---

A federal housing program in the Arctic Inuit regions would not only resolve the housing shortages, but it would also alleviate some of the social problems such as family violence and addictions.— Larry Gordon[17]

Donna Lyon from the National Aboriginal Health Organization talked about limits on post-secondary education support, particularly the difficulties of accessing funding from departmental sources.  She also suggested that, even when resources are available, they may be insufficient to sustain a student with a dependent family:

… you have many people who cannot access funding, and when they do, sometimes a living allowance is provided, which is often not adequate. You have families living on maybe $1,100 a month…[18]

Larry Gordon pointed to the lack of infrastructure and employment in the north for educated Inuit who want to return and contribute to their communities:

Many times when people leave the North and come back, there is no work for them. They have received an education and a degree, but there is no work for them. They become engineers. The only work that they can actually do is in the South because of their training and background.[19]

 

13.1.3.2                        Health Canada’s Programs and Services

Despite some progress in health funding agreements over the past year, witnesses criticized Health Canada’s funding arrangements as being complicated, short-term and insufficient to meet the mental health needs of the population.

They called for more integrated models of funding between federal departments to support more comprehensive programs that could be sustained over the long-term.

 

Irene Linklater noted that, for First Nations, health transfers for mental health programs on-reserve were inflexible, confusing and inadequate:

Sometimes the feds flow the money to the province, and the province holds money on a per capita basis for First Nations based on First Nations population in the region. Some of the services that First Nations receive come directly from First Nations and Inuit health branch contribution agreements. […] Depending on the types and range of services, sometimes the province will enter into an arrangement with a First Nation for specific health cost.[20]

Onalee Randell, Director of Health, Inuit Tapiriit Kanatami, explained that, for the Inuit, the short-term, unstable and uncertain funding presents significant barriers to the delivery of mental wellness programs:

By the time initiatives with three- to five-year timelines are operational in communities, the funding has run out. It is hard to get qualified staff to give up permanent jobs to go into a project that may end in two years.[21]

Even the Non-Insured Health Benefits Program fell short of meeting the needs of the targeted populations. Ms Randall indicated that an analysis of 2003‑04 financial expenditures on the crisis intervention component of the non-insured health benefits for Inuit found:

… approximately $60,000 of that program was spent on mental health for Inuit communities:  $60,000 for communities that have up to 11 times the national average for suicide.  There seems to be an inequity.  The program is designed to provide short‑term crisis counselling.  In some of the communities there are no counsellors who can provide that short‑term crisis counselling, and in many cases the communities choose not to access the short-term [intervention services].  People come in after a suicide, they spend three days in the community, and then they leave.[22]

Lorraine Boucher told the Committee that, for First Nations clients with mental health or addiction problems who must travel to access mental health services outside their remote communities, the Non-Insured Health Benefits Program was inadequate:

Some of our members have had to stop counselling sessions because of government cutbacks, such as medical transportation cutbacks, and those people are lost in the system. The cost to travel to Edmonton or Peace River is too heavy a burden for them to carry without assistance.[23]

Irene Linklater also explained how addiction-related programs and services such as the National Native Alcohol and Drug Addictions Program are affected by policies for health transfers that do not allow for unanticipated population growth or for the complex nature of existing needs:

… the National Native Alcohol and Drug Addictions Program has not kept pace with the community needs, due to the expectations to intervene on family issues such as family violence, suicide attempts, individual crisis, to provide support and aftercare to those returning from treatment, and a community-wide support following tragedies.[24]

According to Onalee Randell, for Inuit trying to access addiction services, a barrier is created by the regional administrative divisions established within Health Canada:

The Inuit in Nunatsiavut want to work with the Inuit in Nunavik to develop an addictions program based on the Inuit culture and values. Right now, it is difficult to share that information and the resources because of where those jurisdictions get their federal dollars from. The Inuit in Nunatsiavut get it from Altantic Region, and the Inuit in Nunavik get it from Quebec region, and never the two shall meet.[25]

 

13.1.3.3                        Departmental and Jurisdictional Confusion

In addition to interdepartmental barriers, First Nations and Inuit clients frequently experience difficulties because responsibilities cut across federal departments. Such cross-jurisdictional barriers between federal and provincial or territorial governments prevent forward movement on mental health concerns.

Shawn Atleo, Chief A-in-chut, B.C. Regional Chief, Assembly of First Nations, commented on the lack of a departmental focal point at the federal level, noting that he had talked to three different deputies from three different departments over the previous week about housing.[26] Jennifer Dickson, Executive Director, Pauktuutit Inuit Women’s Association, told the Committee that she was obliged to deal with six independent federal departments on a weekly basis for various programs, policy and projects.[27]

Jules Picard, Social Services Coordinator, First Nations of Quebec and Labrador Health and Social Services Commission told of a cross-jurisdictional situation that involved a young person with schizophrenia who was in trouble with the law and needed medication. A setback occurred when it was determined that “Health Canada cannot pay for that young person’s medication because he is the responsibility of the provincial prison system.”[28]

Susan Levi-Peters, Chief of Elsipogtog First Nation, New Brunswick, described the enormous uncertainty when people seek financial resources for services and try to determine whether Indian Affairs, Health Canada or the province has responsibility for payment.

When we go to the provincial level, the province tells us it is not our responsibility, it is the federal government.  We go to the federal government and they tell us, “We give the money to the province, go to the province.”  We are the people who are in limbo.[29]

Ian Potter emphasized that there is currently a focus among governments on cross-jurisdictional integration:

The integration of the federal services with provincial services would reduce duplicative services or incidence of services that do not fit together. Service would then be truly focused on the needs of the patient so that the system is clear and not broken up by jurisdictional differences.[30]

However, Valérie Gideon, Director of Health and Social Development, Assembly of First Nations, expressed concern over such integration:

It is our opinion that this could be misconstrued as an off-loading of federal responsibility, certainly something that has often been communicated to us by our regions and our communities.[31]

Ian Potter also noted the need for cross-departmental integration within the federal government between Health Canada and Indian and Northern Affairs Canada. For example, to increase Aboriginal health human resources, he argued that existing bursaries and scholarships for professional medical programs must be connected to educational programs earlier in the system that are overseen by Indian and Northern Affairs Canada, “starting in grade school, so that Aboriginal people see this as a realistic opportunity.”

The Auditor General of Canada has repeatedly criticized Health Canada and Indian and Northern Affairs Canada for not having clearly established legislative authority for programs and services directed to First Nations and Inuit.  In particular the Auditor General has noted that the absence of specific enabling legislation for the Non-Insured Health Benefits program “left a gap in the definitions of purpose, expected results and outcomes of program benefits.” Health Canada was urged to seek “a renewed mandate for the program to clarify the authority base, purpose and objective of the program.”[32]

The Auditor General also pointed out that, although the Indian Act sets out requirements for determining who is a “status Indian” and detailing federal jurisdiction over them collectively, it does not specify the programs and services to be provided. Both Indian and Northern Affairs Canada and Parliament were reminded that:

The lack of substantive legislative authority could undermine parliamentary control and accountability. It precludes parliamentary debate on important questions such as whether a social assistance program for on-reserve Indians should address reducing the demand for services in addition to supplying the services, and what the appropriate benefits ought to be. In addition, it does not provide an instrument for Parliament to hold the Department accountable against program authorities, beyond those approved by the Treasury Board.[33]

13.1.4   Committee Commentary

As noted earlier, in the following chapter (Chapter 14), the Committee addresses the need for a comprehensive approach to the mental health of all Aboriginal peoples.  There, we emphasize the significance of the proposed creation of a National Aboriginal Advisory Committee as part of the Canadian Mental Health Commission. We also point to the need for more transparent reporting of actions via a federal interdepartmental committee of the deputy ministers responsible for all programs and services for all Aboriginal peoples.

The Blueprint for Aboriginal Health document tabled at the First Ministers’ Meeting of November 2005 reiterated previous commitments to clarify issues related to the respective roles and responsibilities of federal, provincial and territorial governments.[34]However, First Nations and Inuit clients have a particular historical relationship with the federal government and their multi-dimensional concerns require specific attention through federal institutional avenues.  The Committee is acutely aware that, while some past and current federal initiatives have targeted the mental health of First Nations and Inuit, the ongoing expenditures for federal programs and services have not created the anticipated positive outcomes. The Committee perceives a huge gap between the financial commitments of the federal government and concrete results of benefit to First Nations and Inuit people.

The Committee believes that some forum for objective oversight is needed with respect to the mental health of First Nations and Inuit, an independent mechanism that would function like an ombudsman. It should be able to undertake investigations to hold the federal government accountable for providing appropriate and adequate programs and services and for the results they achieve.

Other federal client groups such as federal offenders, Canadian Forces and RCMP members already have access to an entity that will systematically investigate, recommend and ensure appropriate responses to their concerns. First Nations and Inuit clients need a comparable specific avenue of redress when interacting with federal departments that have a major impact on their mental as well as their physical health.

The Committee therefore recommends:

69	That the federal government establish a federal entity for First Nations and Inuit clients, similar to the Correctional Investigator, the Canadian Forces Ombudsman, or the RCMP External Review Committee; That this entity be authorized to investigate individual complaints as well as systemic areas of concern related to federal provision of programs and services that have an impact on the mental wellbeing of First Nations and Inuit;
	That the person responsible for this entity be, if possible, of aboriginal origin; That this entity provide an annual report to Parliament.

 

The Committee was dismayed to note that, under the 2005 Blueprint on Aboriginal Health, detailed reporting on the combined outcomes of federal and provincial programs and expenditures on the health of First Nations, Inuit, and Métis peoples will not take place until 2010-2011.[35]  At present, the data from Indian and Northern Affairs Canada and Health Canada is limited and is focused primarily on First Nations. For example, spending information uses the combined term of ‘First Nations and Inuit’ and does not identify the amounts of money spent on each group; the implication is that spending is proportional to the size of each group’s population.  There is no reliable evidence useful for developing and evaluating programs and services for Inuit given that the data are merged with those of First Nations or other Aboriginal groups.

Although the federal government has pledged to develop comprehensive reporting based on distinct health indicators for each Aboriginal group, the Committee is concerned that Parliament and departments will continue to make decisions over the next five years without access to full information.

Thus, the Committee recommends:

70

That Indian and Northern Affairs Canada, Health Canada and any other departments with direct program and service responsibility for First Nations and Inuit clients develop an annual inventory of their respective programs and services currently and for the last five years. That the inventory include a clear description of: each program or service by fiscal year; the criteria for eligibility; the number of First Nations and Inuit clients respectively served by the program by geographical location; the amount of funding allocated and the amount spent; and any evaluation of outcomes related to the determinants of mental health. That the inventory be reported to Parliament annually starting in 2008.

 

Most importantly, the Committee believes that the current configuration of federal departments with their respective legislative or policy bases are not now promoting positive change for First Nations and Inuit. Since the initial transfer of the control and administration of medical services for Indians and Inuit from the Department of Indian Affairs to the Department of National Health and Welfare in 1945, there has been little improvement in the health status of this population. The federal government has had ample time to clarify its own role and responsibilities through legislation and to develop policies to reduce interdepartmental confusion. It is time to take significant steps to rectify the interdepartmental fragmentation that contributes to the overall poor health status of First Nations and Inuit.

The Committee believes strongly that a comprehensive population health approach is essential to reinforce mental health among First Nations and Inuit. The separation of programs and services between Health Canada and Indian and Northern Affairs Canada does not make sense. The Committee believes the services currently offered by Indian and Northern Affairs Canada for housing, education, and income support must be connected to services offered by Health Canada related to the promotion of healthy child development and of coping skills aimed at reducing addiction and suicide. At present, these programs and services are uncoordinated and the departments compete for budget allocations. A dramatic change is needed to ensure that First Nations and Inuit receive an inclusive range of programs and services related to health determinants and linked to positive outcomes. The change must be real transformation of the existing situation, not simply a minor adjustment.

The Committee realizes, however, that any change in the delivery of programs and services that incorporates a clear legislative base requires full consideration of the potential options and their implications.  Thus, the Committee recommends that the federal government conduct an objective and independent examination into the best way to provide programs and services crucial for the promotion and maintenance of the health of First Nations and Inuit, with careful thought to the requisite legislation. At this point, the Committee cannot say with certainty which of the following options would be the best approach:

§         Should the current structures be maintained with significant modifications to the way that Health Canada and Indian and Northern Affairs Canada deliver programs and services;

§         Should the responsibilities of Health Canada’s First Nations and Inuit Branch be transferred to Indian and Northern Affairs Canada; or

§         Should specific resources be transferred, with appropriate accountability and evaluation criteria, to either First Nations (and Inuit) authorities or to provincial (and territorial) governments?

The Committee recommends:

71	That the federal government immediately establish an independent study into the federal provision of programs and services relevant to the overall health of First Nations and Inuit; That this study examine various alternatives for the provision of these services; provide clear assessments of these alternatives; and present a comprehensive report with recommendations to Parliament in 2008.

13.2      FEDERAL OFFENDERS

…incarcerating mentally ill people in jails and prisons is cruel, unjust and ineffective.  Prisons do not have adequate or appropriate facilities, resources or medical care to deal with the mentally ill.  Poorly trained staff is unable to handle the difficulties of mental illness.  The mentally ill suffer from illogical thinking, delusions, auditory hallucinations, paranoia and severe mood swings; they do not always comprehend the rules of jails and prisons.  They are highly vulnerable and prone to bizarre behaviour that prison staff must deal with and inmates must tolerate. —Bonita Allen, mother of bipolar son[36]

13.2.1   Federal Responsibility

Correctional Service Canada (CSC) is responsible for administering sentences imposed by the courts that are two years or longer. The Canada Health Act explicitly excludes “a person serving a term of imprisonment in a penitentiary as defined in the Penitentiary Act” from the definition of insured persons covered under provincial health care plans.[37] The federal government is directly responsible for the provision of health care services to inmates in federal institutions.

