that constant reorganizing… Management of clinical operations will have to be effected by the managed, not the managers.[86]

In March 2000, Ontario’s Health Services Restructuring Commission (HSRC), chaired by Duncan Sinclair, published a report reflecting on its mandate and attempts to restructure the hospital system in Ontario. The HSRC made the following observations about organizational change and governance:

§         There is no one best system/ model of governance, but “there is a need to find better ways to promote greater integration, efficiencies and effectiveness across the various components of the health system.”

§         New governance models should emerge which “allow individual organizations to use their strengths and talents” while preserving and enhancing organizational distinctiveness.[87]

Finally, in a paper on “Mandated Collaboration,” Steve Lurie looked at the implications for mental health reform of the fact that “there is limited evidence that structural or organizational reform improves clinical outcomes.”[88] The general lessons he drew with regard to efforts at system integration include the following:

§         one size doesn’t fit all

§         use best practices and unified funding models to drive system change

§         there is a need to attend to corporate culture and human resource issues if attempting structural change or alliance building

§         Rome wasn’t built in a day; the development of effective collaborative relationships take time

§         there is a need to experiment, evaluate and learn from experience

It is possible to identify many potential ways of improving integration of mental health services and supports. A partial list could include:

§         expanding the use of multidisciplinary teams, shared care and collaborative care arrangements

§         developing common assessment protocols

§         pooling funding

§         putting in place registries of available services

§         linking data systems and electronic health records

§         creating mental health authorities or engaging in area planning

§         developing common service protocols and care pathways

The Committee believes that it is important to allow regions and communities to pursue forms of integration that are appropriate to their particular situations. Each community and region will have to choose strategies that take into account its readiness for change, and the available opportunities for improving access to services.

For example, we will later describe some of the ways that mental health services have been successfully integrated in Brandon, Manitoba. While Brandon’s experience is exemplary in many ways, it is also clear that it would be extremely difficult to replicate that experience precisely in other communities across the country. Not only has it taken 25 years of hard work by a dedicated group of people in Brandon to restructure and coordinate their community mental health services, but their success is also built upon a very particular history of deinstitutionalization that provided a context for change that does not exist in many other communities.  Nevertheless, a lot can be learned from that experience.

While the approach to integration must be based on the particular history and circumstances of each community, it is still critical that integration be recognized as an essential dimension of building a recovery-oriented mental health system. Integration in some fashion is an indispensable ingredient to provide people living with mental illness and addiction with a truly seamless delivery system that can meet their needs throughout their lifespan.

While there will never be a single template for how this is to be accomplished, the goal of recovery is one that must drive efforts to reform the mental health system. Integration must be seen as a means to achieving that goal and not as an end in itself — it must serve the objective of improving the range, affordability, quality, and accessibility of services. This requires measurement, accountability, and a commitment to change.

3.6       TURNING THE VISION INTO REALITY

The remainder of this report will describe the changes required if progress is to be made in creating a recovery-oriented mental health system that rests firmly on the three pillars of choice, community and integration. There are many concrete hurdles to be overcome, many of which were documented in the Committee’s background reports and eloquently recapitulated in the testimony of the witnesses and participants in the Committee’s e‑consultations who were quoted in the first two chapters of this report.

At times the task can seem overwhelming, in part because making progress in any one area seems to depend on making progress in them all. The Committee firmly believes that despite the scale of the challenge it is possible to move forward, but only if a strategic plan is developed and a step-by-step approach is adopted toward its implementation. We recognize that it is indeed impossible to transform the entire mental health delivery system in one fell swoop. However, pragmatic reform that enables real improvements to be made in the lives of people living with mental illness and addiction is achievable and it must happen, and soon.

The Committee is acutely aware that this report will not contain all the answers to the many challenges that confront many thousands of Canadians concerned with mental health and addiction. A parliamentary report in itself can never guarantee that action on its recommendations will follow. Moreover, the effort to implement a reform plan must extend over a considerable period of time.[89]

Nevertheless, the Committee has been encouraged in the course of its public hearings by the sense that the time may just be right to move forward in key areas. Moreover, as will become apparent, the Committee has worked very hard to ensure that the momentum for change that has been building during the three years in which we have been working on this issue can be sustained. In this regard, one of the recommendations in this report (see Chapter 16) stands out as key to the process of transforming the mental health delivery system in Canada.

The Committee believes that only if the Canadian Mental Health Commission, recommended in Chapter 16, is created immediately following the release of this report, will it be possible to maintain a national focus on mental health issues and bring together all the stakeholders who will have a role to play in transforming the system. In this sense, the new Canadian Mental Health Commission is an essential mechanism for the realization of the vision outlined in this chapter and for implementing the reform measures described and recommended in the rest of this report.

