PARLIAMENT of CANADA
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OUT OF THE SHADOWS AT LAST 

Transforming Mental Health, Mental Illness and Addiction Services in Canada

The Standing Senate Committee on Social Affairs, Science and Technology


PART V
Federal Leadership


CHAPTER 13:
THE FEDERAL DIRECT ROLE

 

…initiate and coordinate activity across all federal departments to address federal government responsibilities to specific populations under its direct jurisdiction. —Dr. Albert Schumacher, President, Canadian Medical Association[1]

The federal government has significant responsibility for programs and services related to the mental health of seven client groups. For each group, this chapter provides an extensive description of the source of the federal authority and the array of federal programs and services for mental health, mental illness and addiction that are in place. It then offers some assessment of the needs of each group and a commentary about each situation.

To the best of the Committee’s knowledge, this is the first time a comprehensive look at the mental health needs of all the federal client groups has been undertaken. Therefore, following its examination of each client group, the Committee reviews the broader implications of the federal government’s addressing the mental health concerns of the more than one million Canadians who are its clients. In this chapter’s concluding section, the Committee identifies components of an integrated approach to improving mental health outcomes for all federal client groups.

To facilitate reading this long chapter, the following table provides a brief snapshot of the contents of each section pertaining to specific client groups. It presents a summary overview identifying the particular client groups, the responsible federal departments, and the general mental health activities undertaken by them.

 

Table 1:  Federal Client Groups in Summary


Client Groups

Federal Departments

General Mental Health Activities

First Nations and Inuit (13.1)

Health Canada

Community-based mental health care for First Nations on-reserve;

Non-insured drugs and short-term mental health crisis counseling for registered First Nations and recognized Inuit;

Addiction treatment centres.

Indian and Northern Affairs Canada

Basic services for First Nations on-reserve and in Inuit communities including education, income assistance, housing, family violence prevention.


 


Client Groups

Federal Departments

General Mental Health Activities

Federal Offenders (13.2)

Correctional Service Canada

Basic mental health nursing assessment at reception centres; admission to treatment centres if necessary and available; general services at regular institutions; essential services if in Community Correctional Centre; non-insured health care coverage if approved.

Canadian Forces

(13.3)

National Defence

Non-emergency, outpatient mental health through base clinics, health care centres and support units;

Specialized mental health services purchased from provinces;

Referrals to operational trauma and stress support centres.

Veterans (13.4)

Veterans Affairs Canada

Community based mental health care services extending beyond provincial or territorial plans;

Institutional mental health care in Ste-Anne-de- Bellevue, Quebec and in contract hospitals in provinces;

Shared services with DND on operational trauma and stress.

RCMP (13.5)

RCMP

General health services offered within regional divisions to ensure fitness to perform duties;

Use of provincial services as authorized.

Immigrants and Refugees (13.6)

Citizenship and Immigration Canada

Essential and emergency mental health services (physician, hospital, and drug) for those unable to pay.

Federal Public Service Employees (13.7)

Treasury Board

Coverage of services and other benefits not provided through provincial/territorial insurance plans;

Employee assistance counseling.

 

From the outset, the Committee emphasizes that it expects the federal government, together with its provincial and territorial counterparts, to ensure that federal clients have access to the system transformations already identified in Chapter 5.  Thus, the Committee intends First Nations and Inuit, federal offenders, Canadian Forces members, veterans, RCMP members, immigrants and refugees and federal public service employees to be part of a mental health system that is recovery-oriented, person-centred, community based, and integrated across the full continuum of care and all age groups.

The Committee is pleased with the significant evidence that individual federal departments and agencies have moved in this direction. Some departments have developed approaches that utilize case management and a wider range of mental health providers. Others have focused on mental health enhancements through improvements to the determinants of mental health such as housing, employment and broad social needs. Several departments and agencies are working collaboratively with one another and with their provincial and territorial counterparts on mental health initiatives.


