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4/23/2009

Regional Consultation – Winnipeg, Manitoba, April 8, 2009

Our last stop in this round of consultations was in Winnipeg, as the Red River crested through the centre of town...It is hard to take in how many places we have been and how many great ideas and suggestions we have heard since we held our first session in St. John’s on February 3^rd. I am looking forward to having the time to time to reflect on all that we have heard and to think about how we will respond. We are also looking ahead to how these consultations will shape the next phase of mental health strategy development, namely, HOW to achieve these broad goals in different sectors and constituencies. It is fantastic to know that there are so many dedicated and passionate people across the country to work with.

The dialogue in Winnipeg was very focused and positive. One very supportive service provider asked “How can service providers and their colleagues do more to provide recovery-oriented services?” We were also encouraged to take a stronger stance in the recovery goal by making the “hope of recovery” more than just “available” to all. We were also urged to emphasize the concept of ‘dignity’ in the recovery goal and to reconsider the wording “meaningful life in the community,” so that the goal would apply more broadly to those whose conditions are debilitating and deteriorating.

We were urged to recognize the links between promotion and prevention and reducing stigma and to identify this linkage, and other linkages between goals more explicitly. As we have heard elsewhere, some suggested that the promotion and prevention goal should be an overarching goal in the document. Others liked the distinction between mental health and mental illness, and wanted more of the material in the introduction to be brought into this goal and for us to discuss the concepts of ‘flourishing’ and ‘languishing’ mental health.

We were also urged to use stronger language when calling for joint action across sectors on critical determinants of health. We need to be clear that these are very complex challenges that may be difficult to address, but that at the same time that we are also advocating for the implementation of more easily achievable things such as more widespread access to mental health promotion and prevention programs that have been demonstrated to be effective in schools, workplaces, and families. There was also discussion about whether it was better to focus on an issue such as bullying at school that the general population can identify with, or to focus on issues like sexual abuse and neglect that have devastating effects, but are harder for some to identify with.

The discussion regarding cultural safety was very supportive. A key issue that was raised was the need to balance the capacity to provide non-judgemental services for individuals with the need to build awareness of the social and historical context of diverse groups. Some suggested that the goal be reworded to: “The mental health system is culturally-safe, and responds to the diverse needs of all people living in Canada” rather than “all Canadians” to capture recent immigrants and refugees. It was also suggested that we expand our list of examples by changing “gender” to “sex, sexual orientation and gender identity” to acknowledge the trans-gendered community?

The discussion about the family goal was wide-ranging and captured a number of issues:

· Could the notion that “family” means different things to different people be made clearer, perhaps through a broad definition?

· Would ‘circle of support’ be a better term than family?

· Are the needs of family members different than the needs of circles of support?

· Would it be better if this goal focused on the needs of families for support, and move to their role in supporting recovery and well-being, to the promotion and prevention goal, or would this unnaturally divide up the multiple roles of families?

· Is it accurate to say that parents have the right to make decisions on behalf of children and youth? Would “with the informed consent of people” be more accurate and appropriate?

The access and integration goal was well liked and seen as critical for rural and remote communities. Concerns focused on HOW greater access will be achieved. Participants asked if the concept of “ equity,” could be expanded to include equity across socio-economic status, and to consider minimum standards for core services that should be available in all regions. Other issues to be addressed included:

· Jurisdictional issues for First Nations

· Could the MHCC advocate for fully publically funded mental health services rather than for choice across the public and private systems

· Can we make clear who will define a person’s needs – that it will not be service providers as has been the historical experience?

Strong support was also expressed for the need for some type of help with system navigation – but not necessarily through the exclusive use of system navigators. One participant likened the experience of navigating the system to “playing Dungeons and Dragons - and it never ends!” Some participants felt that it was everyone’s responsibility to help people navigate the system and that giving this role to one person was not appropriate. Others felt technology could play a big role. Others felt there would be a need to embrace multiple approaches, some short term fixes and others longer term in nature.

Participants were very pleased to see such a strong focus on research, data and evidence that reflects diverse sources of knowledge. They saw this as critical for addressing the stigma that is a barrier to funding research and services at levels consistent with the importance of mental health and the impact of mental illness. The need for computerized information systems that would enable service providers to make data gathering a part of everyday practice was identified.

As we have heard across the country, participants liked the focus on stigma and discrimination, but would like to see the goal phrased in more positive, proactive and hopeful language. Some also wanted us to expand on the lifelong impact of stigma and discrimination experienced by children and youth.

Participants found the social movement goal to be a powerful closing piece for the framework. Just having the goal itself can be “one of the raindrops that is needed to make a waterfall,” as one participant stated. At the same time, others questioned if this is really a goal, or a way of achieving the other goals. There were also concerns that it may be difficult to engage the voluntary sector, consumer champions, and families in the movement if they have had bad experiences with the mental health system to date.

All in all, the input at our final meeting was once again excellent. Thank you Manitoba for helping us end this initial process on such a high note!

Posted at 7:05 AM by Gillian Mulvale | Permalink | Email this Post | Comments (4)

4/22/2009

Stakeholder Dialogue with National Aboriginal Organizations – Ottawa, March 31, 2009

Our meeting with National Aboriginal organizations in Ottawa opened with a prayer by Elder Charles Hill, that called for an open, respectful dialogue. The meeting was co-chaired by Bill Mussell, Chair of the Commission’s First Nations, Inuit and Métis Advisory Committee and Madeleine Dion Stout, Co-Chair of the Commission’s Board of Directors. Both underscored the importance of this meeting for the Commission and encouraged participants to spread the word throughout their organizations and networks of contacts to ensure that First Nations, Inuit and Métis voices were heard in the work of the Commission as it develops its Mental Health Strategy.

During their opening remarks, participants recognized the excellent work that has already been done by Aboriginal organizations and encouraged us to work together with the people who developed these plans, rather than ‘reinventing the wheel’. We heard that the issues of on-reserve and off-reserve aboriginal people differ, but are equally important. We also heard that the colour of one’s skin often is a huge source of discrimination that affects mental health and well-being and mental illness and that there is a strong need for a chapter that is specific for First Nations, Inuit and Métis communities and that recognizes the impact of the residential school legacy on the wellness of First Nations, Inuit and Métis communities.