3.7       SUMMARY OF PRINCIPLES

The principles outlined in this chapter can be summarized as follows:

1. While mental illness and physical illness are both like and unlike each other, they must be treated with equal seriousness, and people who are living with mental and physical illnesses must be accorded equal respect and consideration.
2. The central goal of mental health policy is to create the best possible context for encouraging recovery; a focus on recovery places emphasis on wellness as opposed to illness, and sets the goal of facilitating the abilities of people living with mental illness to deal actively with the limits imposed by their conditions and to live meaningful and productive lives.
3. Promoting mental health and recovery from mental illness requires interventions that address the social determinants of health — in particular those related to income, adequate housing and employment, and participation in social networks.
4. A policy approach based on the idea of recovery must acknowledge that:

§         Each person’s path to recovery is unique;

§         Recovery is a process, not an end point;

§         Recovery is an active process in which the individual takes responsibility for his or her own recovery, and success depends upon collaboration among helping friends, family, the community, and professional supports.

5. A focus on recovery will require reorienting the design and delivery of mental health programs; there are three pillars upon which a recovery-oriented system must be founded:

§         Choice: Access to a wide range of publicly funded services and supports that offer people living with mental illness the opportunity to choose those that will benefit them most;

§         Community: Making these services and supports available in the communities where people live and orienting them toward supporting people living in the community;

§         Integration: Integration of all types of services and supports across the many levels of government, and across both the public/private and the professional/non-professional divides.

6. Policy decisions about which treatments, services and supports should receive public funding must be based on the best evidence available; this includes findings from the medical sciences, data and analyses from the social sciences, and the testimony of people with direct experience of mental illness.

APPENDIX: MODELS OF RECOVERY

1)      Psychosocial Rehabilitation Model

The most widely used rehabilitation model is the Psychosocial Rehabilitation Model (PSR) originated in Boston University. 

PSR is a professionally driven model that has shaped the development of many community-based programs and services.^[90] It is based on the view that people with a mental illness can recover even though their illness is not cured. PSR focuses on enhancing functional ability and attempts to look at all areas of a person’s life, including strengths, resources, and barriers. The PSR approach seeks to improve four main life domains:

§         practical skills of personal self-care,

§         home management,

§         relationships and use of community resources,

§         leisure, education, and employment. 

The goal is to help people regain social functioning despite their having symptoms, limitations and taking medications.  The PSR specialist helps the individual move toward self-selected meaningful life goals and provides appropriate social and therapeutic supports to help them do so. Goal-specific skills are taught to assist individuals to achieve self-sufficiency, building on natural social and community support systems. 

Within this model, mental illness is seen as a permanent impairment similar to the way a spinal cord injury produces lasting paralysis.  It is considered that people have a “broken brain” and that, with appropriate and adequate supports, they can continue to function in society.  However, their impairment remains permanent.^[91]  

The fundamental principles that underpin PSR can be stated as follows. PSR:

1. Emphasizes the need for individually tailored interventions;
2. Requires either that the individual’s capacities be adapted to environmental realities or that the environment be changed to suit the capacities of the individual;
3. Builds on the individual’s strengths;
4. Aims to restore hope;
5. Emphasizes the individual’s vocational potential;
6. Extends beyond work activities to encompass a full array of social and recreational activities;
7. Actively involves individuals in their own care;
8. Is an ongoing process that must continue over time.
   
    

Psychosocial rehabilitation focuses on early intervention, wellness, independence, self-determination and most importantly — hope.  Cognitive therapy, or the process of learning positive and self-enhancing self-talk, is used to help people make sense of and manage distressing symptoms of illness.  Mutual support, through peer support groups, is seen to enhance self-sufficiency and expand social networks, build each person’s self-reliance and overcome dependency on professionals.

The belief in the client’s personal capacity for growth, the development of helpful partnerships and seamless services built on individual needs and preferences are core to the psychosocial model.  Clients receive ongoing evaluation to ensure continuous progress. 

Strategies include illness education, family intervention, supported employment, assertive community treatment (ACT), skills training, and cognitive behavioural therapy. 

The practice of psychosocial rehabilitation is done by existing professionals such as psychiatrists, psychologists, social workers, occupational therapists and nurses, all with the necessary skills and training, or by persons who have received specific training in psychosocial rehabilitation in university programs. 

The “client-centred” approach utilized by PSR specialists has been criticized at times for “colonizing” the life of consumers where professionals are actively involved not only during periods of sickness but when people are healthy as well.  There have been instances where professionals have claimed ownership and responsibility not only for illness management but for social, recreational and employment roles as well. This has prompted some consumers to react by saying that “When you say ‘client-centred’, I feel surrounded.”^[92]   

Dr. William Anthony, the “founder” of the psychosocial rehabilitation movement, emphasizes that recovery can occur without professional intervention.  The task for professionals is to facilitate this natural process.^[93]  He named the 1990s the “decade of recovery” because of the gains made in helping people adjust to community living.  However, he cautions that 2000 must be the “decade of the person.” 