In 1992, the Corrections and Conditional Release Act (CCRA) replaced the Penitentiary Act. The CCRA defines “mental health care” and requires the provision of essential health care, and “reasonable access to non-essential mental health care that will contribute to the inmate’s rehabilitation and successful reintegration into the community.”[38] A Commissioner’s Directive on Health Services indicates that essential health services include the provision of both acute and long-term mental health care services.[39]  The legislation also requires consideration of “an offender’s state of health and health care needs” when decisions are made relating to placement, transfer, administrative segregation and disciplinary matters as well as in preparing for release and during supervision.

The CSC departmental performance report for the period ending March 2005 states:

On any given day in 2004/05, CSC was responsible for approximately 12,600 offenders in federal custody and approximately 8,200 offenders serving part of their sentence in the community under supervision.[40]

Francoise Bouchard, Director General, Health Services, Correctional Service of Canada, reported that a high percentage of offenders have mental health problems.

Twelve percent suffer from a serious mental disorder which requires immediate intervention. The percentage of offenders with the diagnosis of mental disorder on admission has risen 61% in seven years, and during the same period the number of offenders on prescribed medication has increased by 80%.[41]

Howard Sapers, Correctional Investigator of Canada, mandated by the Corrections and Conditional Release Act to act as an Ombudsman for federal offenders, reiterated the high prevalence rates of mental illness and addiction problems among inmates:

A comparison between admissions to federal institutions in 1967 and then again in March 2004 indicates that there has been a 60% increase in the number of offenders with mental disorders.  It breaks down as follows:  57% for male and 65% for female.  The prevalence increases to nearly 84% if we include substance abuse in those figures.[42]

Almost half of those with substance abuse problems have another concomitant disorder; the rate of suicide is considerably higher among inmates than in the general population. With respect to Foetal Alcohol Spectrum Disorder, Howard Sapers reported that “data obtained from youth facilities across Canada estimate that about 22% of adult offenders would likely be diagnosed with FASD.”[43]

 

13.2.2   Federal Programs and Services

Correctional Service Canada differentiates between ongoing correctional programs for general offenders who are not living with a mental illness, and specific programs for those in need of mental health services for such conditions as anti-social personality behaviour.[44]

While the current capacity to assess and address mental health problems of offenders is limited, CSC is developing a continuum of care encompassing four key areas:[45]

§         mental health assessment of offenders on arrival to establish treatment plans, facility placement, and data collection for future planning;

§         regional treatment centres (five currently exist) with consistent hospital status, accreditation, number and types of staff, admission criteria and security requirements; which identify clientele (such as those with FASD and personality disorders diagnoses) who need specific treatment interventions;

§         regular mental health services in institutions, as well as some institutional intermediate-care mental health units to accommodate and serve those who need more structure and support but not hospitalization;

 

 

§         community mental health strategy to provide continuity of care to offenders when released, including the development and implementation of specialized services and supports to address employment, accommodation, and particular mental health needs.

In November 2005, the Annual Report of the Correctional Investigator called for Correctional Service Canada to commit adequate funding to its Mental Health Strategy:

The Strategy, approved by the CSC in the summer of 2004, has languished. No funding has been committed for the three front-end components of the plan:  comprehensive clinical intake assessment; improvement to the Service’s current Treatment Centres; and intermediate mental health-care units within existing penitentiaries to provide ongoing treatment and assessment during the period of incarceration. Funding secured for the fourth component, community mental health services to support offenders on conditional release, has not yet reached communities.[46]

While the stated policy objective of the Commissioner’s Directive on Health Services is “to ensure that inmates have access to essential medical, dental and mental health services in keeping with generally accepted community practices,” in practice, mental health care at the reception centres, treatment centres and community health services is generally not available.[47]

 

13.2.2.1                        Reception Centres

The Directive’s requirements for standards of care at a reception centre specify that every offender is to receive, within 2 working days of arrival, a nursing assessment that includes a review of acute mental as well as physical health.  The main purpose of the initial mental health assessment, however, is to ascertain the level of security risk posed by the offender rather than to determine the full extent of any mental health concerns.  Standard suicide risk assessment is also done on entry. If potentially suicidal, the individual can be put under observation for a period of time, and be reassessed accordingly. A comprehensive health status nursing assessment is to occur within 14 days.

After admission, offenders reside in the reception centre for the first three months where they receive regular medical care. If the individual requires medication for an identified mental health problem, the nurse can refer them to the institutional physician for further review. If behavioural problems occur, further assessment by a psychologist might be required. Psychiatrists can also meet with offenders in the reception centre.

13.2.2.2            Treatment Centres

If significant mental health problems develop during the time in reception, or if there is a pre-existing diagnosis on entry, offenders may be admitted to one of the five existing regional treatment centres. These centres also deliver programs to sex and violent offenders.

Care in the treatment centre is provided on a 24-hour basis. The individual is stabilized, medication is analysed, and a further assessment is done to determine if transfer to a regular institution is possible. Prior to transfer, the health service file is reviewed to identify all health problems to ensure continuity of care and fitness for program placement at the receiving institution.

While continuity of care is the goal of the assessment, few federal offenders receive the treatment they require because of the lack of specific mental health services at the necessary levels.

 

 

13.2.2.3            Regular Institutions

Once an offender is stabilized and assigned to a regular institution, whether a maximum, medium, or minimum security institution, health care personnel oversee each individual. There is no dedicated funding or specialized service for mental health, however.

 

13.2.2.4            Community Health Services

Offenders on full parole, statutory release and day parole residing in a Community Residential Facility, receive essential health services paid by the applicable provincial health care plan.  Pre-release arrangements include application for provincial health care coverage.

Those who reside in a Community Correctional Centre are provided with essential health services by Correctional Service Canada. CSC is also responsible for “other non-insured health care expenses, for offenders residing in a Community Correctional Centre or Community Residential Centre who are unemployed and have no other source of income and who are otherwise ineligible for all other forms of government/community assistance.”[48]  In addition, it is responsible for “non-insured, mental health treatment costs, as stipulated by the National Parole Board or the Correctional Plan, for all conditionally released offenders.”

 

13.2.3   Assessments of Client Group Needs

13.2.3.1                        Facilities

Witnesses seriously doubted the capacity of Correctional Service Canada to meet the needs of offenders with mental health issues through its five existing treatment centres. Howard Sapers noted that:

CSC currently has bed space in their treatment centres to respond to the needs of less than 6% of the inmate population.  The Service’s own estimates are that the need is for about 12%..  So, current capacity is less than 50% of identified need.[49]

Natalie Neault, Director of Investigations, Office of the Correctional Investigator Canada, observed that several treatment centres were not capable of providing services to maximum security offenders.  She referred to twelve offenders, all in long term segregation with clear symptoms of mental illness, who were repeatedly refused admission at the Shepody Treatment Centre in Dorchester, New Brunswick, because it was not structured for maximum security. In this situation, even when the inmates do receive a visit from a psychologist, the purpose of the visit is not the treatment of mental illness but assessment of the likelihood of suicide:

Moving them out to another region away from their community-which is often all the support they have, and that in itself is very often very limited- is not consistent with the whole purpose of being able to reintegrate these individuals.  They remain in segregation units, seeing a psychologist once a month to make sure that they are not suicidal.[50]

Robert Miller, Chief of Psychiatry at the Vancouver Island Health Authority argued that the facilities and services available to meet the needs of offenders for mental health care should be comparable to the same standards for mental health care as for those provided to the general population:

… those in need of hospital care should be treated in hospital and not in prison.  Further, when in correctional facilities where people are treated, not everybody needs to be in the hospital.  Outpatient mental health care too can be given in prison, but that treatment should be equitable and to the same standard as is available in the local community.[51] 

13.2.3.2            Community Integration

For offenders with an identified mental health diagnosis who are under treatment and need follow-up by a psychiatrist, Correctional Service Canada tries to assure continuity of service after release. This involves finding a psychiatrist, clinic or hospital that will see the offender upon release and engaging community services in the community release plans. Problems can occur if the offender decides not to go to appointments or to the referral clinic; if the services do not accept the referral; or if the services are not available at the time and place of release. When released to residency in a CSC community centre, services are provided until offenders have left the institutional setting entirely.

The reality is that the community-based services and interventions are limited and because of the prevailing stigma, many difficulties arise in obtaining access to services for offenders living with a mental disorder. Michael Bettman, Acting Director General, Offender Programs and Reintegration, Correctional Service of Canada noted that stigma can be a major barrier to integration:

Basically, I think our biggest challenge is, to a large extent, that stigma. These offenders are part of our community and people do not really recognize it. They want to encapsulate them, not only in a prison but even when they are in the community, and they say that their mental health care is the government’s responsibility, it is not our town’s or city’s responsibility, and as a result, we are often left alone trying to service the needs of our offenders.[52]

The failure to integrate or even coordinate services that involve various provincial and federal government agencies leaves some individuals without necessary medication and at risk of relapsing into crime.  Bernard Galarneau, Psychologist, Policy Director, Shepody Healing Centre pointed out that:

Mentally disordered offenders who are receiving psychiatric medication, and who are released from prison, typically have two weeks of medication supply.  How quickly can they be seen by a physician or a psychiatrist to have their prescription renewed?[53]

Jocelyn Greene, Executive Director, Stella Burry Community Services, noted that an innovative community support program based on a home support model for female offenders with complex mental problems offered the prospect of significant savings for both the prison system and the health care system:

An evaluation of the program has shown a dramatic reduction in hospital and incarceration rates. […] the highlight is the decrease in prison days, which was 73%, and the decrease in hospital bed days, which was 39.2%.[54]

13.2.3.3            Human Resources

Ensuring that there are adequate human resources available to provide mental health services is complicated by the multiplicity of tasks trained professionals are asked to undertake. Françoise Bouchard indicated that there are:

… about 250 psychologists working in the Correctional Service Canada. However, psychologists do not provide only mental health services. They also carry out risk assessment for correctional purposes. In fact, most of the activities of the psychologists within CSC are directed to the risk assessment part of the correctional agenda.[55]

Bernard Galarneau, an institutional psychologist at Shepody Healing Centre, explained that, the workload was heavy and focussed more on risk assessment than on mental health:

With a caseload of anywhere from 100 to 200 inmates there is little time for genuine psychotherapy. You mostly work as a firefighter. You extinguish fires, crises as they arise, and you do a lot of risk assessments.[56]

Although inmates in segregation are supposed to be seen once a month by a psychologist, Natalie Neault pointed out that this is not possible:

… there is a waiting list as long as my arm in terms of offenders who want psychological services, and there are very limited resources.  There are two psychologists for a population of nearly 300 inmates.[57]

Christine Davis, President, Canadian Federation of Mental Health Nurses, argued for more training and an expanded role for nurses:

With proper training, nurses within the prison environment could play a more active role in the area of mental health assessments, evidence-based practice and long-term care of the inmate with mental health issues.  Too often, people are incarcerated because of the lack of forensic beds.  If nurses providing physical care were supported to perform mental health assessments and treatments, there would be less pressure on forensic institutions and more chance that persons within the justice system affected by mental illness could be directed toward care sooner.[58]

Witnesses such as Kim Pate, Executive Director, Canadian Association of Elizabeth Fry Societies, recognized that it is not feasible to train all staff in how to perform mental health assessments, but she stressed that it is extremely important to identify offenders with mental health problems and to get them the mental health care they need quickly. She noted that individuals can improve within a short time when they are “seen through the lens of the mental health issues/psychiatric label, not the lens of criminality.”[59] For Howard Sapers, staff must be trained to distinguish “whether you are dealing with a mental health crisis or a security crisis when you see an inmate who is acting out.”[60]

 

13.2.3.4            Specific Offender Groups — Segregated, Female, Aboriginal

Segregated offenders are more likely to be recipients of inappropriate assessment; it is less likely that their mental health needs will be fully recognized. Howard Sapers noted that offenders who are locked up in segregation for up to 23 hours a day in maximum security institutions are often intellectually challenged or “present behavioural problems, learning disabilities and/or symptoms of attention deficit hyperactivity disorder, ADHD, or fetal alcohol spectrum disorder, FASD.” He painted a bleak picture of the prospects for these offenders within the correctional system:

These offenders are unable to complete regular programs, they are preyed upon by other offenders, they end up in segregation, they have limited coping skills and they are usually classified as maximum security.  They do not have the ability or skills required to focus and concentrate in order to complete regular programming.  They are very vulnerable and their segregation is usually for a much longer period of time than others in segregation.  They are usually referred to see the psychiatrist, who typically finds no evidence of a psychiatric disorder, per se, and identifies these individuals as exhibiting a behavioural problem.  These offenders therefore do not meet the criteria that would allow them to benefit from services provided in treatment centres, so they stay in the general institutions.  They have limited coping skills, which may cause them to withdraw, self-injure, set fires, attempt or commit suicide, and in some extreme situations assault others or guards.[61]

Several witnesses called for staff training on how to provide appropriate interventions for offenders with disorders that might result in segregation and also for appropriate training for staff working with those who are segregated. Natalie Neault explained the need to ensure that those with learning disabilities are properly assessed on reception as they “have difficulty following orders from the officers and thus end up being charged, in segregation, and receiving a disciplinary sanction.”[62]  Kim Pate described her experience with segregated female offenders:

... I have been on my knees in front of a segregation cell, talking to someone through a meal slot, trying to convince her to stop smashing her head on the wall, and had staff say that they are told to count to 20, because that is when it is no longer just an attention-getting behaviour, it may be life-threatening. That is not because those staff are ill-intentioned, but they have been trained to believe that up to a certain point, it may just be a manipulative behaviour.[63]

Although women constitute a small group, an estimated 400 in the federal offender population, they have particular mental health concerns. Howard Sapers pointed to a study comparing admissions to federal institutions in 1967 and 2004 that indicated a 65% increase in the number of female offenders with mental disorders, a figure that increases if substance abuse is included.  He also noted:

Correctional Service of Canada recognizes that women in federal institutions have a higher rate of self-mutilation and attempted suicide than do their male counterparts. The CSC research branch found that more than two-thirds of women in maximum security had previously attempted suicide, compared with 21% of maximum security males.  So it is about three times.[64]

Kim Pate argued that women were particularly affected by deinstitutionalization as well as by cuts in social programs, suggesting that for some women prison is seen as an alternative care system:

With the cuts to national standards for health care, social services and education occasioned by the elimination of the Canada Assistance Plan […], we also saw increased numbers of people who fell through all of those service cracks, and ended up in the criminal justice system.  That is because it is really the only system that cannot close its doors and say, “No, we are full, our beds are full,” and it is not difficult to characterize behaviour that is symptomatic often of mental illness as also criminal.[65]

Several witnesses also pointed to the over-representation of Aboriginal peoples in the criminal justice system.  According to Michael Bettman, specific programs have been designed by Aboriginal people and often delivered by Aboriginal people to Aboriginal offenders. He noted that:

… Aboriginal people represent 3% of the population but 17% of our offender population. In the Prairie region, that number is approaching 65%.[66]

Darrell Downton, Co-Chair, Mental Health and Addictions Advisory Committee, Five Hills Regional Health Authority, emphasized the need for prevention. He insisted that significant cost saving could be achieved by reaching Aboriginal children in a positive way before they interact negatively with the law:

A lot of times there may be programs that are in place once they are in the justice system but it is much more important to have that intervention process and plan in place to reach these children before they ever get into the justice system.  It saves $50,000 a year plus many other things, in terms of benefits to society.[67]

13.2.3.5            Addictions

According to Michael Bettman, close to 80% of federal offenders had a substance abuse problem that is connected to reoffending. He emphasized that Canada’s substance abuse program is internationally accredited and is emulated by various European countries:

We have a national substance abuse program in our maximum, medium and minimum security institutions, with maintenance afterwards. These are programs focused on harm reduction strategies for the offender to reduce and prevent further substance abuse. These programs are followed up by maintenance throughout the offender’s sentence, both in the institution and in the community, once they are released.[68]

Howard Sapers recommended that CSC implement various measures to improve the situation for offenders with substance abuse problems:

… a prison-based needle exchange program to deal with the public health risks associated with the growing infection rate of hepatitis-C and HIV.  There are several jurisdictions in Europe that have prison-based needle exchange programs.  They work, in the sense that infection rates are down and the release of healthy inmates has increased.  There have been no reported increases either in the incidence of drug abuse within prisons or the use of syringes in assaults...⁽[69]⁾

Michael Flaxman, a volunteer with the From the Heart Committee in Toronto, called for those offenders with histories of non-violent drug related crimes to be separated and provided with different programs that focus primarily on addictions:

… why not have a low-medium security facility that deals with non-violent drug-related crimes that delivers programs along a specific continuum that are specific to the needs of addicts. These individuals tend to be serving shorter sentences than others, and with accelerated parole review at which they are eligible for day parole at the one-sixth point of their sentence, their focus can be solely on their addictions.[70]

The lack of continuity between institutional and community based programs and services leads to various problems for offenders who are released. According to Ron Fitzpatrick, Executive Director, Turnings, when an offender who has been on methadone is released, an equivalent program to that available within the correctional milieu must be immediately available in the community, yet frequently it is not:

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 gets sentenced to our provincial prison for stealing for drugs, he goes to prison and he may or may not get into a methadone maintenance program.[71]

13.2.4   Committee Commentary

The Committee has one primary goal for federal offenders — and by extension, for provincial correctional populations — it wants the standard of care for mental health within correctional institutions (and in post-release settings) raised to be equivalent to that available to “non-offender members” of the general community. Not meeting this goal is to condemn far too many offenders to a life of going through a revolving door, repeatedly in and out of prison.  If the goal of incarceration is rehabilitation as well as public safety, this goal must be met.  If it is not, the conclusion must be that Correctional Service Canada places a much higher priority on retention than on rehabilitation.

 

 

 

The Committee understands that the needs of incarcerated people suffering from mental illnesses and addiction can only be met through a significant change in the programs, funding and attitude of CSC.  At the outset it requires a thorough mental health screening when an offender accesses a federal penitentiary.  It requires funding to provide the programs and services to meet the mental health needs of the prison population. It requires that CSC ‘walk the talk’ with respect to the priority to be given to rehabilitation versus retention for public safety. The Committee also recognizes that consistent data collection and careful analysis as well as an expanded research capacity related to mental health will be necessary.  In summary, the Committee urges Correctional Service Canada to give a higher priority to mental health and addiction needs - to devote as much attention to these needs as it does to risk assessment and security issues, to ensure that treatment and rehabilitation are smoothly coordinated.

To achieve equivalent standards of care for mental health for federal offenders within institutions and in post-release settings, the Committee recommends:

72

That Correctional Service Canada (CSC) develop and implement standard of care guidelines for mental health to be applied within institutions and in post-release settings that are equivalent to those applied in settings accessed by the general population. That CSC guidelines be based on the collection of statistical information about federal offenders and their mental health disorders and addictions, including prevalence rates for mental health disorders, type of treatment utilized (psychotherapy, medication, etc.), rate of hospitalization, etc. That CSC performance with respect to implementing the guidelines be reviewed annually by an independent external body with mental health expertise such as the Canadian Mental Health Commission (see Chapter 16). That data used for the guidelines be compiled and made available to the public and that the raw data be made available to researchers for independent analysis. That the performance assessment be reported to Parliament annually starting in 2008.

 

With respect to those offenders in need of mental health care and treatment while in regular correctional facilities, the Committee believes all staff should be trained to distinguish between a mental health crisis and a security crisis.  Offenders must receive needed psychotherapy and other appropriate therapies from professionals who are trained specifically to deal with mental health issues.

The Committee urges that a full mental health assessment of offenders by trained professionals occur at the time of their arrival at a reception centre, and that it be completed within a shorter time frame than is currently the case. It supports expanded harm reduction efforts along with better treatment services for addicted offenders. Going beyond the existing methadone program, the Committee is in favour of a full assessment of the advantages and disadvantages of establishing needle exchange services with federal institutions.

The Committee recommends:

73

That Correctional Service Canada conduct a full clinical assessment by an accredited mental health professional of each offender to determine their mental health and/or addiction treatment needs to be completed no later than seven calendar days after their arrival at a reception centre. That Correctional Service Canada undertake training of correctional officers and other staff immediately following their appointment to enable them to distinguish between a mental health crisis and a security crisis. That Correctional Service Canada make psychotherapy available to offenders, when medically necessary, provided by a psychiatrist, psychologist, clinical social worker or other health care professional who is not responsible for the risk assessment of offenders. That Correctional Service Canada increase the capacity of its existing treatment centres with additional beds as well as additional staff. That Correctional Service Canada immediately implement expanded harm reduction measures in all federal correctional institutions.

 

After the release of offenders to the community, the Committee seeks assurance that Correctional Service Canada will take responsibility for ensuring continuity of care, including access to medication that goes beyond the two-week supply issued on release.

The Committee recommends:

74	That Correctional Services Canada establish a case management system that ensures that offenders have access to appropriate mental health treatment upon their release, including a requirement to supply, without cost, enough medication to last until their transition to provincially or territorially provided community-based care.

 

 13.3      CANADIAN FORCES

… about half of the people who do have issues are not coming forward to seek help, so we are still working on that. Is there a stigma? There is less than there used to be, but I am concerned that we are creating a two-tiered category of mental illness. It is perhaps acceptable to have an operational stress injury or PTSD [posttraumatic stress disorder]; it is not acceptable to have ordinary depression in the military. —Brigadier-General Hilary F. Jaeger, Surgeon General, National Defence[72]

13.3.1   Federal Responsibility

Under subsection 91(7) of the Constitution Act, 1867, sole responsibility for all military matters, including military health care, is assigned to the federal government. The 1984 Canada Health Act specifically excludes “a member of the Canadian Forces” from the definition of “insured persons.” They are also excluded from insurance coverage under provincial health care plans and from coverage under the Public Service Health Care Plan.

Through the National Defence Act, the Minister of National Defence is given the authority for the management and direction of the Canadian Forces.[73]  As explained by Brigadier-General Hilary F. Jaeger, Surgeon General, National Defence:

… the federal government has responsibility for, and authority over, all aspects of health care for regular force members from the time they join until the time they retire, and entitled reservists, including mental health care.[74]

According to the departmental Performance Report for the period ending 31 March 2005, the size of the regular force numbered 61,715 in 2004-2005.[75]  The actual strength of the primary reserve force for 2004-2005 was 25,633 personnel.[76]

To determine the burden of mental illness among members of the regular and reserve forces, National Defence and Statistics Canada developed the 2002 Canadian Forces supplement to the Canadian Community Health Survey.  This survey permitted comparisons between the Canadian public at large and members of the Canadian Forces with respect to the prevalence of certain mental illnesses, perceptions of well being and the use of services.[77]

Brigadier-General Jaeger noted that members of the regular force reported an annual incidence of mental health problems of about 15% compared to 13% in the reserves and a lifetime prevalence of mental illness of between 30 and 35%.[78] In comparing the Canadian Forces with the civilian population, she reported the “prevalence of depression in the year preceding the survey was 80% higher than that found in the general population.”[79]

Furthermore, Brigadier-General Jaeger told the Committee that, while posttraumatic stress disorder is often the primary focus for mental illness in the Canadian Forces, it is not among the three most prevalent disorders:

Depression is our leading cause of suffering at 7.6% in the year preceding the survey. Alcohol abuse or dependency hit 4%, and social phobia 3.6%. PTSD was 2.8% and panic disorder 2.2% — all in the regular force, which, generally speaking, has a somewhat worse incidence of mental illness than the reserve forces.[80]

13.3.2   Federal Programs and Services

Brigadier-General Jaeger reported that the Canadian Forces has engaged in a systematic renewal of its approach to mental health care, and has begun to implement a model of mental health care delivery that addresses multiple factors:

We believe in a very holistic look at mental health. We believe that it is that component of health that pertains to cognitive, emotional, organizational and spiritual matters, and is much more than the mere absence of psychiatric illness; so that sets us a fairly high standard.[81]

In November, 2005, the Office of the Surgeon General released a “backgrounder” providing an update on Canadian Forces Mental Health Programs.[82]  The information covered health services delivery, health protection, casualty support, family support, the mental health component of Rx2000 (acronym for the Canadian Forces Health Services Reform restructuring project) and partnerships with Veterans Affairs Canada.

13.3.2.1                        General Mental Health Services

The Department of National Defence provides Canadian Forces members with non-emergency, outpatient care through base clinics, health care centres and support units at military installations across Canada. These units treat non-life threatening illnesses, perform minor surgical procedures, counsel on minor mental health issues, and provide medication as needed.[83]

If the need for services occurs after operational hours, involves a serious medical emergency, or is in a remote geographical location, CF members receive care at civilian hospitals or other health care facilities. Although larger military clinics can provide specialty services for mental health, most specialized mental health services are purchased from the provinces.

The Canadian Forces Health Services Reform (Rx2000) is a comprehensive medical restructuring project that includes a mental health component. Recent funding commitments totalling $98 million over six years are expected to enhance CF mental health care delivery through several initiatives:

§         Increasing the number of mental health providers available to CF members across the country;

§         Developing standardized approaches to the assessment and treatment of key conditions and ensuring all staff is equally comfortable with the preferred therapeutic approaches;

§         Refining deployment-related psychosocial screenings to allow for earlier intervention;

§         Improving educational outreach services;

§         Conducting research to improve practices and to measure outcomes.

13.3.2.2            Operational Trauma Stress Support

Canadian Forces personnel face unique stressors when deployed on combat, conflict resolution, and peacekeeping missions. The duties that are performed as part of the military life can result in the very traumatic experience of multiple casualties, armed attacks, hostage-taking, massacres, deaths of co-workers and civilians, etc.

In 1999, the department opened five Operational Trauma and Stress Support Centres at bases in Halifax, Valcartier, Ottawa, Edmonton, and Esquimault.  They focus on psychological, emotional, spiritual and social problems that arise from military operations.

In 2002, DND and Veterans Affairs Canada jointly launched the Operational Stress Injury Social Support (OSISS) project, a Canada-wide peer-support network to assist members and former members suffering from operational stress injuries (OSI).

Operational stress injury (OSI) is defined as any persistent psychological difficulty resulting from operational duties performed by a Canadian Forces member and includes posttraumatic stress disorder (PTSD).[84] In 2003, preliminary findings from an evaluation of enhanced post-deployment health screening for CF members on operation in Afghanistan/SW Asia revealed “disturbing levels of impaired physical and mental well-being.[85] On the positive side, many individuals with these problems were identified and referred for care.