We were also urged to remember:

· that communities and families are in crisis,

· the importance of finding ways to value youth and prevent youth suicide and to incorporate youth perspectives in this work,

· the importance of building capacity in communities,

· the particular challenges facing fly-in communities, and

· the importance of housing to people’s well-being and the need to support development of a National Housing strategy.

Strong support for the goals was indicated in the early voting, with scores very similar to other regional stakeholder session. In fact, for the first time, we have a perfect mean score of 5 out of 5 in terms the support for goal 2 - the prevention and promotion goal! Needless to say, this was a wonderful and surprising ‘first’ for members of the mental health strategy team.

During the small group work and plenary feedback, we heard excellent input about each of the proposed goals:

Goal 1

Participants agreed that the concept of hope was the operative word for this goal. At the same time, there were concerns about the concept of recovery. One concern arose because the concept of recovery from mental health problems is based on an illness model, while First Nations, Inuit and Métis tend to focus on a wellness model. The concept of recovery is seen as placing a negative connotation on a particular state of being, compared with a wellness approach which simply looks at different experiences or states of being as occurring at different times without judging them. The concern is then that the concept of recovery tends to reinforce the differences between ‘us’ and ‘them.’ Others stated that for some, the concept of recovery does not apply, because many people are born into a bad situation, so have no opportunity to ‘recover’ what they never had. Nonetheless they can heal and grow, so the term healing was preferred.

People also questioned the positioning of recovery as the first goal, for fear that when people first look at the document they will see an unfamiliar concept and dismiss the whole document. Two suggestions were to change the title of the document to “Toward Well-being and Recovery”, or “Toward Healing and Well-being.” Participants would like to see more of a community emphasis in the goal - one which captures the community-wide trauma that exists in many First Nations, Inuit and Métis communities. We were also asked to include discussion of the need for a ‘harm reduction approach.’

Goal 2

Participants were very enthusiastic about this goal, as indicated by the ‘perfect score’ in the initial voting. They applauded the fact that it addresses the social determinants of health, including mental health and well-being and the emphasis on prevention and promotion. They saw it as a strength-based approach with its emphasis on resilience.

One concern was that we discuss the importance of ‘body, mind and spirit’, but not emotional health – which is the fourth element of the traditional ‘medicine wheel’. There was also concern that the goal may have been overly optimistic, given the tremendous challenges that must be addressed to operationalize it– for example, those arising from jurisdictional issues over who does what, the silos that need to be overcome, the human resources and capacity-building that will be required.

Participants would like to see the goal address the impact of the legacy of residential schools , the Inuit dog slaughter and colonization on mental health in First Nations, Inuit and Métis communities and to include the importance of culture in promoting wellness and the importance of maintaining and building on cultural traditions in contemporary world practices.

Goal 3

Participants were very pleased to see that a cultural safety goal was included in the draft framework. At the same time there were a number of concerns raised:

· We need to explicitly include the words “First Nations, Inuit and Métis” in this goal. If this is not made explicit, aboriginal people who are reading the document won’t ‘find themselves in it’ and therefore won’t feel ‘culturally safe’ reading it.

· How can we ensure this is not just a token notion? How can we ensure that federal, provincial, territorial officials, academics and community leaders are all discussing this and ‘making it happen’ because it is such an important issue?

· Is there a need for a dedicated strategy for First Nations, Inuit and Métis, that is nested within a strategy for Canada at large? One participant argued that if 96% of Canadians are not aboriginal, then there needs to be a separate strategy to ensure their interests are not lost within a larger strategy. Further it was felt that if First Nations, Inuit and Métis are ‘thrown in’ with ethno-racial diversity, this will be seen as another attempt at assimilation.

· The reference to “all Canadians” throughout the document should be changed to ‘people living in Canada.’

· That the different challenges of those on reserve vs. those off reserve must be recognized and addressed.

Goal 4

Participants felt strongly that we needed to reframe this goal so that it focuses on family caregivers’ needs and so that the role of families in prevention and promotion is captured in goal 2. There was also concern that we don’t discuss that some families would like to be caregivers, but aren’t allowed to, and that we should specify that there can be many different types of families. Participants also wanted to have more discussion of family and community healing and intergenerational trauma and child sexual abuse. Participants felt that family members should only be included in decision-making if appropriate and not in situations where there has been abuse. The question was raised about how meaningful ‘consent’ is when asked of a child or an abuse victim.

Goal 5

Participants were very pleased to see that the goal specifically addressed the special needs of Canadians living in northern, remote and rural areas. One participant saw the goal as presenting an opportunity to increase the number of Community Health Representatives in these communities.

Some participants were unsure about how effective telemental health was and cautioned us to explore this further. We were also urged to include the fact that while only 1/3 of people gets access to care that they need, that once care is accessed only about 1/3 get the right treatment. Other recommendations were to make explicit that no ‘mental health system’ exists in northern communities, and that many First Nations, Inuit and Métis are disenfranchised and therefore not attached to the health care system.

One participant raised a fundamental question about equity and advocated for the need for a separate vision for First Nations, Inuit and Métis:

“What does equity mean when we’re starting out at a total disadvantage? We can’t catch up! We need to have our own vision for what we need, which is not necessarily the same as the rest of the country.”

Goal 6

This goal was appreciated, because participants felt that there is a need for more research, however they wondered who would determine the meaning of ‘appropriate research.’ They asked whether this referred to community-based research or western medical research or traditional teachings. The sense was that there was not sufficient acknowledgment of indigenous science in the goal as written. Participants also wondered who would validate research and for what purpose.

Goal 7

This goal was seen to be essential. There was tremendous support for the text of the goal, but there was concern that we add a discussion of the impact of multiple levels of stigma. For example, one participant stated that an Inuit woman with a mental illness faces three levels of stigma which interact to create multiple barriers to housing, employment and services and so on.

Goal 8

While participants like the social movement approach, they were concerned that the First Nations, Inuit, Métis perspectives would be lost within a broadly-based social movement. The suggestion was that a ground-up approach was needed for First Nations, Inuit, and Métis.

By the end of this excellent discussion, there was strong support for the process. Concerns remained about the need for an aboriginal-perspective and in order for aboriginal peoples to ‘find themselves’ in the document. We were also encouraged to consider a way to frame the content in a more accessible way for the general public, by drawing on the First Nations, Inuit and Métis storytelling tradition and present the content of the goal in the context of an individual’s experience.