In his view, rehabilitation must be done “with” clients, not “to” them.  He believes people can make meaningful choices and recognizes that lip service has been paid to the concept of self-determination. The belief that people with mental illness set unrealistic goals and cannot hold demanding jobs has resulted in professionals taking choices away from consumers “for their own good.” In his words, “If people are allowed to choose they may request something that demands we change our actions or programs.”^[94]

2)         Empowerment Model

The consumer advocacy community has championed the empowerment model of Recovery as a means of promoting the idea that psychiatric patients are able to work and live independent lives and should not be defined by their “diagnosis.”  Proponents of the empowerment model argue that designating mental illness as a permanent condition is one of the factors that contribute to ostracizing people living with mental illness from society.^[95] 

For consumer activists, recovery has political as well as personal implications — it is a philosophy with a set of organizing principles and values which can guide the development of supports and services as well as how they are organized and delivered.

On this understanding, to recover is to reclaim one’s life, to be validated as an autonomous, competent individual. It emphasizes that people are responsible for their own lives and affords them the privilege of choice, including the right to make mistakes. Moreover, it insists that professionals cannot manufacture the spirit of recovery.

As one e-consultation respondent told the Committee:

Systemic change will not come from professionals who experience these illnesses through an academic lens but from the lived experience of consumers and families. Ask a professional what is needed and they will always say more professional service. Ask a consumer and family member and they wish and hope for recovery. To be part of the community, a contributing and valued member of society with friends and [a] safe home. No amount of medication will help achieve those goals. Although for many medication is vitally important for clearing the path to wellness.  —Anonymous

Recovery is understood as a manifestation of personal empowerment. Within this framework, recovery happens when there is a combination of supports to (re)establish social function and sufficient self-management skills to take control of the major decisions affecting one’s life.^[96]

According to the Empowerment Connection:

Recovery is the lived experience of persons as they discover, accept, and overcome the challenges of a disability, the effects of a psychiatric diagnosis or emotional or psychological trauma.  It is discovering a new sense of self, of hope and purpose within and beyond the limits of these experiences.  It is the discovery of one’s own strengths and sense of power and control within oneself and the world.  Finally, recovery occurs when a person’s psychiatric diagnosis or emotional trauma is no longer the central focus in that person’s life, but simply becomes a part of who that person is. 

It is not just mental illness and psychological trauma that people have to recover from; they also face the task of recovering from the effects of internalized stigma, learned helplessness, institutionalization, poverty, homelessness, and the wounds of spirit breaking.^[97] 

Empowerment recovery is a values-based approach that puts people first and holds that the experience of illness is not permanent. This means that not only is recovery possible, it is to be expected. Recovery is seen as a continuing internal process that places the person at the centre of his or her own recovery. It is not seen as a linear process with an end point or destination. This approach to recovery also holds that individuals are “expert” in their own care. The re-establishment of social relationships is seen as vital to recovery, particularly with peers who understand viscerally the experience of mental illness.^[98] 

Empowerment recovery does not suggest that professional services are unimportant or unnecessary. However, such services are not intended to “fix” the person, but rather to support him or her as the individual moves towards a healthy life.  Individuals living with mental illness are seen as the agents of change, and professionals are one of the resources to be drawn upon. In this model, psychiatric treatment is viewed as part of self-managed care. 

Adopting such an approach implies a shift away from the goal of treatment being the stabilization of illness through symptom reduction.  Instead, the goal becomes to assist people to gain greater independence and control over their own lives.  Medication is used as a tool to help people reach that goal — not as a solution to their problems. The continued use of medication does not preclude recovery. Rather it is seen as a useful adjunct to help people gain control when they are frightened or confused.

Within this recovery model, supports and services can be accessed without requiring the acceptance of the diagnostic (labelling) process.  Professionals help to foster recovery by believing in the capacity of their clients to heal and by acknowledging their right to make decisions, even at the risk of failure. Demanding compliance and conformity with professional authority is considered to interfere with learning how to become self-determining.  An essential ingredient of recovery is hope. Recovery requires that everyone be given a chance to get better, at their own pace.  The recovery approach asks people what they want and need in order to grow, and provides them with the skills and supports to achieve it.^[99]

Changing the relationship between those who have been labelled “mentally ill” and those who have not can also create a common ground.  Accepting the possibility that any one of us can experience a mental illness, that, in the words of Dr. John Frank, Scientific Director of the Institute of Population and Public Health, we “are all at risk at different times in our lives,”^[100] helps to remove the stigma engendered through seeing it as “them” and “us.”   

Each person’s path to recovery is unique, and what fosters recovery reflects personal experiences and preferences.  Recovery may include 12-step programs, developing close, supportive, and mutual friendships, intermittent or ongoing treatment, participation in social or vocational rehabilitation programs, becoming involved in spiritual communities, and/or consumer-/survivor-run support networks and advocacy groups. Power and responsibility must be shared by actively involving consumers and family as key players in mental health planning, organizational governance, system design, evaluation, and service delivery. 

Recovery-oriented systems recognize that concepts of recovery need to be taught and create educational opportunities such as workshops and conferences for policy makers, planners, professionals, consumers and family. Consumers are seen as recovery educators. A recovery model would ensure that a percentage of funding is allocated for consumer-run initiatives and support such as peer support, self-help, and economic development initiatives, as well as crisis and respite care programs.  It includes recognition that building the capacity for sustained and meaningful participation by consumers and family organizations requires long-term adequate funding, management training, and organizational support to be successful