13.1 FIRST NATIONS AND INUIT

Inuit have embraced the federal commitment to a renewed relationship and believe that a further commitment for an Inuit-specific mental health strategy is important. —Larry Gordon, Chairman, National Inuit Committee on Health, Health Department, Inuit Tapiriit Kanatami[2]


A collaborative action plan and wellness strategy between federal and First Nations leadership would immediately address the mental wellness crisis in a manner that is collaborative, comprehensive and culturally relevant. —Valerie Gideon, Director of Health and Social Secretariat, Assembly of First Nations[3]

13.1.1    Federal Responsibility

Under the Constitution Act, 1867, section 91(24) allocated exclusive legislative responsibility over “Indians and Lands reserved for the Indians” to the federal Parliament. In turn, Parliament passed the Indian Act of 1876 that established the criteria for a “status Indian” together with a framework for federal jurisdictional responsibilities. A ruling of the Supreme Court in 1939 further determined that Inuit (then called Eskimos) were Indians for the purposes of section 91(24).[4]

It is important to note that this section looks only at the First Nations and Inuit clients who are identified primarily as federal clients. The federal government does not acknowledge responsibility for all Aboriginal peoples; it is estimated that one-third of Aboriginal peoples do not have specific access to federal programs and services. At the present time, the federal government provides certain federal programs and services to status Indians (also known as Registered Indians and First Nations) that are not available to non-status Indians or to Métis.  In addition, some but not all federal programs and services have been extended to Inuit.

This chapter considers only the First Nation and Inuit considered eligible for federal programs and services relevant to mental health, the main focus being on those delivered through the departments of Health Canada and Indian and Northern Affairs. The following chapter (Chapter 14) provides a broader perspective in that it covers the mental health of all Aboriginal peoples, including non-status (and off-reserve status Indians) as well as Métis.  Chapter 14 also presents the components for a comprehensive, integrated, community-based wellness and healing strategy that supports distinct approaches for all groups of Aboriginal peoples.

Indian and Northern Affairs Canada has primary responsibility for the constitutional and statutory obligations and responsibilities of the federal government to Indian and Inuit people. Through the administration of the Indian Act, the department supports self-government, economic, educational, cultural, social, and community development for registered Indians and certain Inuit. According to the departmental performance report of 31 March 2005, the total Status Indian population was 733,626.[5] The report provides no indication of the size of the Inuit population.

Text Box: Health Canada has primary federal responsibility for health services, including mental health services, to First Nations and Inuit on all reserves and in many remote and isolated communities; it delivers these services through nursing stations and health centres.Health Canada has primary federal responsibility for health services, including mental health services, to First Nations and Inuit on all reserves and in many remote and isolated communities; it delivers these services through nursing stations and health centres. In addition, the 2005 departmental performance report indicated that Health Canada provides “supplementary health benefits to approximately 765,000 eligible First Nations and Inuit people.”[6]

 

Text Box: The division of mental health responsibilities between the federal health department and its provincial or territorial counterparts is “often confusing, even for those of us who are in this on a day-to-day basis.”

Ian Potter, Assistant Deputy Minister, First Nations and Inuit Health Branch, Health Canada described the agreement on Federal Indian Health Policy signed in 1979 that defines the current roles of the federal and provincial governments.[7]

 

 

It meant that on isolated reserves and areas where provinces were not providing primary care, the federal government would continue to finance and provide that. It meant that the federal government would provide public health services on all reserves, including prevention services. As well, it meant that the federal government would provide non-insured drugs, dental work and transportation for all First Nations and Inuit on and off-reserve.[8]

Mr. Potter acknowledged that the division of mental health responsibilities between the federal health department and its provincial or territorial counterparts is “often confusing, even for those of us who are in this on a day-to-day basis.” He nonetheless offered the following capsule description:

Basic mental health services and addiction services are provided primarily by provincial governments to all residents of the province, which includes First Nation, Inuit and other Aboriginal people. They provide hospital care, psychiatric and general physician services. Provinces also provide community-based prevention, outpatient treatments, aftercare, detoxification services and residential addiction treatment services.[9]

 

13.1.2   Federal Programs and Services

Text Box: Within the federal jurisdiction, Indian and Northern Affairs Canada has the widest scope of programs and services related to the broad determinants of mental health. It offers services to First Nations on reserves that are similar to those delivered by provinces to their general populations.Indian and Northern Affairs Canada and Health Canada have increasingly delegated to First Nations authorities and some Inuit commu­nities their departmental responsibility for the administration and delivery of many programs and services vital for mental health.  Specific eligibility criteria still apply to these programs regardless of who provides them:

 

 

§         Indians must be registered as an Indian under the Indian Act and be recorded on the Indian Register; Inuit have a recipient identification number.

§         For some services, prior approval is required from departmental authorities.

§         The programs serve eligible individuals resident or ordinarily resident on a reserve or in a recognized Inuit community.

Within the federal jurisdiction, Indian and Northern Affairs Canada has the widest scope of programs and services related to the broad determinants of mental health. It offers services to First Nations on reserves that are similar to those delivered by provinces to their general populations. These services include education, income assistance, and infrastructure support and account for more than 80 percent of total on-reserve funding.