The Commission staff expressed thanks to all the participants and recognized the importance of this meeting in helping to foster better relationships with the community and to encourage their engagement. A number of participants offered to ‘spread the word’ through their networks and to encourage people to participate in the online consultations.

At the end of the day we were thanked by participants for our openness to listen carefully in a respectful way. The process was seen as a great learning opportunity which was well-structured and well-organized. Several participants stressed how nice it was to be invited to be ‘at the table’ at early stage in developing a strategy for people living in Canada and expressed their hope to have meaningful engagement throughout the process of developing the Mental Health Strategy.

Posted at 2:20 PM by Gillian Mulvale | Permalink | Email this Post | Comments (24)

4/15/2009

Regional Stakeholder Dialogue - Iqaluit, Nunavut, March 17, 2009

This regional dialogue was unique on many fronts. Twenty-five people from across Nunavut participated, including four elders (two of whom were unilingual), the president of Inuit Tapiriit Kanatami and MHCC Board Member Mary May Simon, representatives from Nunavut Tunngavik Inc., the Embrace Life Council, the Government of Nunavut, and a group of mental health worker students from Arctic College.

Two thirds of the participants were Inuit, and much of the discussion was held in Inuktitut with simultaneous translation services (in-kind support from the Government of Nunavut and Nunavut Tunngavik was much appreciated!). All of the materials for the meeting were also translated into Inuktitut. Support from the Embrace Life Council was critical for the success of the meeting.

After prayers from the elders, Mary Simon welcomed the participants, and expressed her hope that the work of the Mental Health Commission would help to address the acute gaps in access to mental health services for Inuit and northerners, even relative to the shortages and barriers experienced elsewhere in the country.

Participants were largely supportive of the draft framework, and called on the MHCC to: use more positive, strengths-focused, and plain language; give more consideration to the impact of colonization and residential schools on Inuit; frame the issues more in terms of developing communities and families; support an Inuit-specific strategy; and acknowledge the acute mental health needs and service shortages for Inuit.

With regard to the hope of recovery, this seemed to resonate for people in terms of the recovery of community and culture, but less in terms of individuals and families struggling with a mental health problem of illness. Does the term “recovery” make sense for Inuit who are coming to terms with the legacy of residential schools and historical traumas? Is there a more positive, holistic term that could be used?

In a great Canadian moment, Jesse Mike, president of the Embrace Life Council, “you can recover the puck if it is stolen, but is not so clear cut with a mental health issue.” Can more emphasis be placed on teaching life skills and coping skills for those who may face significant and life-long limitations arising from a mental illness?

The discussion around promotion and prevention focused on the need to recognize and support community-driven, Inuit-specific programs. This theme carried on through the discussion of cultural safety, which was viewed as critical for the success of mental health services in Nunavut. Key aspects that were mentioned included culture, environment, language, and country foods. Will the rest of Canada support the need for an Inuit-specific mental health plan?

While many others across the country have called on the MHCC to define families more openly, I found it interesting that this group felt that we had defined families very openly and flexibly. One of the elders told a story that illustrated an aspect of family life that I think we had overlooked: taking responsibility for one’s family can lift people up, give them a reason for living and be a major component of a “meaningful life.”

The discussion about access and integration issues in Nunavut was very passionate. Participants liked the goal and saw it as absolutely critical for their communities, but felt that the mention of the unique needs in “northern, rural and remote communities” and the mention of “as close to home as possible” did not go far enough. Can the MHCC do more to acknowledge the acute lack of access in Nunavut to even the most basic mental health services that most Canadians take for granted?

The research goal was supported, but less strongly than the other goals. The group echoed concerns we have heard elsewhere about research not leading to change on the ground, and to more effective programs and services. Given the issues in the north, would it make more sense to place a higher priority on improving access to services?

Language was a critical issue for addressing stigma among Inuit. How can Inuit develop Inuktitut terms for mental health and mental illness that can help to raise awareness and support mental health literacy across generations?

With regard to the social movement, a link was made to the social movement that lead to the settlement of the land claim and the establishment of the Government of Nunavut. To the extent that this movement has had mixed results, this colours the reaction to the idea of a broad social movement on mental health. A hope was expressed: Will the mental health social movement include a recognition of those with the greatest needs, including Inuit?

All in all, this was a very significant dialogue for the Mental Health Commission. The feedback offered by participants will be very helpful in bringing a Nunavut perspective to the work of developing a mental health strategy for Canada.

Blog entry by Mary Bartram

Posted at 11:28 AM by Gillian Mulvale | Permalink | Email this Post | Comments (1177)

4/9/2009

Regional Stakeholder Meeting – Edmonton, March 26, 2009

The group in Edmonton started off with a great deal of energy, passion and support, which I really appreciated heading into our thirteenth and close to final stakeholder dialogue! In addition to a great cross-section of Albertans from various sectors, several Mental Health Commission staff members also took advantage of the proximity to our head office in Calgary and joined as observers or participants.

The opening comment that most resonated with me was that this framework phase of mental health strategy development was, in a sense, “a necessary evil” to build the consensus and momentum to drive system transformation in the next phases. This sounds bad but I think it speaks to the impatience we all share to move toward action, to see the mental health strategy driving change on the ground and making a meaningful difference in people’s lives.

There were some overall comments that stood out. An interesting suggestion was made regarding the use of the term “goal.” Would terms such as “pillar”, “elements”, or “direction” do a better job of showing the interconnections across the framework? The need to consider the integration with addictions, and to strengthen the discussion of gender in the document, was also raised at different points of the day.

The discussion on recovery was very lively, and underscored the complexity of the terms “recovery” and “hope,” which is reflected in the diverse ways in which they can be interpreted. The fundamental question seems to be: Taking the strengths and weaknesses of this wording into account, is there a better way to convey the underlying principles?

There was strong support for the goal on prevention and promotion, however the group challenged the Mental Health Commission: Why not really strengthen it, use stronger language, tie it to an accountability framework across all sectors, and put more emphasis on the underlying social determinants of health, including sexual abuse, family violence, and intergenerational trauma? For the first time, we also heard a call to put more emphasis on flourishing, on the business case for promoting mental health not just as a means of protecting against the onset of mental illness.

There was a rich dialogue on cultural safety. Those who were strongly supported felt that it was “very Canadian” in the sense of being very respectful of diversity. We heard some great suggestions: Can we acknowledge how people living with mental health problems and illnesses also have a culture? Can we apply an intersectional lens, one that looks at how each individual is diverse according to their demographic variables (age, geography), ethnographic variables (race, ethnicity), status (sexual orientation), and socio-economic status? Would this emphasize our commonality and complexity more, rather than dividing us into various groups?