13.2.2.3            Stress and Addictions

When duties take them away from their families, both the process of separation and of eventual reunion create particular emotional demands and stresses for CF members. In 2000, the Directorate of Medical Policy at National Defence prepared a series of pamphlets on stress, including deployment stress and reunion stress as well as critical incident stress.[86] 

Departmental policies on alcohol and drugs provide guidance on effective interventions.[87] Supervisors are encouraged to recognize early warning signs of alcohol, drug and gambling addiction and to intervene early to prevent later health and safety problems. Initial steps can include educational sessions and the involvement of medical personnel, while addiction counselling and treatment programs can be prescribed by an attending physician.

The department also offers programs to promote mental health and prevent negative behaviours linked to stress, such as addictions, family violence and suicide.  The interdisciplinary approach of these programs involves psychiatrists, clinical psychologists, mental health nurses, social workers, addiction counsellors and chaplains, all of whom share responsibility with primary care providers.

13.2.2.4            Medical Releases

Brigadier-General Jaeger estimated that about 42% of all medically-related time off work among CF personnel was for mental health issues, and that about 23% of CF members who are released for medical reasons have mental illness as their primary diagnosis.[88] She noted that the department is able to adapt work situations to a larger degree than most employers and that this helps to reduce the need to release members from military service:

We can direct part-time work, we can direct work of less stress, and we can direct work of less physical stress.[89]

Nonetheless, Colonel D. R. Boddam, Canadian Forces practice leader for psychiatry and mental health, National Defence, told the Committee that, while a majority of individuals diagnosed with mental illness return to work after treatment, about 300 people yearly are released for reasons related to mental illness.  He noted that National Defence has recently established a project to work with Veterans Affairs Canada:

For those people who have sustained a mental injury as a result of their employment, we wish to work together to be able to provide that continuity in a seamless way, from where they start to get care to when they become civilians.[90]

Brigadier-General Jaeger emphasized that medical releases from the military and employment restrictions are a serious issue for the department as well as for the affected members:

About 2300 of our members every year undergo a review of their suitability to continue serving in the Canadian Forces. About 23% of these cases every year are due to mental illness and that perhaps is not surprising. They are disproportionately likely to end up being released from the Canadian Forces.[91]

13.3.3   assessments of Client Group Needs

13.3.3.1      General Mental Health Care

Brigadier-General Jaeger acknowledged the challenge of providing team-based mental health care to meet the needs of CF members. She pointed out that the department will have to double its personnel and that finding trained people to fill these positions will be difficult, since the department will “have to recruit professionals from the civilian sector, where we know there is already an overall shortage of care providers.”[92]

Colonel Boddam noted that the dependence upon the civilian health care system to treat more severely ill members is also a concern for CF members with serious mental illness:

Psychiatric beds exist at a premium. We do not run our own, and we cannot always readily access such beds. This is a particular concern for us as the highly mobile nature of military careers means that support systems such as extended family and friends of long standing are less likely to be able to provide help when a member is suffering.[93]

A number of joint efforts of National Defence and Veterans Affairs Canada are intended for still-serving Canadian Forces members as well as those in transition to civilian life. Brigadier-General Jaegar expressed optimism about the current partnership and the goal of consistency in mental health services:

The vision is to have VAC mental health resources available to members of the CF where this makes sense, and CF mental health resources available to VAC where this makes sense. It is desired by us that blended staffing eventually take place.[94]

13.3.3.2      Mental Health Outcomes

In response to concerns that revealing a mental illness might lead to the termination of a person’s military career, rather than having them return to work after treatment, Brigadier General Jaeger said:

The vast majority of people who present with a mental illness receive appropriate treatment and go back to work. They are invisible to everyone else. We would like to have a spokesperson that is willing to stand up and say, “I did that.” We have General Dallaire, who has been an eloquent spokesperson for posttraumatic stress disorder and operational stress injury, who did end up having to take his retirement from the Canadian Forces. However, we would like to have a public example who is willing to be a spokesperson from the other side. With confidentiality concerns, we cannot force people to do that. We can only ask for volunteers.[95]

The access to, and adequacy of, pensions for individuals who are medically released was also raised as an issue. Brigadier General Jaeger voiced particular concern about stringent eligibility criteria for the Service Income Security Insurance Plan (SISIP).[96]  This group insurance plan provides long term disability insurance to Canadian Forces members who become injured or disabled and are medically released:

On the question of pensionability, if you are medically released from the Canadian Forces at any point past 10 years of service, you are entitled to an immediate annuity based on the number of years of service, 2% per year of service. If you are released after 16 years of service, it is a 32% pension indexed to the rate of inflation. You are entitled to the Service Income Security Insurance Plan, SISIP, which augments that to 75% of your salary but only if you meet their criterion, which is all-occupation disability. It is a stringent disability to meet.

If you make the case with Veterans Affairs that your disability is attributable to military service or has been exacerbated by military service, you will receive a favourable response from their administrators and would be eligible for whatever percent disability you end up being awarded.[97]

13.3.3.3      Mental Health Redress

In recent years, two avenues have opened for Canadian Forces members with grievances related to mental health and other issues emanating from their work. In 1998, the Minister established an Ombudsman position within the department to investigate complaints and to serve as a neutral third party on matters related to members and employees of National Defence and the Canadian Forces.  In 2000, the Canadian Forces Grievance Board was created as a separate, independent civilian administrative tribunal with the power to hear grievances related to various aspects of military life, including entitlement to medical care.

As recently as 2004, the Ombudsman conducted a follow-up investigation on operational stress.[98]  He praised the high quality of care provided at Operational Stress Injury Support Clinics; the increased level of funding committed to the treatment of Operational Stress Injuries; the successes of the Operational Stress Injury Social Support group that provided peer support to over 1,000 CF members. The Ombudsman’s report called for further work, however, including:

… training and education to change attitudes about operational stress injuries; communications between the operational chain of command and those who provide treatment to CF members suffering from Operational Stress Injuries; and coordination of OSI training, education and initiatives across the CF.[99]

The Ombudsman Office of National Defence received multiple complaints about release (218), medical (97) and posttraumatic stress disorder (35) in 2004-2005. The Canadian Forces Grievance Board does not provide clear identification of cases related to mental health issues.[100]

13.3.4   Committee Commentary

The Committee is pleased that the Department of National Defence offers such a wide array of services to Canadian Forces members who may experience mental health problems.  The provision of services for family support as well as medical treatment and casualty support is commendable.  The Committee is especially supportive of increased efforts to reduce the stress incurred for CF members and their families due to factors such as separation for operational reasons and frequent relocations.

The Committee is aware that many of these mental health programs and services are relatively new and are dispersed across many military establishments. These initiatives should be adequately evaluated and the results reported to Parliament.

The Committee recommends:

75	That National Defence develop an annual inventory of its programs and services for mental health; That the inventory include a clear description of each program or service with number of clients served, the amount of funding allocated and spent, and any evaluation of outcomes achieved; That the inventory be reported to Parliament annually starting in 2008.

The Committee understands that many serving members of the Canadian Forces and Canadian Forces veterans as well are reluctant to talk about their traumatic experiences.  The Committee believes that the department has a responsibility to provide multiple and frequent opportunities for military members still-serving to address the implications of operational stress injuries. Although social support for Canadian Forces members and their families has improved and their access to necessary programs and services has increased, the Committee believes that more work can be done by the department to enhance the peer support network and, in the longer term, to implement cultural change to ensure early identification and follow-up services to address the needs of both members and their families with operational stress injuries.  This includes, not only a focus on posttraumatic stress disorder, but on anxiety disorders and depression as well as other symptoms of stress such as alcohol or drug abuse and family dysfunction.

The Committee recommends:

 

 

 

76

That National Defence require that all medical personnel receive mandatory training with respect to operational stress injury and that this training include: ·         proper recording of military and trauma histories; ·         methods to recognize/detect symptoms of operational stress injury; ·         understanding of multiple treatment modalities; and ·         appropriate long-term follow-up processes; That National Defence make the information available to National Defence and civilian medical personnel through publications, seminars, or other public forums; That National Defence explore measures to encourage more widespread use of peer counselling and increased engagement of family and community.

 

The Committee is also concerned about the Reservists who work with National Defence but have a different relationship to the department than do regular Canadian Forces members.  When they return from mobilization missions and exercises, they may not have access to the support offered on military bases. The Committee believes that the department has a responsibility to ensure that follow-up services are readily available to Reservists as well. Sufficient time must be allowed for an orderly transition from regular to reserve units, ensuring that Reservists are given adequate medical assessments, with proper evaluation of the potential for operational stress injury. For the department, this may require that the employment commitment for Reservists be extended while they are being properly screened.

The Committee recommends:

77	That National Defence evaluate and report to Parliament on the programs and services currently available to Reservists for mental health problems resulting from their duties while mobilized, including services for post-traumatic stress disorder and addictions.

13.4      VETERANS

… good mental health is important for re-establishment, good re-establishment programming is important for mental health. — Brian Ferguson, Assistant Deputy Minister, Veteran Services Branch, Veterans Affairs Canada[101]

13.4.1   Federal Responsibility

Unlike serving members of the Canadian Forces, veterans are considered to be “insured persons” under the Canada Health Act with respect to mental (and other) health services. For most veterans, Veterans Affairs Canada (VAC) does not provide health insurance to cover services above and beyond those offered by the provinces or territories, although income-qualified veterans may get some additional assistance. Veterans with disability pensions do receive financial coverage for treatment of their pensioned condition.

The principal legislative authority for veterans and their health care is found in the Department of Veterans Affairs Act and the Pension Act and, since 2005, in theCanadian Forces Members and Veterans Re-establishment and Compensations Act.[102]  Under the Department of Veterans Affairs Act, the Veteran’s Health Care Regulations define health as a state of physical, mental and social well-being. This Act outlines eligibility for multiple benefits including medical care, home adaptations, travel costs for examinations or treatment and other community health care services.[103]

The Pension Act defines disability as “the loss or lessening of the power to will and to do any normal mental or physical act.” The Canadian Forces Members and Veterans Re-establishment and Compensation Act authorizes the Minister to provide job placement assistance, rehabilitation services, vocational assistance and financial benefits, disability awards, and health benefits for Canadian Forces members and veterans.

Brian Ferguson, Assistant Deputy Minister, Veteran Services Branch, Veterans Affairs Canada, described the departmental process that is followed for mental health services:

Under the Veterans Health Care Regulations, if a need for health care is related to a pension condition, Veterans Affairs Canada will pay for those treatment benefits directly. For eligible veterans, we will pay for non-pension conditions if the service is not covered under provincial health care plans.

With the exception of those services provided at our own Ste. Anne’s Hospital, all health services provided to our clients are delivered either by provincial jurisdictions, non-governmental organizations or private registered providers. Through our network of regional and district offices, we have an ongoing relationship with provincial governments.[104]

As of March 2005, VAC was providing benefits and services to approximately 219,000 clients.[105]  These include military personnel and others:

§         members of the Canadian Forces and Merchant Navy veterans who served in the First World War, the Second World War or the Korean War;

§         certain civilians who are entitled to benefits because of their wartime service;

§         former members of the Canadian Forces (including those who served in Special Duty Areas) and the Royal Canadian Mounted Police;

§         survivors and dependents of military and civilian personnel.

Speaking specifically about disability pensions and health care, Brian Ferguson reported the number of clients served by the department to be slightly fewer, approximately 209,000 people. He also pointed out the significant increase in Canadian Forces clients among those served by VAC:

… 18% of [our clients] are Canadian Forces members and veterans. Their numbers have increased 58% in the last three years and we anticipate having more than 58,000 Canadian Forces clients by the year 2013.[106]

Mr. Ferguson explained that a survey of Canadian Forces members and ex-Canadian Forces personnel showed that 15% of responders reported symptoms of posttraumatic stress disorder but had never applied for a pension. Despite the potential under-application, he reported that:

We have more than 8,000 clients pensioned for mental health-related conditions. More than half of these clients suffer from PTSD alone, and the incidence among our younger CF members is increasing each year.

 

13.4.2   Federal Programs and Services

13.4.2.1      Disability Pension Program

Pension entitlement depends on the nature of the claimant’s service. For war, peacekeeping service and other special duty service, the relevant injury or disease must have been incurred during, or be attributable to, the claimant’s service. For peacetime military and RCMP service, the claimed injury or disease must have arisen out of, or be directly connected with,the service. This leads to two different types of pension coverage as described by the Veterans Review and Appeal Board:

The first, for war, peacekeeping and special duty service, is intended to provide 24 hour a day coverage and consequently is commonly referred to as the insurance principle. The second, for peacetime military and RCMP service, is known as the compensation principle. The coverage is meant to be similar to that provided under workers’ compensation programs.[107]

Veterans Affairs Canada administers the Pension Act and through the Disability Pension Program provides disability pensions to those suffering from disabilities related to peace or wartime military service and to eligible RCMP members. The disability pension is based on the severity of the disability, as verified by a medical examination, and is assessed in accordance with an established Table of Disabilities.[108]

This disability pension program has been the gateway to the health care benefits and other programs offered by Veterans Affairs Canada, benefits and programs that were designed to meet the needs of traditional war service veterans rather than the present-day Canadian Forces members and veterans.

The New Veterans Charter — the Canadian Forces Members and Veterans Re-establishment and Compensations Act — has changed the process, however. Draft regulations published in December 2005 are more responsive to the needs of Canadian Forces members who are released due to disability.[109]  The regulations are targeted to fill gaps in programs and services for eligible members released for medical reasons and for members who voluntarily leave the Canadian Forces and then develop later a service-related disability.