Text Box: Health Canada’s First Nations and Inuit Health Branch estimated its annual spending on mental health, mental illness and addictions-related programs and services to be $267.5 million.Indian and Northern Affairs Canada’s Elementary/Secondary Education Program provides access to schools, either by funding instructional services on reserves, or by covering the cost of attending provincial or territorial schools. Its Social Assistance Program helps First Nations individuals and families living on reserves meet basic needs for food, clothing and shelter. Its Family Violence Prevention Program funds some shelters on-reserve, reimburses shelters located off-reserve for services provided to First Nations people who ordinarily live on a reserve and also funds community-based family violence prevention programs.

Health Canada’s First Nations and Inuit Health Branch estimated its annual spending on mental health, mental illness and addictions-related programs and services to be $267.5 million. This included $36.4 million in 2004/2005 spent through the Non-Insured Health Benefits Program on pharmaceuticals to treat mental illness and addiction.[10] 

The estimate also included community-based prevention and promotion programs on reserves and in Inuit communities:

… $40 million a year in ongoing funding to community-based mental health programs through a program called Building Healthy Communities, and an additional $51 million per year for mental health and child development activities through Brighter Futures.

In addition, addiction programs were provided to First Nations and Inuit organizations through

… the National Native Alcohol and Drug Abuse Program ($59 million per year), the Youth Solvent Abuse Program ($11 million per year), the First Nations and Inuit Tobacco Control Strategy ($12 million per year), and the Canadian Drug Strategy ($1 million per year).[11]

Mental health counselling, usually provided by psychologists, was available through the Non-Insured Health Benefits program to eligible First Nations and Inuit regardless of residency. Kathryn Langlois, Director General, Community Programs Directorate, First Nations and Inuit Health Branch, Health Canada, emphasized that federal provision was limited to short-term counselling:

We would provide the short-term crisis mental health counselling and then a referral would be made to the provincial system. It would be accessed in the same way as any individual off-reserve, through emergency or a family physician. The province would pay.[12]

Text Box: Health Canada has also convened a First Nations and Inuit Mental Wellness Advisory Committee (MWAC) to develop a strategic action plan to improve mental wellness outcomes for First Nations and Inuit.Kathryn Langlois also referred to substantial departmental work on suicide that was begun after a suicide prevention advisory group was set up in 2002 by then National Chief Matthew Coon Come and Health Minister Alan Rock. New funding announced in September 2004 included $65 million allocated over five years for an Aboriginal youth suicide prevention strategy; $5 million was allocated for 2005 and $15 million for each of the next four years.

Health Canada has also convened a First Nations and Inuit Mental Wellness Advisory Committee (MWAC) to develop a strategic action plan to improve mental wellness outcomes for First Nations and Inuit. The committee includes representatives from the Assembly of First Nations, Inuit Tapiriit Kanatami, Federal/Provincial/Territorial networks, mainstream and Aboriginal expert mental health and addictions organizations, Indian and Northern Affairs Canada, and the Public Health Agency of Canada. Following a strategic planning session with content experts in November 2005, a draft plan was made available for the committee’s review in February 2006.[13]

 

13.1.3   Assessments of Client Group Needs

Text Box: Overall, these clients have poor health status, “well below that of the rest of Canadians”.The registered Indians and recognized Inuit that make up the defined federal client group have a very diverse set of characteristics. For example, while the services and programs are available primarily for First Nations living on-reserve, many individuals migrate in and out regularly. Some Inuit live within the area covered by land claims agreements while others do not. 

Overall, these clients have poor health status, “well below that of the rest of Canadians.”[14] Furthermore, providing services to them is made more difficult due to their geographic dispersal across wide areas; many live in remote or isolated communities.

 

13.1.3.1    Indian and Northern Affairs Canada’s Programs and Services

Indian and Northern Affairs Canada has responsibility for several key factors that are essential to a comprehensive approach to the mental health of First Nations and Inuit communities, factors such as economic development, housing and education. Witnesses told the Committee that the Department’s efforts fell short of expectations. Irene Linklater, Research Director, Research and Policy Development Unit, Assembly of Manitoba Chiefs criticized the fact that:

… the Department of Indian Affairs spends 13 million on social assistance to every $1.00 in economic development. The impact has been that Manitoba First Nations communities have at least one-third to one-half of the First Nations on-reserve population on income assistance, with a range of 24 to 88% in some communities.[15]

Witnesses also made a connection between serious housing inadequacies and the resulting negative effects on mental health:

The experience of what is considered homelessness and what we see as invisible homelessness is that by living in such crowded conditions, there is a constant moving of people and houses, and they are not found within the statistics; in other words, you do not see that reflected within a statistical framework. Lack of proper housing is associated also — and research studies confirm this — with lack of personal care, ill health, and lower longevity.  — Irene Linklater[16]


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

Text Box: 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.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]

Text Box: The short-term, unstable and uncertain funding presents significant barriers to the delivery of mental wellness programs.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]

Text Box: 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.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]

Text Box: For Inuit trying to access addiction services, a barrier is created by the regional administrative divisions established within Health Canada.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

Text Box: Cross-jurisdictional barriers between federal and provincial or territorial governments prevent forward movement on mental health concerns.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]

Text Box: There is 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.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.