Others in the group were uncertain about the term “cultural safety,” in many cases as a result of its being a new concept. Does it mean that this will be enforced? Would it require that we accept cultural norms without critical assessment? How is it different than cultural sensitivity? What about “cultural mindfulness?”

Advanced directives were highlighted as having the potential to bridge the incredible divisiveness of the issue of family involvement and consent. Can the MHCC play a role in advocating for more widespread support for advanced directives? Is there a need to review mental health legislation, can the MHCC play a role there? Does the MHCC need to include the wording in the goal description about “with the consent of... families are involved...,” isn’t this going to get people’s back up right from the start? As we have heard elsewhere, the MHCC was also encouraged to be clearer about its definition of family. I wonder, how can we both gear this goal to the needs of families of origin, and also families by choice? What about different cultural understandings of families, such as a Cree understanding that includes a very wide extended family?

With regard to access and integration, the group argued passionately that, in order for this goal to be achievable, there is a great need for policy and legislative back-up. Could the MHCC call for legislation such as the recently passed mental health parity act in the U.S.? Why can’t it call for mental health to be fully covered under the Canada Health Act, as part of the publically-funded health system? What can the MHCC do to advocate for alternatives to general emergency rooms, where people in psychiatric crisis can wait for days? What about the barrier to timely access for children to services when their parents prevent them from receiving services according to current legislation? What about a mental health rights tribunal, to uphold the charter rights of people living with mental health problems and illnesses?

The group was largely supportive of the goal on research, and pointed out a few gaps that require research attention. These include gender-based analysis and concurrent disorders, mental health and illness in diverse populations, and areas of mental health practice that may be harder to measure such as therapeutic alliance.

With regard to stigma and discrimination, there was wide support for a suggestion to adopt an “educate, legislate, regulate” approach, and an interesting call for a “Canada Mental Health Act” that was based on the same five principles as the Canada Health Act.

The discussion around the social movement goal revolved around question of sustainability. Can the MHCC speak to this in the final version of the framework, including a discussion of the role of the new charitable organizations, Canadian Partnership for Mental Health, and the new voluntary organization, Partners for Mental Health?

In every meeting, we have started out by quickly polling (using electronic keypads) the level of support in the group for each goal, and then repeating this at the end of the day. In most cases, the degree of support for the goals has been between 4 and 5 on five point scale, with a bit of drop over the course of the day once people have had a chance to look at them more critically. In this Alberta session, the degree of support for goals taken as a whole actually went up over the course of the day, which was very encouraging. Thank you to everyone for your excellent participation!

Posted at 11:15 AM by Gillian Mulvale | Permalink | Email this Post | Comments (16)

Regional Stakeholder Dialogue - Yellowknife, March 24, 2009

Our visit to Yellowknife afforded an opportunity to ‘walk on water’ – or more accurately ‘run’ back against a howling wind after visiting the Ice Castle on Great Slave Lake at night, following our day of consultations. The experience certainly brought home to us what advocates for housing in the north mean when they say that people facing temperatures of – 50 degrees have an acute need for housing and food security before they can even begin to contemplate recovery from mental health problems and illnesses.

This was just one of many realities about living in the north that we heard about over the course of the day. Others included:

· The acute lack of services. For example, there are no psychiatrists in the whole of the Northwest Territories. In fact, services are so limited that people are not able to access care until their needs are acute. This means that families are often the primary caregivers of very ill family members and that nurses, social workers and others provide most mental health care. Some are completed overwhelmed by the complexity of problems individuals are facing and truly ‘do not know where to begin’ to offer hope.

· The large distances to travel for specialized services. This results in high transportation costs for the person who needs care, and for an escort when required.

· The special needs of aboriginal communities, as well as of children, youth, and elders in those communities. There is often a traditional suspicion of any services offered by the ‘government’ and therefore a particularly important role for non-government community-based organizations. The need to send people south for services was described as a newer form of ‘residential schooling.’ Some people may get sent from place to place in Edmonton and Yellowknife from age 16 to 34.

· A lack of integration between community-based services and fly-in specialist services. Community services often work with a patient for many years and know them well, while a fly-in locum or psychiatric consultant often has only a brief encounter with patients. There is a need for visiting specialists to give credibility to community organizations who can help them to understand the lives of northerners and to understand the person’s history and context.

There was also concern raised that the focus in the north has been on the negative; on broken people, and broken services. It is equally important not to miss all the things that are working and the natural helpers who have been doing work in the communities for decades and centuries. It will be important that a northern strategy build on the strengths that always have been there.

Similarly, there is a need for community organizations which do exist to learn more about each other and how to work together when serving the same clients, in order to improve the services being offered. Such networking could also strengthen the voice of community organizations across the territories in policy-making.

As in other regions, there was strong support for the goals in the early voting. It was clear during the plenary discussion that there was a huge appetite to understand HOW the goals will be implemented. The need for a feasible, sustainable, cost-effective approach was underscored because of the scarcity of resources and associated capacity for reform in the Northwest Territories. Several important questions were raised in the discussion:

· Is there a need for a health human resources strategy for the north? In the Northwest Territories, most communities do not have psychiatrists, psychologists, addictions counsellors or mental health workers. Providers who relocate to the area usually do not stay because of differences in culture and lifestyle, including isolation, and the overwhelming needs of the people they are trying to help. Different professional categories, with different education levels may be required and there may be a need to expand informal support networks, and use more peer counsellors.

· Are we medicalizing what are ‘normal’ responses to stress and other challenges in the north?

· How can the Mental Health Commission help to overcome the’ long-standing tradition in this country of focusing on major cities and ignoring the north?’ How can the Mental Health Commission recognize the unique needs of the north while not treating the north as an ‘add-on’ to the overall strategy?

Recovery

There was considerable concern about the concept of recovery as described in the document. The description of recovery as ‘a journey’ was seen as negative, because a journey often takes a ‘very long time’ and can be quite onerous. This was contrasted with a ‘path’ that would involve fewer steps. The real concern was that we not present recovery in a way that seemed too overwhelming, or it would destroy hope. This is a particular concern in the north, where there is a long history of having no hope.