The introduction to the draft regulations states:

[T]he New Veterans Charter will bolster the current benefit packages provided by the Service Income Security Insurance Plan (SISIP) and VAC. Most CF members who voluntarily release and later develop a service-related disability could, up to now, only qualify for a VAC pension and related health care. SISIP will continue to provide eligible medically releasing CF members with income replacement and vocational rehabilitation benefits. Under the New Veterans Charter, VAC will meet the needs of the “gap” group and will provide top-up benefits for the SISIP group, such as additional vocational rehabilitation or earnings loss benefits, medical or psychosocial rehabilitation, and Canadian Forces income support.[110]

13.4.2.2            Health Benefits Program

At present, clients eligible for health care benefits or services are provided with a VAC Health Care Identification card that gives them access to providers across the country. Veterans Affairs Canada delivers a wide range of services and benefits covered under the mandates of the Treatment and Benefits, Long-term Care, and Veterans Independence Programs. These include:

§         Community-based mental health care (including a comprehensive range of health care benefits not provided provincially) for war and Canadian Forces veterans who meet service and income requirements or who have been awarded disability pensions resulting from military service;

§         Institutional mental health care (largely psycho-geriatric, including Alzheimer care) to eligible veterans in the departmental hospital at Ste-Anne-de-Bellevue, Quebec, in contract hospital beds located in provincial health care institutions and in hospitals of choice;

§         General mental health care as well as care for posttraumatic stress disorder and operational stress, through services offered jointly with the Department of National Defence.

The Canadian Forces Members and Veterans Re-establishment and Compensation Act authorized the Minister to “establish or enter into a contract to acquire a group health insurance program comparable to the Public Service Health Care Plan established by Treasury Board.”[111]  It is expected that the proposed Health Benefits Program “will fill gaps in post-release health coverage by ensuring that medically released CF Veterans (with some exceptions for reservists), CF Veterans with a ‘rehabilitation need’ and certain survivors who are currently ineligible for health coverage have access to group family health insurance.”[112]

13.4.2.3            Joint Efforts on Mental Health

Some programs and services resulting from the joint VAC/DND mental health strategy announced in 2002 include:

§         VAC assistance line in partnership with DND and Health Canada to provide telephone crisis counselling services for veterans and their families;

§         joint DND/Veterans Affairs centre in Ottawa for the care of injured and released members veterans and families with assistance expedited through a 1‑800 number;

§         cross-Canada case worker system of VAC and DND for early identification of the transition needs of clients, including their needs for disability assistance;

§         network of operational stress injury clinics across the country with St. Anne’s Centre taking the clinical lead and others in London, Winnipeg, and Quebec City.[113]

The mental health strategy also includes continuing education to keep staff aware of changes to services and programs designed to meet changing client needs and ongoing research in the area of operational stress injuries in partnership with DND and others.  The draft regulations of the Canadian Forces Members and Veterans Re-establishment and Compensation Actprovide information on mental health care delivery, using multiple providers to:

… involve the use of multiple service providers from different agencies, organizations and private providers of service, with the delivery being coordinated under the direction of a case manager within VAC. For example, for a mental health problem, the medical rehabilitation phase could involve the family physician, a hospital-based psychiatrist, a community mental health team or a VAC-supported private sector therapist. A psychosocial phase may involve an occupational therapist or pain management clinic, and a vocational phase may involve specialized assessment services and training providers.[114]

On posttraumatic stress disorder and other operational stress injuries, there is ongoing work within the military structure and the civilian medical community.  In particular, Veterans Affairs Canada supports the Operational Stress Injury Social Peer Support Program established by DND:

The peer support program is made up of Canadian forces members and veterans across the country who have experienced an operational stress injury themselves, and who want to help others heal and recover. DND has established 13 peer support coordinators located across the country and to date they have helped more than 1400 clients. This network uses a large number of volunteers and we have a brochure we will circulate to the members that shows some of the work volunteers do in helping with these peer support coordinators. —Brian Ferguson[115]

13.4.3   Assessments of Client Group Needs

Veterans with mental health concerns constitute a diverse group needing a range of re-establishment programs:  transition assistance; job-finding help; rehabilitation; retraining; income support; health care; family assistance; and other elements that encourage independence.

 

 

 

13.4.3.1      Disability Pensions

According to Brian Ferguson, Veterans Affairs Canada aims to provide the same basic approach for aging veterans and for younger veterans with mental health problems:

If they have a pension condition and they require treatment, we pay for it; and we keep track of the treatments that are made on their behalf.[116]

However, former or current peacetime members of the Canadian Forces, who, together with survivors and the dependents of military personnel, now form a larger group of disability pension recipients than war service veterans, reported dissatisfaction with the process for accessing pensions.  An audit of the Disability Pension Program conducted in 2005 reported that CF clients felt that there was:

… insufficient understanding of the DND culture, including the command structure, and the physical, mental, and emotional stress of military training and deployment to hazardous overseas operating environments.[117]

At present, the Veterans Review and Appeal Board provides two levels of appeal on disability pension applications as well as a final level of appeal on allowance decisions. In the period between April 2004 and March 2005, the Board heard 6789 claims.[118]  Clients and other observers noted difficulties in assessing mental disability claims when criteria and standards are not clear and objective. They noted that reporting and record-keeping during periods of conflict may be a low priority, especially for non-life threatening incidents that could have an effect on mental health.

In June 2005, the Esprit de Corps magazine issued a press release calling for a Veterans Affairs Canada Ombudsman, similar to the one for the CF, noting that:

The irony is that healthy, (for the most part) employable soldiers in DND have an independent ombudsman while disabled and often unemployable veterans do not.

The press release went on to point out the complexities of current disabilities and the resulting low pension awards:

Minimal awards of 20% or $400/month have been quite common for disabilities that have rendered a veteran unemployable. As a consequence, psychologically and/or physically disabled veterans are forced to enter an indescribably demoralizing review and appeal process, frequently requiring three to five years or more before receiving adequate compensation.[119]

 

13.4.3.2      Case Management

The case management approach implemented by Veterans Affairs Canada permits the department to track the development of each client’s illness. The goal is to simplify access to existing programs and provide adequate case management services, especially for those who are medically released and often need the most help getting re-established in civilian life.  The hope is that case managers will be able to assist people in navigating the maze of providers and benefits that might include Veterans Affairs, National Defence, the Service Income Security Insurance Plan, the Department of Social Development, the Canada Pension Plan disability pension program, the applicable provincial/territorial health care system, and local social assistance avenues.

The list of potential service providers is lengthy, the inter-relationship between different programs is complex, and the choices to be made are not always clear. Sometimes, winning benefits from one program results in benefits being clawed back from another. This is administratively cumbersome and gets in the way of best service.[120]

Mr. Ferguson noted how a case manager could simplify the situation facing a client dealing with the loss of income and career.  Case management services could help clients and their families cope with psychological disability and work their way through a complex landscape of programs:

A forty-year-old male veteran was pensioned 80% for PTSD related to his service in his special duty area. He is suicidal at times and his wife and children have left home in fear for their own safety. After being discharged from his local hospital, he was faced with a lack of medical resources to help him in his time of need, a familiar refrain. He called Veterans Affairs Canada and spoke to an area counsellor who worked with his local district office staff to explore options. We had to make arrangements with our partners in the United States to get him treatment, but then a local opportunity presented itself. Through our partnerships with DND and local medical practitioners, we were able to get him treatment at the local DND Operational, Trauma and Stress Support Centre, OTSSC. This client will be assisted through case management services at the local Veterans Affairs Canada district office to maintain contact with his clinical service providers.[121]

 

13.4.3.3      Service Provision

Veterans Affairs Canada, like other federal departments with clients experiencing mental health problems, has difficulties accessing mental health services through provincial providers. Mr. Ferguson explained that it is trying to adopt an approach of early intervention to keep mental health situations from growing more serious:

Currently VAC, like DND, must compete for scarce acute psychiatric services along with other Canadian citizens. For this reason, we are putting our emphasis on early detection and intervention to detect problems early and prevent acute crisis situations from escalating. Our district office health professionals can intervene on behalf of clients to assist them in receiving the appropriate acute care and monitor their progress after the acute phase.[122]

Telehealth is one option that shows promise for the department and its clients. Veterans Affairs Canada, in cooperation with the Memorial University School of Medicine in Newfoundland, is using video-conferencing technology to link clients with professional psychological counselling experts.[123]

Dr. Ted Callanan, President, Psychiatric Association of Newfoundland and Labrador, commented on the Veterans’ Affairs Canada peer support program and treatment program for those suffering from posttraumatic stress disorders or other conditions related to military service.  He noted that, while some choose to come to St. John’s where most of the services are located, telehealth has provided options for those living in other areas of the province:

… they can also access their counsellors via telehealth technology now and that is actually proving to be fairly popular.  They have worked out some ways around identifying why the different individuals would be coming to the telehealth centre in the small towns and that is moving now into Nova Scotia and going across the country, not as a replacement, but as another means of veterans accessing service.

13.4.4   Committee Commentary

The Committee is supportive of efforts to overhaul the way that mental health of veterans is assessed and injured veterans are compensated. It commends the increased efforts directed at partnering and the greater coordination of activities between VAC and DND. The establishment of a strong network between the two departments will encourage improvements of services for CF members as well as other clients.

As with other federal client groups, the Committee is concerned that Parliament may not be aware of the full extent of efforts to assist transition to civilian life and to give disabled veterans a high quality of life.

The Committee therefore recommends:

78	That Veterans Affairs Canada in conjunction with National Defence prepare an annual inventory of programs and services for mental health, including the number of clients served, the funding allocated and spent, and the outcomes achieved. That the report be tabled in Parliament annually starting in 2008.

 

The Committee is concerned that there is no forum for veterans similar to the Canadian Forces Ombudsman.  It sees merit in having an independent and objective body to review and make recommendations on concerns of veterans.

The Committee recommends:

 

79

That the Government of Canada establish an entity for veterans, similar to the Correctional Investigator, the Canadian Forces Ombudsman, or the RCMP External Review Committee; That this entity be authorized to investigate individual complaints as well as systemic areas of concern related to federal provision of programs and services that have an impact on the mental wellbeing of veterans; That this entity provide an annual report to Parliament.

13.5      ROYAL CANADIAN MOUNTED POLICE

… traditional policing practices do not work in the way they are meant to work in dealing with people who are in a mental health crisis.
—Shirley Heafey, Chair of the RCMP Public Complaints’ Commission[124]

13.5.1   Federal Responsibility

Under the Canada Health Act, “a member of the Royal Canadian Mounted Police who is appointed to a rank” is excluded from the definition of “insured persons.” The Royal Canadian Mounted Police is organized under the authority of the Royal Canadian Mounted Police Act,[125] whichsets out the qualifications required for being a member of the RCMP. The Royal Canadian Mounted Police Regulations outline the basic conditions for regular members or special constable members to have access to health services, subject to approval by the Commissioner.[126]  As of 31 March 2005, the Force had 22,557 employees, including regular and civilian members and public service employees.[127]

The Royal Canadian Mounted Police Regulations contain several specific provisions that deal with mental health issues as a disability, although they do not distinguish between an incapacity that is work-related and one that is not. With respect to administrative discharges, “a member, other than an officer, may be discharged from the Force, and it may be recommended that an officer be discharged from the Force, on any of the following grounds, namely, (a) physical or mental disability after consideration by a medical board.”

Royal Canadian Mounted Police members who have become disabled as the result of Special Duty Service,[128] and who have consequently been released or discharged from the RCMP are entitled to be appointed ahead of others to positions in the public service for which they are qualified.[129]  Also, after discharge or compulsory retirement, the Royal Canadian Mounted Police Superannuation Act specifies that a recipient of supplementary benefits can be

a person who, not having reached sixty years of age, is in receipt of a pension as a result of having been compulsorily retired from the Force by reason of any mental or physical condition rendering the person disabled,[130]

In 2003 Veterans Affairs Canada undertook responsibility for administering the RCMP disability pension and health care benefits for RCMP members who are pensioned for service-related injuries and illnesses. It assumed responsibility for the direct payment of disability pensions for approximately 3,800 RCMP pensioners as well as the provision of health care benefits for approximately 800 retired and civilian pensioners.[131] By early 2005, it was estimated that VAC delivered benefits and services to more than
5,000 RCMP clients, including 300 pensionable survivors of RCMP members.[132]

13.5.2   Federal Programs and Services

The RCMP External Review Committee was established in 1988 to provide impartial reviews of certain grievances as well as appeals relating to formal disciplinary measures.  Upon completing its review of a case, the External Review Committee presents recommendations to the Commissioner of the RCMP, who is the final decision-maker, but who must provide reasons if he disagrees with the Committee in any given case.

Various reports of the External Review Committee yielded information about the mental health, mental illness and addiction concerns of RCMP members, including increased sick time, impaired work performance, and alcohol dependency as outcomes associated with increased stressors for RCMP members.[133]  In some cases of dismissal for conduct deemed disgraceful that were reviewed by the RCMP External Review Committee, stress-related incidents led to recommendations ranging from orders to voluntarily resign or be dismissed to medical discharge on grounds of mental disability.