Text Box: 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 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.

Text Box: 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.

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.

 

Text Box: 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.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.

Text Box: 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:

 

 

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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.

 

Text Box: 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 interdepartmen¬tal fragmentation that contributes to the overall poor health status of First Nations and Inuit.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.

Text Box: 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.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:

 

 

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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

Text Box: Almost half of those with substance abuse problems have another concomi¬tant disorder; the rate of suicide is considerably higher among inmates than in the general population.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.

Text Box: 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.
— Howard Sapers

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]

Text Box: About 22% of adult offenders would likely be diagnosed with FASD.
— Howard Sapers
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;

§         Text Box: The Mental health Strategy, approved by the CSC in the summer of 2004, has languished.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]

Text Box: In practice, mental health care at the reception centres, treatment centres and community health services is generally not available.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

Text Box: 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.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.

Text Box: 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.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

Text Box: 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.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:

Text Box: 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.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

Text Box: 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.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

Text Box: Although inmates in segregation are supposed to be seen once a month by a psychologist, Natalie Neault pointed out that this is not possible.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:Text Box: Segregated offenders are more likely to be recipients of inappropriate assessment; it is less likely that their mental health needs will be fully recognized.

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]

Text Box: 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.Text Box: 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”.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]

Text Box: Significant cost saving could be achieved by reaching Aboriginal children in a positive way before they interact negatively with the law.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:

Text Box: The lack of continuity between institutional and community based programs and services leads to various problems for offenders who are released.… 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

Text Box: 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. If the goal of incarceration is rehabilitation as well as public safety, this goal must be met.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.Text Box: 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.

 

 

Text Box: 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.

 

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:

 

 

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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:

 

 

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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:

 

 

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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.

Text Box: 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.”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]

Text Box: 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.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

Text Box: Most specialized mental health services are purchased from the provinces.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

Text Box: About 42% of all medically-related time off work among CF personnel was for mental health issues.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]

Text Box: 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.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]

Text Box: 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.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

Text Box: The access to, and adequacy of, pensions for individuals who are medically released was also raised as an issue.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

Text Box: 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 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.

Text Box: The provision of services for family support as well as medical treatment and casualty support is commendable.

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:

 

 

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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.

Text Box: 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.The Committee recommends:

 

 

 

 

 

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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:

 

 

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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

Text Box: 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.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

Text Box: 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. This disability pension program has been the gateway to the health care benefits and other programs offered by Veterans Affairs Canada.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

Text Box: It is expected that the proposed Health Benefits Program “will fill gaps in post-release health coverage by ensuring that medically released CF Veterans have access to group family health insurance.”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

Text Box: 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.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

Text Box: Former or current peacetime members of the Canadian Forces, reported dissatisfaction with the process for accessing 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]

Text Box: The irony is that healthy, (for the most part) employable soldiers in DND have an independent ombuds¬man while disabled and often unem¬ployable veterans do not.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]

 

Text Box: Case management services could help clients and their families cope with psychological disability and work their way through a complex landscape of programs.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

Text Box: Veterans Affairs Canada has difficulties accessing mental health services through provincial providers.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]

Text Box: Telehealth is one option that shows promise for the department and its clients.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

Text Box: 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 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:

 

 

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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.

 

Text Box: 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 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:

 

 

 

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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.

Text Box: Lack of training in dealing with public manifestations of mental illness is also endemic to the internal workings of the RCMP.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.Text Box: The judge stated that RCMP training to deal with mentally ill people varied from non-existent to less than adequate.
— Shirley Heafey

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.

Text Box: Police officers may be hampered by a belief that admitting to problems and seeking help suggests weakness.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.

Text Box: 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.”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

Text Box: 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.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

Text Box: The Committee is unaware of the training provided to RCMP officers to increase their understanding of mental illness.  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.

 

Text Box: 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.