Other suggested concepts were wellness, wholeness or a ‘vision of where people want to be’ and then asking people for their ‘vision of how they will get there.’ A vision was seen as something that could continue to expand over time with each success.

Prevention/Promotion

This goal was strongly supported. As we have heard elsewhere, some felt it should be expanded to include educators to encourage them to move away from punitive approaches so that children get the right support and the encouragement they deserve. We also heard a need to develop programming for young people, and social outlets, to help them feel they can be successful. One participant also stressed that with a 10-year mandate the MHCC has an opportunity to examine medical, community, and cultural models on a longitudinal basis to measure outcomes.

Cultural Safety

There was particular support for the cultural safety goal in a community like Yellowknife, where there are more than 110 different cultural groups. One participant stressed that this can’t be just a ‘touch-up’; it needs to be a real shift in attitudes and approaches. At the same time, many questions were raised:

· Will funding bodies recognize traditional practice as a legitimate approach? How will traditional healers be recognized as legitimate?

· How can issues of gender be given more prominence? Treatment has left women very vulnerable and many have been assaulted in treatment.

· If we are truly to develop culturally safe services, will communities need to be given the resources to develop and deliver their own services?

Family

There were a number of concerns raised about this goal being too idealistic. First, the goal needs to recognize that some family environments contribute to the mental health issues of family members. Other questions were:

· How do children get to select who’s on their team? At what age do children get to choose?

· What does this goal mean for the elderly?

· How can families cope with the fact that a family member must be sent somewhere else for care when there is a crisis?

Access and Integration

This was seen as a great goal, but people questioned whether it was realistic in the north. One participant said it’s ”not practical that we will have seamlessly integrated system that will provide services that support their needs. It’s not possible. Who’s going to make it possible?”

Research and Outcomes

Participants felt that in order for research to be effective, it needs to involve the community and ensure that the community knows how the results will be used.

Stigma and Discrimination

There was strong support for this goal, but a sense that it should have a more positive spin by describing what we want to move toward, rather than what we want to eliminate.

Social Movement

The concept of a social movement was not well understood by participants at first. After discussion there was recognition that we all have a role to play by simply talking about mental illness in order to open up a dialogue, educate others and allow other people to speak of their experience.

Posted at 11:08 AM by Gillian Mulvale | Permalink | Email this Post | Comments (54)

4/1/2009

Regional Stakeholder Meeting - Montreal - March 10

On the morning of March 10, 2009, participants from several regions of Quebec representing a number of sectors of the mental health community seemed happy to reconnect with acquaintances, partners or colleagues, while others were wondering what to expect.

As soon as the stakeholders were introduced, an atmosphere of trust was established. All of them generously shared information on their link with mental health and their expectations for the meeting. Humour and good spirits were on the agenda, but everyone knew that they had little time in which to get all the day’s work done.

The various sectors of the mental health community were well-represented, and, clearly, the stakeholders were very knowledgeable in their field and had a high level of involvement in their community. Some praised the Commission’s initiative.

From the start, it was important that the participants comment on the translation of the draft national mental health strategy. Despite the relatively good quality of the French version, it is difficult to accurately express the contexts and concepts and to convey the spirit of the English version of the strategy in the language of Molière. It was suggested that the wording of some paragraphs be changed, that the concepts and definitions be used in a congruent and rigorous manner, and that some typographical errors be corrected. The group was of the opinion that a committee should be established to examine the two final versions of the strategy and ensure that they match as much as possible.

First of all, some people suggested that the current title of the document be changed to “Toward Well-Being and Recovery/Vers le bien-être et le rétablissement.” The switching of the order of the words in the title was suggested to emphasize well-being, while ensuring the recovery of persons suffering from mental disorders and mental illness. There was already some debate on mental health promotion and disease prevention.

Overall, the participants more or less agreed with the eight goals, but they had much to say regarding each. Although they did not deem it necessary to remove any, they wondered whether the order in which they are presented reflects the order of priority.

The concept of hope that underlies Goal 1 was welcomed enthusiastically. While keeping this basic concept in the description of the goal, it was suggested that more dynamic wording be used, along the lines of “Make sure that recovery is available to all/Veiller à ce que tout le monde puisse se rétablir.” Therefore, it is not just a matter of hoping to recover, but of actually recovering.

This concept of recovery must be defined only by the individuals suffering from mental disorders and mental illness, as it varies from person to person. Also, even when people recover, it is important to ensure that their care continues.

Although the concept of a “productive life” is defined in the text of Goal 1, some participants feared the current wording might lead to misinterpretation. They feared that some readers would take it to mean only having a paying job, even though the concept can mean something quite different for some people suffering from mental disorders and mental illness.

Some participants suggested that the order of goals 1 and 2 be reversed. Some were of the opinion that promotion of mental health must become the foundation of the entire strategy. Otherwise, they felt there was a risk of it being one of the things to do if enough time and money remain. The promotion initiatives must be targeted. Although school and the workforce remain important environments for mental health promotion, ways must be found to reach children 0 to 6 years of age. Prevention of drug addiction should also be part of the goal.

The participants had reservations about the terms “sécurité culturelle” (culltural safety and culturally safe). They seemed to agree with the orientations of the goal, but felt that the terminology posed a problem in a Francophone context. They suggested that French-speaking anthropologists be consulted to better define the principle of “cultural safety,” in order that it might truly resonate with Francophones.

Some participants said that there was some confusion in the Goal 4 statement on the importance of families in the recovery of family members. Reference should be made, not to “promotion du rétablissement” [promotion of recovery] (the comment seems to pertain only to the French text), but to “à promouvoir le rétablissement” [promoting recovery]. It was also suggested that common-law partners be considered family members: they also need support.

While recognizing the importance of confidentiality, some participants expect spouses and families of persons suffering from mental disorders and mental illness to be informed of their family member’s situation, in the same way that they are when family members are suffering from any other physical illness.

It was clear to the participants that services and programs must be based on people’s needs, rather than on available resources. Access must be equitable and services must be: integrated; flexible, rather than homogeneous; efficient, rather than effective; and continuous, in order that people may be supported throughout the journey. Also, there should be discussion regarding gaps in the system, rather than a focus on shortages in the systems.

Some were of the opinion that it would be appropriate to develop outreach services to identify people needing services in some environments, and to offer them the services they need.