Several witnesses spoke to the Committee about the lack of sensitivity exhibited by RCMP officers dealing with mentally ill individuals in the community. They also suggested that lack of training in dealing with public manifestations of mental illness is also endemic to the internal workings of the RCMP.In this regard, Shirley Heafey, Chair of the RCMP Public Complaints’ Commission told the Committee:

In 2003, during the course of a judicial inquiry into the RCMP shooting death of a person in a mental health crisis, the judge stated that RCMP training to deal with mentally ill people varied from non-existent to less than adequate, and that all three RCMP incident officers welcomed the idea of more and better training in this area.[134]

Doris Ray told the Committee of her experience as a family member:

The officer confided that he had learned about the symptoms of schizophrenia through his brother-in-law who suffered from the disease.  His training in the RCMP, most often the first line of defence for families in crisis situations, especially in small towns, included very little training in recognizing and dealing with symptoms of psychosis.  I recently inquired of a young officer if he had had any more training in that line and he said they now receive even less training than in years past.[135]

In general, the RCMP provides comprehensive health services to ensure that regular members are emotionally and medically fit to perform their duties. Should a serving member of the RCMP use services provided by a given province, they present their client registration number which ensures that authorization is obtained from an RCMP Health Services Officer; the provincial service then bills the RCMP. Each RCMP division usually has a physician as regional health services officer, together with a regional psychologist and a variable number of occupational health nurses.

A study in 1992 identified three general sources of occupationally-linked police stress that can lead to such common mental health symptoms as depression, burnout and suicide:[136]

 

§         external stressors linked to factors such as court appearances, cross-examinations, lengthy judicial decisions, lack of encouragement from the public, relations with minority groups and the general mass-media image of police;

§         internal stressors related to police organization and structure such as lack of participation in work organization, communication problems, insufficient support from superiors, and excessive bureaucracy, training, performance evaluation, salary, promotion, inadequate human and material resources; and

§         task-related stressors such as work overload alternating with periods of inactivity, role conflicts and ambiguities, perception of danger, task complexity, lack of autonomy, ambiguous feelings and the responsibility of facing misery, pain and death.

This study revealed a relationship between occupational stressors and reductions in productivity, increases in reaction time and judgement errors, work dissatisfaction, the desire to quit, absenteeism and accidents.[137]  Another report on Employee Assistance Programs emphasized the difficulty in implementing assistance programs in the policing sector where police departments operate as a “closed society.” Also, police officers may be hampered by a belief that admitting to problems and seeking help suggests weakness.[138]

Services available to RCMP officers through the RCMP Health Services are variable. Health services officers generally act as case managers — providing assessment, referral and follow-up for such things as treatment and rehabilitation programs for substance abuse and related personal problems.[139] Dorothy Cotton, Co-chair/Psychologist, Canadian National Committee for Police/Mental Health Liaison, pointed out that when the RCMP recruit psychologists, they try to hire them at “$20- to $30,000 less than what the hospital down the street is paying.” She insisted that “you cannot hire people for that kind of money. It also speaks to what they think of the profession.”[140]

 

13.5.3   Assessments of Client Group Needs

The RCMP recently announced its recognition as one of the country’s top employers in the 2006 edition of Canada’s Top 100 Employers.[141] Its own surveys of performance in 2003-2004, however, identified problems with morale, work environment, communications, tools and training, workload, responsibility and support systems.  The survey reported “overall employee satisfaction:  61%; although employees are proud of our organization and the work they do, there were numerous issues regarding workload, fairness and career development.”[142]

In 2002, Norman Sabourin, Executive Director and Senior Counsel for the External Review Committee, wrote an article titled “Medical Discharge and the Duty to accommodate in the RCMP.” In his conclusion, he argued that “the Force will have to find a suitable position for a member with an impairment who wishes to continue working, or else demonstrate that it would face undue hardship by doing so.” He emphasized that “this will require significant changes to existing policies.”[143]

For RCMP members, there is a disparity between the disability services and benefits available to them and those available to other clients served by Veterans Affairs Canada.  For example, the RCMP do not have access to the Veterans Independence Program services (home care, home adaptations, transportation, ambulatory health care and nursing home care). Veterans Affairs Canada indicated that it is prepared to consider ways of addressing some of the gaps in services:

To date, research undertaken in collaboration with the RCMP reveals that, while not necessarily sharing the same views, attitudes and mind-set as CF clients, the RCMP understand and appear to relate well to CF issues and concerns. This is, no doubt, linked to both groups having worked in/been exposed to similar situations and environments, including peacekeeping/SDA deployments. In order to adequately address gaps in services/benefits, training will be required for VAC staff to increase their general understanding of the RCMP and the ‘police’ culture.[144]

However, the RCMP was not included in the New Veterans Charter and thus was excluded from the proposals for change to Veterans Affairs Canada programs and services aimed at CF clients. Instead, the RCMP indicated that it would do its own assessment of needs:

The RCMP has opted to conduct an assessment of its still-serving and retired members’ needs for modernized services and programs. This assessment is necessary as there are considerable differences in the profiles, roles, career paths and qualifications of today’s RCMP and CF members. Consequently, the needs of RCMP members may be quite different than those of CF members.[145]

Several RCMP veterans’ associations reported on correspondence from the RCMP Commissioner stating that a Task Force on the Modernization of Disability Programs and Services had been established to oversee a comprehensive needs analysis. The assessment was to look at both the service by RCMP under the Pension Act and the access to long term care and in-home independence benefits (Veterans Independence Program) that go beyond those available in the Attendance Allowance.[146] Claiming other priorities, the RCMP had already delayed this needs analysis from previous years and, although expected to be reported in the fall of 2005, it was not available to the public by early 2006.

13.5.4   Committee Commentary

The Committee is aware of the efforts by the RCMP to address the needs of its officers who pursue disability claims, some of them related to mental health issues. Nevertheless, more readily available public information on this federal client group is needed.

 

The Committee wants to know if the RCMP provides counselling to employees after a traumatic situation or to them and their families during and after a stressful relocation. It is also interested in ways to address the particular transition needs of RCMP members who are being discharged and determine what adjustments may be required to legislation, health care policies and programs, and service delivery mechanisms to ensure their appropriate access to services.

 

In addition, the Committee is unaware of the training provided to RCMP officers to increase their understanding of mental illness.  Witnesses suggest that it is limited or non-existent.  Incorporating training about mental health and addictions can enhance not only officers’ ability to deal with the public but also their ability to understand facets of mental illness among their colleagues within the Force itself.

The Committee recommends:

80

That the federal government fund a mental health and addictions training program aimed at RCMP members. That the RCMP make public as soon as possible in 2006 the results of the ongoing analysis by the RCMP task force looking at RCMP disability and the need for programs and services. That the RCMP establish the use of peer counselling for RCMP members following the DND/VAC model for post-traumatic stress. That the RCMP include these initiatives and other programs and services in an annual inventory on programs and services for RCMP officers. That the inventory be reported to Parliament annually starting in 2008.

 

The Committee is pleased that the RCMP has established an External Review Committee to undertake investigations into specific issues. This body appears to be well-placed to conduct more analysis of the mental health needs of RCMP members.

The Committee recommends:

81	That the RCMP External Review Committee do an analysis of the mental health needs of RCMP members and RCMP veterans and report to Parliament by 2007.

13.6      IMMIGRANTS AND REFUGEES

The mental health system recognizes the need to address posttraumatic syndrome, but fails to recognize that, until racism is addressed, which is the trauma refugees and new immigrants experience on a daily basis, such an approach will be ineffective. —Martha Ocampo, Co-Director, Across Boundaries, Ethnoracial Mental Health Centre, Toronto[147]

13.6.1   Federal Responsibility

Citizenship and Immigration Canada (CIC) is responsible for the admission into Canada of immigrants, foreign students, visitors, temporary workers and refugees.  As described by Dr. Sylvie Martin, Acting Director, Immigration Health Program Elaboration, Medical Services Branch, Citizenship and Immigration Canada.

Under the Immigration and Refugee Protection Act and its regulations, the department admits temporary residents and immigrants who contribute to the economic and social growth of Canada, it provides resettlement, protection and a safe haven to refugees, it assists newcomers to adapt to Canadian society and eventually obtain citizenship, and it manages access to Canada in order to protect the security and health of Canadians as well as the integrity of Canadian laws.[148]

Under the Immigration and Refugee Protection Act, all applicants for permanent residence and some for temporary residence (e.g. visitors, students and workers) undergo a physical and mental examination.[149] Based on this examination, applicants may be refused entry into Canada if they have a physical or mental health condition that is considered likely to be a danger to public health or safety, or that could be very demanding on health or social services.  Information from the Department is not specific about possible responses to applicants who are living with mental disorders.

The term, “excessive demand,” refers to “the burden placed on Canada’s health or social services due to ongoing hospitalization or medical, social or institutional care for physical or mental illnesses, or special education or training.”[150] To determine if an applicant will likely create such excessive demand, a departmentally-designated Medical Officer will consider the diagnosis, prognosis, and the health and/or social service needs of the individual concerned over a period of time (usually five years). The Medical Officer will then assess the anticipated costs of these needs over a five year period and determine if there are waiting lists for any of the necessary services.  If the anticipated costs exceed the average Canadian’s per capita health and social services costs over five years, of if there are waiting lists for any of the necessary services, the applicant will be deemed inadmissible.[151] Certain groups defined in section 38(2) of the Immigration and Refugee Protection Act receive an “excessive demand exemption” and will not be refused entry based on possible health demands.[152]

After admission to Canada, the expectation is that the delivery of programs and services related to mental health that fall into the public health care sphere will be a responsibility of the provinces and territories.  This is dependent, however, on variables such as the length of time it takes for federal processing of a claimant’s application and the nature of the agreement between the federal government and a province or territory with respect to settlement and integration services.  Landed immigrants are expected (but do not always manage) to arrange their own health care, including private insurance to cover the 3 month waiting period for coverage imposed in four provinces (British Columbia, Ontario, Quebec and New Brunswick).[153]

In the department’s 2005 performance report to Parliament, Citizenship and Immigration Canada indicated that a total of 235,824 people were admitted to Canada as permanent residents in 2004.^([154]) Of the newcomers admitted, the department noted that:

§         57% (133,746) were economic immigrants and their dependants;

§         26% (62,246) were in the family class;

§         14% (32,685) were refugees and other protected persons;

§         3% (6,945) were granted permanent resident status on humanitarian and compassionate grounds.

 

13.6.2   Federal Programs and Services

13.6.2.1      Interim Federal Health Program

Citizenship and Immigration Canada’s direct role in the provision of mental health services is through the Interim Federal Health Program. This program originated with a 1957 Order-in-Council and was moved from Health Canada to Citizenship and Immigration Canada in 1995.  As Dr. Martin indicated:

… it offers health services to migrants, currently refugee claimants, refugees, detainees in immigration detention centres and failed refugees still in Canada who are unable to pay for their health care services. It covers essential and emergency medical services, including mental health services such as consultation with physician, hospitalization and essential medication. The overall budget for this program was $51 million in 2002-2003, with 97,000 users and 700,000 claims.[155]

The program is administered by FAS (Funds Administrative Service Inc.) Benefit Administrators in Edmonton. Mental health services covered under the Interim Federal Health Program are limited but do include:  consultations with a psychiatrist, hospitalization for psychiatric disorders, initial psychotherapy session with a physician (follow up covered if approved) and essential medication.

The department did not provide a breakdown of expenditures that relate to mental illness or addiction. It is reasonable to assume, however, that these could be significant, given that many refugee claimants have been victims of torture and have endured other strains on their mental health.

Some provinces have raised concerns about the adequacy of the Interim Federal Health program to meet the overall costs of immigration-related medical and health services. They have asked for reviews of levels of permitted fees, scope of covered services, and reimbursement of provincial costs incurred for service provision. For example, the 2004 British Columbia accord authorized under the Immigration and Refugee Protection Act points to the need for consideration of provincial costs incurred in providing services for refugee claimants; for immigrants deemed to be medically inadmissible who are allowed to proceed to Canada under new legislation (excessive demand exemption), and for people admitted with serious health problems during the three (3) month waiting period for British Columbia’s Medical Services Plan coverage.[156]

 

13.6.2.2      Other Initiatives

Dr. Martin pointed out that the department also has other initiatives designed to contribute positively to the mental health of newcomers to Canada:

If mental health is defined as each person’s ability to experience, reflect and act in such a way as to obtain the greatest enjoyment from life and to cope with different challenges, it can be said that Citizenship and Immigration Canada is responsible for a number of initiatives that are either directly or indirectly linked to mental health.

Several of our programs are aimed at facilitating and improving the social, cultural and economic integration of newcomers, thus reducing the stress involved in settling in a new country for the benefit of such newcomers.

These different programs provide information relating to existing resources and facilitate the access to such services.[157]

Citizenship and Immigration Canada attempts to ease the stress of integrating into Canadian society through several programs:

§         The Immigrant Settlement and Adaptation Program funds service provider organizations to provide counselling and non-therapeutic services to newcomers, including referrals to services for educational, legal, social and health needs as well as employment and housing.

§         The Host Program funds the recruitment, training, matching and coordination of volunteers who can help newcomers to deal with educational and health issues and to learn about and access available services in their community.

§         The Resettlement Assistance Program provides income support and a range of immediate services.  For the regular stream of government-assisted refugees, the department provides up to 12 months of income support; for those with special needs, this can be extended to 24 months. The amounts are guided by provincial social assistance rates.

Citizenship and Immigration Canada is also involved in other partnership arrangements at different levels.  For example, it supports the Canadian Centre for Victims of Torture and the Metropolis project, a national/international forum for research and policy on migration.  In addition, the F/P/T Working Group on Settlement and Integration discusses issues of a multilateral nature.  Interdepartmentally, there are joint initiatives with the Public Health Agency of Canada on migration health challenges, as well as with Industry Canada, Human Resources and Skills Development Canada and Health Canada on informational projects to facilitate integration.