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:

 

 

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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:

 

 

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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

Text Box: All applicants for permanent residence and some for temporary residence (e.g. visitors, students and workers) undergo a physical and mental examination.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.

Text Box: 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.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]

Text Box: Citizenship and Immigration Canada’s direct role in the provision of mental health services is through the Interim Federal Health Program.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

Text Box: In many towns, no language program or support services exist for immigrants, leaving them without access to resources that would enhance their mental health.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.Text Box: 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.

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]

Text Box: Over time, the underutilization of services by newcomers could prove very costly to the health care system.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]

Text Box: Underutilization may be also result from fear that using mental health services could jeopardize ongoing immigration applications.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

Text Box: 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.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:

 

 

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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.

 

Text Box: 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.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:

 

 

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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

Text Box: 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.  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.

Text Box: 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.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]

 

 

Text Box: 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.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

Text Box: 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.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]

Text Box: The way the federal government, as an employer, treats its psychologists actually contributes to the overall stigma of mental illness.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 Text Box: 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.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:

 

 

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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:

 

 

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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. 

Text Box: 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.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.Text Box: 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 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:

 

 

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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

Text Box: The Committee believes that the government has both the opportunity and obligation to apply population health concepts to its own clientele.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.

Text Box: Given its substantial responsibilities for the provision of mental health service, the federal government must lead by example.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:

 

 

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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

Text Box: 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 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:

 

 

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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

Text Box: The federal government is completely respon¬sible 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.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]

 

Text Box: 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.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]

Text Box: 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.  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:

 

 

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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

Text Box: 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.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.

 

Text Box: 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.

 

 

 

Text Box: The Committee also believes it essential for the federal government to provide regular reports to Parliament on its mental health 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]

Text Box: 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.  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:

 

 

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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.

 


CHAPTER 14:
ABORIGINAL PEOPLES OF CANADA

14.1      INTRODUCTION

… for Aboriginal people the health continuum is about wellness and not illness. Aboriginal mental health is relational because strength and security are derived from family and community. Apart from sharing healing traditions, Aboriginal communities are bound by a concept of wellness wherein the mind, body, spirit and soul are interconnected. —Debbie Dedam-Montour[194]

Text Box: The Committee can reach only one conclusion — Canada’s record of treatment of its Aboriginal citizens is a national disgrace.For too many Aboriginal peoples, the wellness continuum has been seriously disrupted. Individuals and communities wage a daily battle with adverse conditions in their physical, social and emotional environments.  For large numbers, the outcomes are chronic unemployment, violence, addictions and suicide. The Committee can reach only one conclusion — Canada’s record of treatment of its Aboriginal citizens is a national disgrace.

Text Box: Despite multiple reports and subs¬tantial allocations of human and financial resources, the overall mental health of Aboriginal peo¬ples continues to be at serious risk. Their mental health is located at the extreme negative end of the continuum.

It is highly misleading, moreover, to speak of Aboriginal peoples as a single homogeneous unit.  The Constitution Act, 1982 recognized three groups of Aboriginal peoples — defined as the “Indian, Inuit and Métis peoples of Canada.”[195]  Witnesses, acknowledging the diversity that exists between and within each of these groups, emphasized:

To have a fundamental impact on the mental health of Aboriginal peoples, a number of changes or actions must take place.  Policies, programs and procedures developed by the government need to be respectful and inclusive of all First Nations, Métis and Inuit concepts of health and healing.  —Bernice Downey[196]

The Committee struggled with the knowledge that, despite multiple reports and substantial allocations of human and financial resources, the overall mental health of Aboriginal peoples continues to be at serious risk. Taking the rates of suicide and of addiction as measures, their mental health is located at the extreme negative end of the continuum. Witnesses expressed frustration over the frequency of governmental consultations and the absence of actions that lead to improved outcomes. In the words of one presenter:

The reality is that our comments and our suggestions are documented, but it has yet to be proven that they have been implemented. —Lorraine Boucher[197]

The Committee acknowledges that it cannot in a single chapter review the long and negative legacy of Canada’s Aboriginal peoples. Our intent in this chapter is to give another voice to the individuals who took the time to share their ideas with us.  The Committee heard that the same factors that promote wellness for Aboriginal peoples — family and community support, economic opportunities, social and physical security, etc. are, in their absence, the ones that create the need for healing.  We heard also that if Aboriginal peoples could take ownership and control of their personal and community health, much of their present ill-health would be prevented.