There was interesting discussion regarding Goal 6. First of all, The participants would like “evidence” and “promising practices” to be defined. Then the following questions were asked: “What is the difference between evidence and knowledge?” “What is done with experiential knowledge?” Some stakeholders emphasized the importance of people’s experiences based on common sense. According to other stakeholders, precautions must be taken when using such experiences.

The importance of evidence was recognized by the participants. They also agreed with the need to create an appropriate database for monitoring mental health as described in the strategy. Some participants even said that the absence of such data is, for some decision makers, a good reason to do nothing.

Everyone agreed on the existence of discrimination against people living with mental disorders or mental illness. One participant told of a battle she had to wage for a number of years and of her victory against an insurance company in relation to a major depression she had suffered 30 years before. Stakeholders and persons suffering from a mental disorder or mental illness admitted that they themselves sometimes had prejudices.

Even though the participants agreed with the importance of a social movement, some felt that the concept of accountability is non-existent. Who will be responsible for the movement, accountable for it? How is the mental health community defined? These are questions that must be answered in Phase II, when the HOW of the strategy will be developed. Meanwhile, the participants want the wording of Goal 8 to be changed to remove the word “shadows” and put the emphasis more on light.

In closing, some participants noted that no goal related directly to the people using the services. How do they perceive the mental health system? What are their real needs? What do they hope for from the programs and services?

Some participants would also like a goal regarding the funding of mental health to be added. They feel that mental health is the “poor cousin” in the health field, and that ensuring appropriate funding that meets the needs of the population is a priority.

The results of the final vote on the 8 goals were not very different from those in the morning. Overall, the participants more or less agreed with the goals, despite the comments made with a view to improving the mental health strategy.

Most of the participants left smiling, with the feeling that they had got some work done!

The Commission thanks them for their outstanding contribution.

Posted at 10:52 AM by Mary Bartram | Permalink | Email this Post | Comments (154)

3/19/2009

Regional Stakeholder Meeting - Whitehorse, Yukon, February 27

Whitehorse - February 27. This was the first of three meetings planned in each of the three territories. We met in a sunny community room on the second floor of the local bakery/vegetarian restaurant, with a good mix of service providers, people with lived experience of mental health issues, a mother/son duo, government officials, NGOs, and First Nations Health and Social Directors from communities across the Yukon. Many of the issues that were brought forward reflected a unique northern perspective.

With regard to recovery, there was a real diversity of views. Some called for more of an upstream focus, others called for more focus on meeting the urgent and complex needs that are so pervasive in some communities. Much as we heard in St. John’s, there was a real concern about invoking the HOPE of recovery – does it raise false hopes when there are such barriers to access to services (poverty, shortages of services in remote communities, and lack of supportive friends/families/communities)? I found this interesting, as these are not the usual concerns about false hope, which centre more on concern that it raises false hope to say that recovery is possible for people with serious mental illness.

Another theme that emerged related to alternative approaches to healing and recovery – could the framework do more to advocate for greater recognition and support of alternative approaches?

The discussion around the promotion and prevention goal echoed the discussion of the recovery goal. While some felt that this goal needed to be strengthened (can we do better than “action is taken? How about strong leadership?), others felt that goal 5 should come before this, that our real priority should be access to services.

An interesting idea emerged on cultural safety – given concerns about slotting people in to cultural stereotypes, would it be better to focus on safety in the face of unequal power relationships? Is it hard to really talk about something that goes beyond cultural sensitivity and competence, that still uses the word “culture?” How is cultural safety really different than cultural sensitivity? There was strong support for the inclusion of support for translation services, and a suggestion to acknowledge literacy as well.

With regard to family, there was a very balanced and respectful discussion that on the one hand supported the call for greater recognition of and increased support for families, and on the other hand, raised concern that the goal as currently formulated seems to gloss over the fact that not all families are supportive or interested in being supportive. Consent and confidentiality issues were flagged, particularly given the northern and remote nature of their communities. And the importance of being able to choose who we consider to be our families was also raised. Questions included:

· Can the goal be re-balanced to put more emphasis on personal choice, while still honouring the contribution of family and their need for increased support?

· One participant memorably likened the onset of mental illness to “being run over by a truck.” Can we strengthen the discussion of prevention, to make clearer that sometimes it is very hard if not impossible to prevent mental illness?

· Where is the discussion on legal issues such as community treatment orders?

· Has adopting a comprehensive framework led the commission to dilute the clarity on the needs of family caregivers that Out of the Shadows had?

Another issue that we haven’t heard before – what can be done to address the differences in legal and policy frameworks between territorial and provincial services when people are sent south, to improve integration of services across jurisdictions?

The discussion of the access and integration goal kept coming back to the primacy of addressing inequities, of looking at access issues through the lens of major socio-economic disparities. Other issues with a northern flavour included continuity of care with services in Alberta, and the need for choice of services in order to address concerns about confidentiality in small communities.

A striking point was made regarding the research goal, that it isn’t just about translating knowledge into practice, but also about translating knowledge into POLICY.

With regard to stigma, there was some questioning of the term “illness,” is it stigmatizing? Would it be better to reframe the goal more positively, as in “everyone is accepted” ?

With regard to the social movement, similar concerns were raised as in other sessions regarding support for consumer organizations and how the movement will be managed. There was also a passionate call for this to focus on adequate funding of services and supports for people with urgent needs.

Posted at 9:25 AM by Mary Bartram | Permalink | Email this Post | Comments (39)

3/13/2009

Stakeholder Meeting - Federal Departments, Ottawa, February 20th

On February 20^th, we held a half-day meeting with officials from federal government departments in Ottawa. At least 17 departments were represented, including: several branches and agencies of Health Canada; departments with direct service responsibilities such as the Department of National Defence and Corrections Canada; and departments whose mandates have a strong influence on mental health and mental illness, such as Human Resources and Development, Services Canada, the Canada Mortgage and Housing Corporation, Justice Canada, and Indian and Northern Affairs Canada. Overall , support for the goals was quite strong, with some reservations and concerns expressed.

Many participants expressed concern regarding the structure of the framework, in so far as it combines vision and goals and in so far as it doesn’t clearly articulate how its success could be measured. Many also expressed a keen interest in being part of the discussion of HOW to achieve the goal on research, outcome measurement, and appropriate evidence.

As has been the case elsewhere, some participants were strongly supportive of starting the framework with a recovery goal, and others felt that the framework should lead with promotion and prevention. The latter group also asked: could the goal on access and integration more clearly articulate that this includes promotion and prevention programs?