Citizenship and Immigration Canada is also responsible for various linguistic programs including the Language Instruction for Newcomers to Canada Program that provides basic language instruction to adult immigrants to help them integrate successfully.

13.6.3   Assessments of Client Group Needs

Individuals who enter Canada as immigrants and refugees constitute a heterogeneous group. Some come to this country under an economic or a family category, some as refugees and others as asylum seekers.  Some arrive having already received permission to live in Canada permanently while others arrive requesting acceptance as refugees. Regardless of the category, immigrants and refugees are newcomers to Canada carrying multiple experiences that shape how they will adapt to their new country.

Sister Mangalam Lena, a Franciscan Nun from Ottawa, spoke to the Committee on behalf of immigrants and refugees. Sister Lena, who is also a hospital chaplain and nurse as well as being a home-based spiritual care provider, talked of the many factors such as “loneliness” and “uprootedness,” “woundedness” and “brokenness,” that can affect a person’s mental health. She described a program, initiated by immigrants themselves, that allows them to share their stories one-on-one. She explained:

Journeying with these immigrants, we know that many of them from these war countries have seen atrocities, they have seen their loved ones being killed and they have seen their mothers and sisters raped. In this new program, we see how creating a safe environment has brought them peace of mind and comfort.[158]

The separation from family and community, combined with the inability to speak English or French, can contribute not only to serious emotional distress but also to reduced access to needed services. Although language programs may be in place, not everyone has access to them.

In many towns, no language program or support services exist for immigrants, leaving them without access to resources that would enhance their mental health. Moreover, even when people take language classes, they are not necessarily able to communicate their mental health needs, especially since language education is often geared primarily to individuals destined for the labour market.

Raymond Chung, Executive Director, Hong Fook Mental Health Association, Toronto called for mandatory guidelines to be made available as required on the funding, training and service delivery model of trained mental health interpreters.[159]  He stressed that, over time, the underutilization of services by newcomers could prove very costly to the health care system:

It is only through ethnocultural, language-specific mental health prevention and promotion strategies that we can achieve the goal of early identification and early intervention. In turn, you will help to reduce the financial and human costs in our society and, in the long run, for treating more serious mental illnesses.[160]

Others witnesses observed how certain individuals, especially elderly persons and women from traditional cultures, are also more likely to experience difficulties during resettlement. Steve Lurie, Executive Director of the Canadian Mental Health Association, Toronto, pointed out that immigrant women with mental health problems need particular attention.[161]

Robena Sirett, Manager, Older Persons Adult Mental Health Services, Vancouver, indicated that there are knowledge gaps about the elderly victims of trauma or torture who come to Canada as refugees.

We are trying to develop programs that can be more responsive and flexible, depending on the refugees that are coming to our city…we did not have that cross-cultural competence where we could go in and work with them.[162]

Racism may be one reason why eligible immigrants and refugees underutilize health services. Underutilization may be also result from fear that using mental health services could jeopardize ongoing immigration applications. As well, language barriers, experiences with culturally inappropriate care, or difficulties in navigating the health system can discourage people from using the services that are available.[163]

Martha Ocampo emphasised how the overall mental as well as physical health of newcomers, as for other Canadians, is strongly influenced by their social environment.  Racism in combination with poverty, unemployment, inadequate housing and limited community support can all affect their successful integration, as can their relationship with those providing mental health services. Ms. Ocampo told the Committee:

The mental health of members from racialized communities cannot be understood in isolation from the social conditions of their lives. These conditions are characterized by social inequities which influence the type of mental health problems people from these communities develop and impact on how these problems are understood and treated by health professionals and the mental health system.[164]

For Ms. Ocampo, the key to full participation is accommodation:

… you must remember that new immigrants or refugees are trying to settle and will need certain accommodations in order for them to participate fully.  If the issue is child care or transportation expenses, there are many things that you have to consider.[165]

 

13.6.4   Committee Commentary

The Committee acknowledges that Canada is regarded as a safe refuge for many of the increasing number of immigrants and refugees seeking to enter the country. But Canada’s commitment to provide this safe refuge must include assurances that individuals have access to health services to help them deal with any mental health issues they face.

As with other federal client groups, the Committee has identified a role for an external body to provide oversight and assessment of how well the federal government is meeting its commitments to immigrants and refugees.

Thus, the Committee recommends:

82

That the federal government establish an entity for immigrants and refugees, similar to the Correctional Investigator, the Canadian Forces Ombudsman, or the RCMP External Review Committee; That this entity be authorized to investigate individual complaints as well as systemic areas of concern related to federal provision of programs and services that have an impact on the mental wellbeing of immigrants and refugees; That this entity provide an annual report to Parliament.

 

The Committee supports greater involvement of immigrant and refugee communities as partners in research, program development and services delivery. There is a need for more Canadian research into the identification and evaluation of culturally appropriate systems of care for immigrant populations, particularly in relation to such vulnerable populations such as children, women and seniors.

 

 

Language is a key tool to facilitate successful integration and positive mental health among immigrants and refugees. All immigrants and refugees should have equal access to official language education. The federal government has an obligation to provide and pay for linguistically and culturally appropriate services; it must not offload them onto the provinces.

The Committee recommends:

83

That Citizenship and Immigration Canada provide an annual inventory to Parliament on its programs and services relevant to mental health, including clients served, expenditures allocated and spent, and outcomes achieved, starting in 2008. That Citizenship and Immigration Canada increase funding for and access to language training by diverse groups through increased training allowances, appropriate scheduling of instructional hours, and the location of classes in places that facilitate access.

 13.7      FEDERAL PUBLIC SERVICE EMPLOYEES

As the country’s largest employer, I want to assess what the federal government is doing to address mental health issues in the workplace. Simply stated, we need to be a leader and example for employers across the country. — The Honourable Ujjal Dosanjh, former Minister of Health.[166]

13.7.1   Federal Responsibility

Through the authority of the Financial Administration Act, Treasury Board is the employer of the federal public service and responsible for labour relations, pensions and benefits, as well as employee and military compensation.[167]Other legislation also impacts on the working conditions of federal employees. For example, the Employment Equity Act requires federal employers to provide reasonable accommodation for persons with disabilities,[168] while the Government Employees Compensation Act authorizes compensation for loss of earnings, medical care and other related benefits to federal employees with employment-related injury or disability.[169]

According to the 2005 departmental performance report for the Treasury Board of Canada Secretariat:

The federal public sector is the largest organization in Canada. With over $200 billion in expenditures, it is seven times larger than any other enterprise in the country. With 450,000 employees, 200 organizations, 400 million transactions a year and 1,750 points of service, it is arguably the most complex institution in Canada.[170]

13.7.2   Federal Programs and Services

The majority of federal public service employees rely on the governments of the provinces or territories in which they work for essential mental health services.  In its role of employer, the Treasury Board sets policies that govern the public service health care and the disability insurance plans for departmental and agency employees under its authority.  These plans cover the cost of services and other benefits for mental health not available through other insurance plans.

The Public Service Health Care Plan (PSHCP) applies to Public Service employees, members of the Canadian Forces (CF), members of the Royal Canadian Mounted Police (RCMP), pensioners, and their respective dependants.[171] A PSHCP Directive notes, however, that only eligible dependents of members of the CF and RCMP are covered; the members themselves are covered under their own specific plans.[172] The Plan reimburses participants for all or part of costs incurred for eligible services, only after they have taken advantage of benefits provided by the relevant provincial/territorial plans.  The extended health provision includes coverage for services provided by a psychologist and prescribed by a physician up to $1,000 in a calendar year.

According to Phil Charko, Assistant Secretary, Pension and Benefits Division, Treasury Board Secretariat, in one year, the federal government paid out an estimated $64 million for prescribed drugs and $10 million on psychological services under the Public Service Health Care Plan.[173]

 

 

The Disability Insurance Plan is designed to give Public Service employees a measure of income protection.  It provides for a monthly income benefit for employees who are unable to work for a lengthy period of time because of a totally disabling illness or injury. Income replacement during long-term disability can be up to 70% of an individual’s annual salary. Benefits are payable for up to 24 months if the individual is totally disabled (i.e. in a continuous state of incapacity due to illness or injury, prevented from performing regular occupational duties). If, at the end of this 24-month period, the disability continues to prevent the performance of a commensurate occupation requiring similar qualifications, the benefit can be continued up to age 65 years.[174]

Mr. Charko pointed out that, in 2003, 44 percent of new long-term disability cases were for anxiety and depression. He noted that this was “a fairly high number” but stressed that there is also a fairly high rate of recovery and return to work. He suggested that approximately 70% of people who go on long-term disability return to work in the public service. According to him, the return to work involved:

… a flexible approach whereby individuals can come back temporarily in a less demanding job or can come back on reduced hours. If they are coming back on reduced hours, the [disability insurance] benefit is continued to the point where they are back to their main income.[175]

For Mr. Charko, the successful management of mental health issues in the federal public services entails three factors:

If you have managers that are focused on [human resource] issues and well trained, that is one success factor. If you have a suite of work place policies that deal with leave and duty to accommodate employees with mental health problems, that is another success factor. The third deals with your insurance programs when in fact the employee finds himself in difficulty.[176]

Mr. Charko indicated that a comprehensive set of workplace policies to assist federal employees and address issues such as mental health and addiction problems and work place well-being should:

… include things like flexible working arrangements, telework, job sharing, mobility policies, child care. We have generous leave policies, anti-harassment, fitness, duty-to-accommodate policies, employment equity, pride and recognition, and policies with respect to the code on values and ethics.[177]

In relation specifically to the employee assistance program, Mr. Charko noted that it is mandatory in all government departments:

It provides for short-term confidential counselling. It is paid for by the department and allows for counselling of employees with all kinds of problems, not just mental health, without prejudice to job security or career.[178]

13.7.3   Assessments of Client Group Needs

Federal government employees are located in every province and territory and work in communities of every size.  They do many things:  inspect food, report weather conditions, patrol fisheries, guard borders, staff correctional institutions, conduct scientific research, issue passports, assist in travel abroad, monitor infectious diseases, and have multiple other responsibilities.

Over the last decade, a number of factors that contribute to making federal workplaces more stressful present significant challenges to both the physical and mental health of federal employees. These include the cumulative affect of downsizing, restructuring, and devolution of authority, as well as constrained resources and intense media scrutiny in the wake of a variety of controversies and scandals.

This increase in stress at the workplace is illustrated by the results of internal surveys conducted by Treasury Board Secretariat.[179] Significant numbers of survey respondents reported being pressured in their jobs and confused by constantly changing priorities. Respondents indicated that they are experiencing instability in their departments and are being left out of decision-making processes in areas that directly affect their work.  Twenty-one percent reported having been the victims of harassment, and 17% reported having been discriminated against in the workplace.

The National Joint Council, a body that includes public service bargaining agents and Treasury Board representatives, strives to find collaborative solutions to workplace problems. It reported that the Disability Insurance Plan delivered $223 million in 2004 in support to affected employees.  The Council pointed out that:

Psychological conditions including stress and anxiety remained the major cause of disability for new claims in 2004 as it has in the last thirteen (13) years. Increasingly cases presented deal less with objective verifiable medical data verified by traditional diagnostic protocols and more with the challenges that are posed by the difficulty of diagnosing these illnesses.[180]

Mr. Charko asserted that a work place in which individual differences are respected “can do a lot to eliminate the stigma associated with mental illness which is a problem in the public service.” In this regard, the Treasury Board Secretariat has developed a Policy on the Duty to Accommodate Persons with Disabilities in the Federal Public Service[181] in response to a requirement of the Employment Equity Act that employers provide reasonable accommodation for persons with disabilities. The guideline definition of persons with disabilities that accompany this policy includes individuals who suffer from a “long-term or recurring physical, mental, sensory, psychiatric, or learning impairment.”[182]

While the federal government’s policy framework to support its employees and to create workplaces conducive to their wellbeing seems appropriate, reports of actual experience with the individual programs and policies suggest that there are still many unresolved issues. For example, Alan Fournier,a federal employee diagnosed with mental disabilities who submitted a brief to the Committee, indicated that “there have been those in the Public Service who have been very helpful and supportive. However, they are in the minority.” He told the Committee that he was:

… not pointing at any one individual or organization with [in] the public service. Rather, the problem seems to [be] more systemic in nature from a culture that talks the talk but will often not walk the walk on disabilities such as mine.[183]

Mr. Fournier also referred to the limited coverage for professional services provided by the Public Service Health Care Plan.