Cultural safety was new to many people, and those who were familiar with it asked, can more be done to link cultural safety with a recovery-orientation, since both focus on partnership and empowerment?

Questions emerging from the discussion regarding family included:

Can more emphasis be placed on “families of person’s choosing?”

While family caregivers need increased recognition and support, could this not entrench the reliance on families for services and supports that should be accessed through the mental health system?

Can the goal be rebalanced to include greater reference to the ways in which families can be both a bad and a good influence?

With regard to the goals on stigma and the social movement, suggestions were made to frame the goals more positively. Rather than not tolerating stigma, can we talk about empowerment and mental health literacy? Rather than keeping mental health issues out of the shadows forever, can we talk about mental well-being for all Canadians?

There was also discussion about the need to look more closely at the role of fear in perpetuating stigma, and to more clearly define the parameters of the MHCC’s ability to be an advocate for a social movement that will bring pressure on the federal government, given that it is federally-funded.

We also took the opportunity to explore with this group the opportunities and challenges presented by the draft framework for the federal government, and for “whole of government” approaches. Participants encouraged the MHCC to engage the top levels of government on this question, and to learn more about the initiatives happening in individual departments and also interdepartmentally.

Posted at 3:42 PM by Mary Bartram | Permalink | Email this Post | Comments (368)

3/6/2009

Regional Stakeholder Meeting - Vancouver, B.C.

A happy coincidence led us to be in Vancouver for our regional dialogue on the MHCC’s draft framework at the same time as the government of BC was launching its own consultations about the 10 Year Plan to Address Mental Health and Substance Misuse in BC. Many participants in the MHCC session had just spent a day engaged in discussion of the BC plan. Talk about building momentum!

One participant gave feedback that I was very glad to hear. She expressed her appreciation for the consensus building process that the Commission was undertaking, and looked forward to seeing that consensus emerging in the mental health strategy development process.

The group was largely very knowledgeable about recovery, and supportive of a recovery orientation to mental health services and supports. There was an interesting discussion about hope: some thought that it was the most important word and concept in the whole framework, and others thought that including the term ‘the hope of recovery’ in the goal statement made it too soft, that it would be better to focus on achieving recovery, and include discussion of hope as part of that. Does it work to include “hope” as part of a broad, visionary goal?

Another theme that emerged that we hadn’t heard as much about to date was the need to focus on the biological factors that contribute to mental illness, in addition to the social factors. This was a particular concern with regard to the prevention and research goals. By talking about social risk factors such as bullying in schools, workplace stressors, family conflict, have we minimized the role of biological factors, particularly related to severe mental illnesses such as schizophrenia? Have we inadvertently kept the door open for families to be blamed for mental illness?

With regard to the promotion/prevention goal, there was strong support for this to be included as part of a mental health strategy for Canada. Some questions emerged that are in keeping with the proposed plan in BC. Can the goal statement speak more to how mental health touches everyone? Is “good” mental health clear enough, would “optimal” be better? Can addictions and harm reduction be brought in more (this was also raised in the discussion of all of the goals)? Can more emphasis be placed on social inclusion? Can this framework be more explicit about the critical role of the education sector?

Cultural safety was well-received by the group, particularly with regard to how it situates culture very broadly, as something everyone shares, and yet recognizes the political and historical context, and resulting power imbalances, that shape people’s experience of mental health services and supports. Could more be done to make explicit the roots of this concept in addressing the impact of colonization for indigenous peoples in New Zealand and elsewhere, and to explain the concept more clearly, given that is new to many people? Do we need this goal to address the history of racism and ongoing racism experienced by indigenous peoples in this country?

An idea emerged that was also expressed in an earlier consultation: Should we stop talking about the mental health system and start talking about the broader health and social system of services and supports, including both informal and formal systems? How about the mental wealth system? Do we need to keep some parameters in order to be realistic about what can be achieved? I wonder. I think we have tried to use the term mental health system in a broader way, that the mental health system includes the broad array of health and social services and supports. However, given the way that people have understood the mental health system more narrowly, I am not sure that we can use it to refer to a broader, transformed system.

The discussion around the family goal focused on the issue of consent, and the tension between the rights of the individual and the rights of the family. What about those who are too incapacitated by brain disorder to consent? Does the MHCC need to advocate for change in legislation to provide more rights to families in these cases? When consent is not provided, is their ability to support recovery undermined? On the other hand, how can we ensure that people’s support system is broader than their families, in the event that their families may be unsupportive or even abusive? Is it possible to introduce distinctions regarding whether people are competent to provide consent, or is there too much individual variability?

The group challenged the Commission to be bolder with regard to access and integration. It is not just about helping people navigate a poorly integrated system. Shouldn’t the strategy call for mental health (and addictions) to be integrated across the primary health sector, with strong support for the voluntary/peer support sector as well? Why is there no recognition of unregulated mental health providers, and how this lack of recognition limits access to these important services and can create a two-tier system?

With regard to practice being based on appropriate evidence, a caution was sounded regarding clinical practice guidelines. Do these guidelines limit the ability of service providers to provide culturally safe care, that takes each individual’s unique values, beliefs and social and political context into account?

As we have heard elsewhere, participants asked if the goal on stigma and discrimination could be framed more positively. If we talk about not tolerating something, is that a form of intolerance? Are we setting ourselves up to compete with funding for physical illnesses, when we should be looking to integrate our approach to mental and physical health? Shouldn’t the severe stigma associated with addictions be acknowledged? Can we do more to acknowledge how fear of mental illness and addictions, including death from suicide, contribute to stigma?

A suggestion was made for the social movement goal to be re-framed as a bridge to the next phase. The group also noted the strong links between a social movement and mental health promotion, particularly as they relate to strengthening community. Could they be merged?

Finally, this was the first meeting I have been at where, when the goals were put to a quick vote at the beginning and end of the meeting, support remained very high despite all of the concerns and questions raised.

And now on to Whitehorse, for our first regional dialogue that will be held in a Territory....

Posted at 8:43 AM by Mary Bartram | Permalink | Email this Post | Comments (53)

Regional Stakeholder Meeting Regina, Saskatchewan

February 24, 2009

From the moment people entered the room, we felt a real buzz of excitement, positive energy and welcome in Regina. There were many diverse viewpoints in the room, including people living with mental health problems and illnesses and providers from the fields of occupational therapy, psychology, social work, psychiatric nursing, psychiatry and some participants who represented viewpoints we had not yet heard from, including the Women’s Health Network, the Canadian Association for Suicide Prevention, and a former police officer.