An overwhelming number of those of us seeking the services of therapists rely on professionals not covered by provincial heath plans. Therefore we are limited to the $1000.00 annual coverage of the public service health care plan. Most addiction therapists and psychologists charge at least $100.00 a session. In my case I require a number of professionals including an Addiction Therapist and a Psychologist who is a Learning Disability Specialist. At their rates, I am limited to eight visits annually. Effective therapy, especially at the early stages of addiction is required on a weekly basis. I should be seeing my addiction therapist bi-weekly. I also require a substantial number of expensive prescriptions. Even at eighty percent coverage I often find myself in financial difficulties meeting the difference. The requirement to pay medical expenses up front means a substantial portion of my income is always in transit waiting for claims to be processed.[184]

Dorothy Cotton, Co-chair/Psychologist, Canadian National Committee for Police/Mental Health Liaison, pointed to the fact that, in practice, the way the federal government, as an employer, treats its psychologists actually contributes to the overall stigma of mental illness:

The Federal Government is a bad employer in this way. You know, wages are easily 30% below market value for psychologists in the Federal Government scales, it is humiliating, and which contributes to the whole stigma issue.[185]

Diana Capponi, consumer/advocate, was pleased that the federal Minister of Health had appointed the Hon. Michael Wilson and Bill Wilkerson to review issues relating to mental health and the workplace within the federal government. However, she cautioned that:

Being Canada’s largest employer, I would suggest there are changes to be made. I would hope that these changes would include the targeted recruitment of people with mental health or addiction issues, and that the Federal Government will go well beyond the efforts of our banking sector, in that all positions, all levels or classifications of employees be filled by people with mental health and addiction issues. This would demonstrate to the Canadian public and your employees that you are “Walking the talk.”[186]

13.7.4   Committee Commentary

The Committee notes the initiatives taken by the former federal Minister of Health, the Hon. Ujjal Dosanjh, to focus attention on mental health issues in the public service. One example was the February 2005 appointment of the Hon. Michael Wilson, now Ambassador to the United States, as special ministerial advisor on mental health in the federal government workplace.[187]

In Chapter 8 on general workplace issues, the Committee drew heavily on the work of the Global Business and Economic Roundtable on Addiction and Mental Illness (the Roundtable), that was founded in 1998 to serve as an “instrument of information analysis and ideas concerning the linkage between business, the economy, mental health and work.”[188] Among employers, the Roundtable has raised the level of awareness of mental health issues and has facilitated the sharing of best practices. Indeed, effective solutions and approaches to promoting better workplace wellbeing have already been developed by the private sector.

The federal government, as an employer, could benefit from the establishment of wider community relationships in developing better practices for its own workplaces, in particular, the elimination of the stigma associated with mental illness.

The Committee therefore recommends:

84	That the federal government draw upon the model established by the Global Business and Economic Roundtable on Addiction and Mental Illness in coordinating interdepartmental mental health policies, programs and activities for employees.
	That the federal government, as an employer, form a partnership with other sectors and jurisdictions, including the Global Business and Economic Roundtable on Addiction and Mental Health, to stimulate and facilitate the exchange of best practices in the support of workplace wellbeing and better employee mental health. That, as it develops strategies to support mental health in its workforce, the federal government place a specific emphasis on measures that will reduce and eventually eliminate the stigma attached to mental illness.

 

The Committee believes it essential to evaluate programs regularly to see whether they are meeting their objectives and satisfying real needs. To determine the efficacy of the programs and policies currently in place that are designed to assist government employees facing mental health problems, the federal government must do more than simply list the programs and policies.

Accordingly, the Committee recommends:

85

That the Public Service Human Resources Management Agency conduct annual evaluations of the federal government’s provision of policies, programs, and activities designed to support mental health in the public service; That these evaluations be based on clear performance indicators that include the use of surveys to assess employee satisfaction; That the evaluations be used as a basis for adjustments to policies, programs, and activities in order to better suit them to the needs of employees; That results of these evaluations, and the adjustments that were made based upon them, be reported to Parliament on an annual basis starting in 2008.

13.8      TOWARD A FEDERAL GOVERNMENT STRATEGY FOR FEDERAL CLIENTS

Federal clients, like all Canadians, need a range of programs and services to sustain or attain positive mental health.  As we have seen throughout this chapter, each federal client group confronts particular challenges and each requires solutions specifically targeted to their needs.  Thus, for example, attention to fundamental determinants of health such as housing and community supports are a crucial factor among veterans and First Nations and Inuit populations.  For federal public service employees, on the other hand, workplace conditions and accommodations for people living with a mental disorder are of prime importance. 

It is also important to reiterate that the federal government is responsible for these different client groups for varying periods of time. Some, like First Nations and Inuit, are clients for life. Veterans generally access mental health services at a later stage in their lives.  Refugees, as they gain access to provincial services, may be able to stop relying on the federal government within a few months of arrival in Canada, while federal offenders remain in the care of the federal government until their release. Others, like the RCMP, Canadian Forces members and public servants, are the responsibility of the federal government for as long as they are employed within the federal jurisdiction.

The Committee recognizes that this wide range of situations poses a challenge to the federal government in ensuring that the necessary programs and services for mental health, mental illness and addiction are available to all clients. Nevertheless, the Committee cannot understand why the federal government has never developed a clear and consistent approach to address the concerns of the client groups for which it is responsible.  The Committee believes it necessary to develop such a comprehensive strategy aimed at improving the health status of all federal client groups while acknowledging also the distinct needs of each group.

 

The Committee therefore recommends:

86

That the federal government develop a strategy for mental health that is inclusive of all federal client groups and that takes into account each group’s particular needs. That the strategy set goals, including a timetable for implementation and for subsequent evaluation. That the strategy have as its objective making the federal government a model employer as well as model provider with respect to its various clients.

 

 

13.8.1   Incorporating a Determinants of Health Approach

Historically, the federal government has been a leader in the development of the concepts of population health, starting with the landmark Lalonde report. The Committee believes that the government has both the opportunity and obligation to apply these concepts to its own clientele.

In 2004, the federal government reported that it was the fifth-largest provider of health services to Canadians, serving approximately 950,000 people at a cost of $3.4 billion annually.[189] The Committee believes that the federal government’s commitment to mental health must include a focus on the determinants of health that extends beyond health services as such, given the many factors relevant to the various client groups. These encompass a range of determinants including:  adequate housing, access to income, the presence of social support networks, as well as educational opportunities and the availability of employment.

Given its substantial responsibilities for the provision of mental health service, the federal government must lead by example, including by focusing on the promotion of mental health and the prevention of mental illness and addictions. Through interdepartmental collaboration and sustained work with its client groups, the federal government could set a standard for the whole country in the development and application of population health models.

The Committee therefore recommends:

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That the mental health strategy to be developed by the federal government incorporate a population health approach to the determinants of mental health, and that it specifically address the economic, educational, occupational and social factors that have an impact on the mental health of all federal clients; That the federal government report to Parliament in 2008 on what precisely it is doing to implement a population health approach for federal clients.

 

13.8.2   Initiating Anti-Stigma Activities

In Chapter 16, the Committee recommends that the Canadian Mental Health Commission undertake a sustained, ten-year campaign to combat the stigma associated with mental illness. The presence of a federal representative on the Board of the Mental Health Commission will provide a federal input into the Commission’s pan-Canadian anti-stigma campaign. The Committee believes, however, that the federal government also has a responsibility to lead directly in reducing the stigma associated with mental health among its specific client groups.

The Committee recommends:

88	That the federal government immediately develop and implement an anti-stigma campaign for all federal client groups.

 

13.8.3   Providing an Avenue of Redress

As stated previously in this chapter, over several decades various federal departments have established some form of external independent, impartial oversight body for a broad range of matters affecting federal clients.  Many of these entities are mandated to include reviews of mental health concerns. For example, the Correctional Investigator and the RCMP External Review Committee are mandated through legislation to investigate and assess mental health issues, as well as other issues of concern relevant to their respective groups; they report to the relevant federal ministers with recommendations for action. Others like the Canadian Forces Ombudsman and the special advisor on mental health in the federal government workplace have no legislated mandate.

The Committee has recommended that the responsible federal departments establish similar forums for other federal client groups like veterans, First Nations and Inuit, immigrants and refugees that currently have no recourse to such a person or entity.

As part of the overall federal strategy, the Committee believes it is important to link oversight positions within individual departments to each other to provide a coordinated federal ombudsman role for specific issues relating to mental health.  It envisions an entity that can investigate and resolve individual complaints, review and make recommendations, identify systemic areas of concern, and follow-up for clients from all federal client groups.

The Committee recommends:

89	That the federal government establish a central coordinating mechanism for the development and delivery of mental health policies, programs, and activities across its departments and agencies; That this federal body work with the Correctional Investigator, the Canadian Forces Ombudsman, and the RCMP External Review Committee and other similar entities to be established by departments to ensure that the needs of individual client groups are being addressed;
	That this federal body coordinate and monitor the work of these individual entities in investigating and getting responses to concerns about mental health services for each federal client group; That this federal body provide an annual report to Parliament.

 

 

13.8.4   Assessing Federal Insurance for Mental Health

The conditions established under the Canada Health Act (CHA) that must be met by provincial health-care insurance plans to receive federal cash transfers expressly exclude some federal client groups. Under “insured health services,” the CHA excludes “any health services that a person is entitled to and eligible for under any other Act of Parliament.” It also excludes any “hospital or institution primarily for the mentally disordered.” More specifically, it defines “insured persons” for whom health services would be provided under provincial health care plans to mean a resident of the province, other than:

“(a) a member of the Canadian Forces,

(b) a member of the Royal Canadian Mounted Police who is appointed to a rank therein,

(c) a person serving a term of imprisonment in a penitentiary as defined in the Penitentiary Act.”[190]

 

Thus, the federal government is completely responsible for the provision of health programs and services to three client groups — Canadian Forces, RCMP and federal offenders. Others — First Nations and Inuit, veterans, immigrants and refugees and federal employees — are under federal responsibility to significant but varying degrees.

The federal government believes that provincial governments should shoulder the broad responsibility for the health of these latter groups of clients just as they do for the general Canadian population. As Ian Potter explained with reference to First Nations and Inuit clients:

… those services that are covered by the Canada Health Act, what we call insured services, are provided by the province. If the federal government is arranging for physician services or hospital services, we charge the province back for those services.[191]

However, each client group has mental health needs that are not covered under provincial insurance plans. To meet these uninsured needs, the federal government has developed a separate approach for each client group.  The Canadian Forces, RCMP and Corrections Canada cover non-insured health care and mental health treatment as a matter of operational necessity; First Nations and Inuit have access to the Non-Insured Health Benefits Program; veterans have the Health Benefits Program; refugees have the Interim Federal Health Program; and public servants have the Public Service Health Care Plan. In addition, there are a variety of disability insurance plans.

George Lucki, Chair, Alberta Alliance on Mental Illness and Mental Health, noted that federal efforts to cover the additional needs of its clients were characterized by a lack of coordination with the provinces: 

The federal government is a leading purchaser of uninsured benefits that provide those who work for the federal government or those whose health care is a federal responsibility with mental health care that is not available to the people of Canada at large.

These services themselves are often not particularly well coordinated with other health services that are delivered by provincial authorities.  We believe that these programs should be comprehensibly reviewed to ensure that they reflect best practices, address the mental health needs of those they serve.[192]

The Committee was surprised to learn not only about the wide range of insurance plans that exist to cover federal clients, but also about the lack of coherent reporting on and assessment of these plans.  Health Canada’s Non-Insured Health Benefits Program for First Nations and Inuit was the only plan that provided a comprehensive annual report to Parliament. The Committee heard occasional references to other plans but received no formal descriptions or reports.

 

The Committee therefore recommends:

90

That the federal government immediately undertake an assessment of all of its insurance plans for all federal clients to determine their applicability and effectiveness; That this assessment include a comparative evaluation of benefits, of coverage for specific mental health, mental illness and addiction needs, of administrative costs, and of results achieved under the various insurance plans; That this review of insurance plans be reported to Parliament in 2008.

 

 

13.8.5   Coordinating and Reporting to Parliament

In 2005, the Minister of Health initiated an interdepartmental task force to identify better ways to integrate services and approaches between federal departments with a stake in mental health issues. This task force includes representation from 20 departments and agencies and is jointly led by Health Canada and the Public Health Agency of Canada. Its mandate is to study federal activities and improve coherence in the areas of mental health promotion and prevention, the provision of services, and policy development. The Committee believes that this is an important first step in the right direction, but sees the need for the federal government to go much further in its efforts to coordinate its various programs and services.

 

 

 

 

 

 

 

Despite the presence of policies, programs, and activities in numerous departments and agencies of the federal government that address the mental health needs of various client groups, the Committee found no central source with overall knowledge of federal activities in this area. There is no forum in which the exchange of solutions and best practices can occur, and no single source of information on the availability of programs, their cost, or their performance. Importantly, no one has a complete picture of either the state of mental health of federal clients or of the full range of services available to support them. This lack of coordination can only lead to overlap and wasteful duplication of effort.

The Committee also believes it essential for the federal government to provide regular reports to Parliament on its mental health programs and services. At present, Parliamentarians are expected to make decisions about mental health, mental illness and addiction for federal clients without having access to full information. For example, when the Auditor General of Canada reported in 2004 on federal drug benefit plans, she noted that, while federal organizations have highly useful and current data about drug use, that information is not systematically assessed or disseminated to facilitate meeting client health needs.[193]

While departments provide some limited details in their plans and priorities or performance reports, no full reporting on federal health programs is made to Parliament.  The Committee notes that, under the Canada Health Act, each provincial and territorial government is required to submit a report annually on physician, hospital and other relevant health services.  In the meantime, the federal government does not provide comprehensive and coordinated annual reports to Parliament on any aspect of its provision of health and health care services.

The Committee has already called for reports from individual departments with significant responsibility for the mental health of particular groups of Canadians. It wants a coordinated approach to this reporting to provide Parliament with the comprehensive information it needs to make legislative and budgetary decisions affecting these specific clients.

The Committee therefore recommends:

91

That all federal departments with direct program and service responsibility for specific client groups — including First Nations and Inuit, federal offenders, immigrants and refugees, veterans, Canadian Forces, RCMP, and federal public service employees — develop an annual report that includes a description of federal responsibility, federal programs and services, and the extent to which these meet the mental health needs of clients; That this annual report include an annual inventory of their current respective programs and services as well as a three-year comparison; That the inventory include a clear description for each program or service by fiscal year of the criteria for eligibility, of the number of clients served by the program, of the amount of funding allocated and the amount spent, as well as an evaluation of outcomes related to the determinants of mental health; That the inventory be tabled in Parliament annually starting in 2008.

 

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