Important themes that emerged in the opening plenary were the importance of remembering minorities, including the French-speaking minority in Saskatchewan, as well as recognizing the mental health needs of immigrants and First Nations in the province. We also heard the importance of recognizing that there is much diversity within the First Nations communities across Canada and that those in Saskatchewan may have different views than those in other parts of the country. We heard particular concerns about access to care in rural Saskatchewan and got a sense of just how widely dispersed the population is and the enormous distances to travel for care.

There was very strong support for all of the goals in the early voting. As well, several new perspectives and questions were raised by participants including:

Are we conducting a sex and gender based analysis in this document? While we refer to gender as one aspect of diversity that is important to consider for cultural safety, we need to also recognize that there are fundamental biological sex-based differences between men and women, that influence how we experience mental illness and respond to various treatments. It is important that the document captures this not only in Goal 3 that focuses on cultural safety and diversity, but throughout all the goals where pertinent.

Have we thought about giving different priority to the various goals? Upon further discussion the view was that all the goals are interrelated and very important, so that it would be difficult to set priorities among them. For example, is fighting stigma and discrimination more important than adopting a recovery orientation or cultural safety? Is promotion and prevention more important that having ready, equitable access to programs, services and supports that are seamlessly integrated? Instead, the goals need to be taken as a package, and the interlinkages and interdependencies between them must be recognized. Priorities will need to be set during the HOW phase, when the difficult choices will need to be made about where to focus our energies as various stages of the strategy are developed.

Does the term ‘mental health problem’ give a negative connotation – that it is indeed a problem? Is there a way to use a term that is less stigmatizing?

Other specific comments on each goal were as follows:

Goal 1

There was a general consensus from the small groups that recovery was an important concept, but that it would need a lot of explaining to Canadians. We were urged to come up with a catch phrase that put it in simple terms, such as “Recovery is.....” and to stress the importance of hope and a forward-looking concept. While the word recovery can imply , ‘getting something back’, the concept, especially as it applies to children and youth, involves recovering a capacity to move forward in life, to develop and to grow.
We were urged to remember that recovery can mean cure, and that in an aspirational goal, we would hope that over time, it will increasingly be able to mean this. We were urged to remove “despite any limitations caused by their condition” from the goal statement and replace it with something more positive.
Recovery needs to be positioned as a shared responsibility and to be careful that people are not ‘blamed’ for not recovering. One participant used the metaphor of a ‘bridge’, where programs, policies, services and supports and the social determinants of mental health in particular, such as ‘a home, a job, and a friend’ were the bridge and part of the shared responsibility. This ‘bridge’ must be in place in order that a person could take responsibility and walk across it as part of his or her recovery journey.
We were also asked to note that gender differences can be important to recovery. For example, women are less likely to use temporary shelters than men are, and are more likely to stay in an abusive relationship rather than seeking temporary shelter.
Finally, we heard that it will be extremely important to have extensive dialogue with providers about the recovery concept in order for it to be understood and embraced. Without such a dialogue, there will be a patchwork application of the principle in this country. Some providers may think they understand recovery and yet may not be practicing in a recovery-oriented way.

Goal 2

We were strongly urged to discuss suicide prevention as a part of this goal and to recognize that suicide is “the elephant in the room” that no one is discussing. We were also urged to refer to prevention of drug, alcohol and other addictions in this goal.
We were encouraged to recognize that this goal plays a huge role in being able to ‘sell’ the strategy to Canadians, and to appeal to a much broader audience because of the potential benefits of reducing the growing costs associated with treatment and the economic and other benefits of improving overall mental health.
We were told that the discussion of prevention needs to be clarified. For some illnesses, we are not yet in a position to fully prevent them, but we may be able to prevent episodes and lessen severity of episodes. Nonetheless, we should be aspiring toward a day when we can prevent all mental illnesses.
Once again, we heard that the education system has an important role in teaching resilience and the importance of having a balance in one’s life.
There was also concern about whether the concept of prevention can be used to blame people and their families for someone having a mental illness.
We were also told that there is much education to be done by the media, schools and workplaces to ‘drill’ the mental health promotion message into us, before people will begin to actively think about their own mental health.

Goal 3

As in other meetings, we heard that the term cultural safety was not familiar to most participants and at the same time, that participants were glad to see that the issues of racism, power imbalance, oppression and gender were raised. There was also support for recognizing that culture can be a source of strength and meaning.

Goal 4

There was good support for this goal, and people were glad to have families recognized. At the same time, the term ‘family’ was questioned, because some individuals have no family. Instead, we could use the terms ‘circle of care’ or ‘natural supports’.
One participant suggested that rather than having a new ‘system navigator’ role, everyone who interacts with a person and their family should take responsibility to ensure that appropriate help is found well before people and families are in crisis.
We were also encouraged to capture the fact that families need support in terms of their own recovery, particularly those families who have lost a loved one to suicide.

Goal 5

A major concern was how we could ensure services as close to home as possible in a province like Saskatchewan where the population is so widely dispersed. While a laudable objective, there is a need to refine it so as to not create unrealistic expectations.
We were encouraged to build capacity of other health care providers, teachers, police and other people a person comes in contact with to recognize a mental illness.

Goal 6

Participants stressed the importance of linking research and clinical practice, and to promote sex and gender-based research.
We were asked whether measurement and evaluation should be treated as a goal, or as a way of doing business?
We need to state that the Mental Health Strategy itself will be informed by evidence and evaluated.

Goal 7

Participants felt strongly that we needed to include the role of the media in perpetuating stigma.
Some argued that we should focus on discrimination rather than both stigma and discrimination and to root the issue in human rights.

Goal 8

· There was good support for the idea of a social movement, but that rather than being a goal, it should be part of the implementation of the strategy and HOW the goals will be achieved.

· There was also concern that more recognition should be given to the good work of existing organizations.

· One participant raised concern about how we would attract volunteers, given that most people would never expect to develop a mental illness.

The day concluded with continued strong support for all of the goals in the final voting. Participants were very supportive of the process and pleased to be able to participate. We now head for Vancouver with lots of new ideas to consider.

Posted at 6:37 AM by Gillian Mulvale | Permalink | Email this Post | Comments (119)

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