14.1.1    A National Aboriginal Advisory Committee

Text Box: The Committee wants to ensure that ongoing national mechanisms are put in place to provide avenues for obtaining the advice of Aboriginal peoples and translating it into action.The Committee wants to ensure that ongoing national mechanisms are put in place to provide avenues for obtaining the advice of Aboriginal peoples and translating it into action.  In its recommendation to create a Canadian Mental Health Commission (see Chapter 16), the Committee incorporated three specific measures designed to guarantee that this happens.  First, one of the governmental nominees will be a representative of the territorial governments, and will therefore be in a position to speak to the specific concerns of Aboriginal people living in the north.  Second, the Commission report specifies that the non-governmental members of the governing Board of the Commission must include people who have experience of, and understand the issues confronting, people of Aboriginal origin.  Third, of the two advisory committees that must be put in place by the Commission, one must be an Aboriginal Advisory Committee.

Text Box: Within the structure of the Mental Health Commission, the Aboriginal Advisory Committee will have a status equivalent with and parallel to the status of the advisory committee representing the provincial and territorial governments.

The Committee recognizes that a report such as this one that is focused on mental health, mental illness and addiction cannot address all the broad constitutional, policy and governance issues that have a real impact on the health and well-being of Aboriginal peoples.  However, the Committee strongly believes that its recommendations for improving the mental health of Aboriginal peoples may help open the door to broader initiatives. 

In this regard, it should be noted that, besides the Aboriginal Advisory Committee, the Mental Health Commission is required to create only one other advisory committee which will be composed of representatives of all the provincial and territorial governments.  Thus, within the structure of the Mental Health Commission, the Aboriginal Advisory Committee will have a status equivalent with and parallel to the status of the advisory committee representing the provincial and territorial governments.

For the Committee, this Aboriginal Advisory Committee is a vital component of a larger (and longer-term) endeavour aimed at significantly improving the mental health and well‑being of all Aboriginal peoples.  The Committee believes that the Aboriginal Advisory Committee will provide a crucial focal point for furthering the development of a specific strategy for mental health that reflects the distinct approaches needed by all groups of Aboriginal peoples.  As the following sections emphasize, this strategy must be based on the recurring calls by Aboriginal peoples for community authority and control, cultural accommodation, and equity of access with respect to mental health programs and services.

The Committee also believes that the recommendations it makes in this report for ensuring that Aboriginal peoples themselves are fully involved in the design and delivery of improved mental health services and supports are entirely consistent with the community-based orientation for mental health that the Committee is advocating for the general population.  It therefore hopes that the Aboriginal Advisory Committee will be able to promote a fruitful two‑way dialogue within the Mental Health Commission that will allow non-Aboriginal Canadians to learn from the experience and traditions of Aboriginal Canadians in promoting mental health and well-being.

The Committee thus emphasizes the recommendation made in Chapter 16:

 

 

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That the Canadian Mental Health Commission (see Chapter 16) establish an Aboriginal Advisory Committee comprised of representatives of Aboriginal communities, whose membership shall be determined by the Commission in consultation with Aboriginal organizations, and shall provide representation from First Nations, Inuit and Métis and broadly reflect the geographic distribution of Aboriginal communities across the country.

14.2      WELLNESS AS THE GOAL

Text Box: Witnesses representative of all Aboriginal peoples emphasized that the focus must be changed from mental illness to mental wellness. They called for a holistic and comprehensive approach addressing all determinants of health.Witnesses representative of all Aboriginal peoples emphasized that the focus must be changed from mental illness to mental wellness.  They called for a holistic and comprehensive approach addressing all determinants of health.

Valerie Gideon, Director of Health and Social Secretariat, Assembly of First Nations, noted a call for a comprehensive and holistic First Nations wellness strategy:

Certainly, that strategy would have mental health and suicide prevention as a key point of focus. It would look at a holistic approach for mechanisms that would enable communities to have the flexibility to allocate resources toward priorities and make linkages with some of the health determinants that are fundamental, such as education, housing, and social and environmental issues.[198]

The Inuit also seek an approach reflective of their particular circumstances. According to Onalee Randell, Director of Health, Inuit Tapiriit Kanatami, Inuit need:

a…continuum of services that incorporates traditional knowledge and practices that are based in their home community or, at a minimum, their home region; …that provides supports for individuals and families; and services that breach the barriers and [address] both the medical and non-medical determinants of mental wellness, including economic and environmental matters, and housing and education.[199]

Although few Métis organizations participated directly in Committee proceedings, Bernice Downey, Executive Director, National Aboriginal Health Organization, presented the perspective of the Métis health unit.  She emphasized that the development of a comprehensive and inclusive plan for mental health, mental illness and addiction:

…hinges on the awareness of the governments to acknowledge and respect not only the jurisdictional rights of Metis, but also the concept of health and wellness from a Metis perspective.[200]

 

14.2.1   Mental Health Rather Than Mental Illness

Text Box: Witnesses spoke of the need to adopt a holistic approach to address an individual’s spiritual, emotional, mental and physical needs when placed against the external social, cultural, economic and political reality experienced by that individual.Talking only about mental illness constitutes, for most witnesses, a negative, stigmatizing approach that discourages people from raising particular mental health issues.  Some like Arnold Devlin, Dilico Ojibway Child and Family Services, argued that:

It is important to differentiate between mental problems and mental illness. There is no reason to expect, and I see no evidence that mental illness is any greater within the native community than it is in the general population. The fact that we have more mental problems is true. That is what we are referring to and looking at. There is a highly significant difference between the two.[201]

He emphasized that, for many Aboriginal peoples, the outward manifestations of their situation should be seen “as mental distress versus mental illness. The level of mental distress can be a specific episode that lasts a certain length of time but I would not classify it as a mental illness.”[202]

The Committee heard that Aboriginal peoples are not more predisposed than anybody else to particular mental illnesses but that individuals can manifest profound inability to manage in Canadian society, a powerlessness too often expressed as depression, suicide and addiction. Elsie Bastien, Aboriginal Liaison Coordinator, Alberta Mental Health Board, argued that:

Mental health is a concern for Aboriginal communities not because Aboriginal people have higher rates of severe mental illness such as schizophrenia, but because so many show signs of low level yet debilitating disturbances.  The indicators of this are the high rates of alcohol and drug abuse, suicide, accidents, violence, as well as educational failure, unemployment and incarceration.[203]

To prevent or to address these negative outcomes, witnesses spoke of the need to adopt a holistic approach to address an individual’s spiritual, emotional, mental and physical needs when placed against the external social, cultural, economic and political reality experienced by that individual. As expressed by Sheila Levy, President, Nunavut Kamatsiaqtut Help Line:

Poverty, crime, violence, addictions, all categories of abuse, overcrowded housing, alienation, abandonment and suicide are all connected to mental and physical well-being. That interconnectivity of mental health issues is often forgotten.[204]

14. 3     WELLNESS THROUGH HEALING

Achieving the emotional wellness desired by and for the individuals, families, and communities of all Aboriginal peoples requires healing. While recognizing the continuing impact of past injustices, witnesses expressed a strong desire to move forward using healing practices appropriate to their traditional cultures.

Bernice Downey talked about the Métis perspective on healing that:

...includes the provision of services in their Aboriginal language and the inclusion of traditional knowledge and healing practices.[205]


Jennifer Dickson, Executive Director, Pauktutit Inuit Women’s Association, called for:

…a healing centre in each of Canada’s remote Arctic communities. Well-trained mental health resource people must be available. These centres might provide places where Inuit elders, adults, youth and organizations could truly listen to each other and involve each other in meaningful interventions and traditional healing.[206]

Text Box: Witnesses expressed a strong desire to move forward using healing practices appropriate to their traditional cultures.Bill Mussell, Chair, Native Mental Health Association, insisted that, if First Nations people had the chance to understand their past through healing processes, they would adopt healthier ways of coping:

When you think about grieving, healing, and the effects of trauma, there is a process of helping people to get in touch with what happened so they can continue to grow and develop. They must get in touch with their experiences. This process can be successful when performed with people who care about them that can provide them with the safety that is necessary to begin to get in touch with the dynamics of their life.[207]

 

14.3.1   The Need for Healing

Text Box: Of the almost 1 million Aboriginal people currently in Canada, over one-third have been affected either directly by residential school experiences or indirectly as family or community members linked to survivors.In addition to socio-economic and situational factors, the Royal Commission on Aboriginal Peoples identified culture stress brought about by the loss of land and control over living conditions, suppression of belief systems and spirituality, weakening of social and political institutions, and racial discrimination as destructive forces that continue to damage the confidence and overall health of Aboriginal peoples.[208]

To understand fully the need for healing, Tarry Hewitt, Project Coordinator, Aboriginal Survivors for Healing, reminded Committee members that:

…the historical context is critical.  In revisiting the impact of colonization and, in particular, the legacy of the residential school system, it may appear that we are going over old ground already dealt with in the previous reports produced by this committee.  However, it is important to connect the dots to examine how we got here from there in order to understand how to move ahead.[209]

According to Gail Valaskakis, Director of Research, Aboriginal Healing Foundation, the trauma for Aboriginal people exposed to residential schools will take several generations to remedy:

It has to do with the loss that people who attended residential schools suffered in regard to language, to culture, to family, to nation, and with the impact that had on Aboriginal communities with respect to a cycle of abuse over a long period of time; in regard to the lack of parenting skills that related to their experience in residential schools and historical trauma — something we have learned a great deal about lately — with regard to the grief and loss that Aboriginal people have felt over many years of displacement, loss of culture, loss of language and death in their own communities.[210]

She estimated that “it takes a community an average of 10 years to reach out, to dismantle denial, to create safety and to engage participants in the therapeutic healing process.”[211]  Of the almost 1 million Aboriginal people currently in Canada, over one-third have been affected either directly by residential school experiences or indirectly as family or community members linked to survivors.

 

14.4      STRATEGY FOR WELLNESS AND HEALING

Text Box: The pressing need is for a wellness and healing strategy with a clear action plan that can and will be implemented.  So what is the way to build and to restore wellness for all Aboriginal peoples? Out of the many individual submissions and interventions, one message emerged clearly.  For First Nations, Inuit and Métis, the pressing need is for a wellness and healing strategy with a clear action plan that can and will be implemented.  People want action on overall mental health that will produce positive results for their communities.

The strategy must be inclusive of all groups — Indian (status and non-status), Métis and Inuit — from all regions of Canada.

In 2001, the North American Indian population was the largest, at 62%, of the total self-identified Aboriginal population of Canada.  Of those North American Indian individuals, about 505,000 were registered Indians with legal status and 104,000 were not registered and lacked legal status.  Métis represented about 30% of self-identified Aboriginal peoples, about 292,000 individuals in total. Inuit represented about 5% of the self-identified Aboriginal peoples, enumerated at about 45,000.[212]

The multiplicity of individuals who identify themselves as Aboriginal people makes it difficult to generalize about overall mental health status and needs. As well, witnesses emphasized the value of approaches designed to meet the specific needs of each particular group:

Just as we now know that the mainstream approaches do not work, are not totally effective, we know that a cookie-cutter application to the three constitutionally recognized groups is not the answer either.  It must be specific to the Nations.  —Bernice Downey[213]

Text Box: Any approach must be focused on the broad determinants of health and involve participation and cooperation across the economic, social, cultural and health sectors.And what are some key components of such a compilation of strategies?  Witnesses stressed that any approach must be focused on the broad determinants of health and involve participation and cooperation across the economic, social, cultural and health sectors.

A comprehensive strategy must include changes to the education system and ways to create economic development opportunities; is not just a look at mental health and family violence and suicide. They are all interrelated — there is interconnectedness. —Debbie Dedam-Montour[214]


Economic opportunities, adequate and effective housing, improved education, gender equity, actions to protect the environment and attention to justice issues are some of the issues that cry for a strong, holistic approach.  —Jennifer Dickson[215]

Virtually all witnesses saw the current jurisdictional quagmire as the primary barrier to progress toward wellness and positive mental health.  While all groups of Aboriginal peoples (whether First Nations, Métis or Inuit) face disadvantages, each has been forced, through legislative and administrative channelling, into a different relationship with the federal government and hence into different program and service delivery situations with the provincial and territorial governments.  Frustration led Donna Lyon, Director, National Aboriginal Health Organization, to call on the federal government to acknowledge that:

…health programs to all three Aboriginal peoples is a federal, constitutional or treaty obligation as the case may be…[216]

Witnesses were clear about the necessary building blocks of a successful strategy.  They emphasized the need to focus on the determinants of health and on clarification of the jurisdictional and departmental confusion currently surrounding responsibility for the overall health status of Aboriginal peoples.  They insisted that, if such a strategy is implemented, many of the negative mental health problems currently facing individuals and communities will be prevented.Text Box: Virtually all witnesses saw the current jurisdictional quagmire as the primary barrier to progress toward wellness and positive mental health.

 

 

Text Box: The Committee strongly supports the development of a strategy oriented to promotion of wellness, to restoration of positive mental health and to prevention of worsening mental health outcomes for Aboriginal peoples.

 

 

 

 

Text Box: The strategy must focus on recognized partnerships and meaningful collaboration.The Committee strongly supports the development of a strategy oriented to promotion of wellness, to restoration of positive mental health and to prevention of worsening mental health outcomes for Aboriginal peoples.  The strategy must be capable of measurably improving the aggregate health status of all Aboriginal peoples and take into account the distinct needs of First Nations, Inuit and Métis regardless of where they live.  The strategy must focus on recognized partnerships and meaningful collaboration across social, economic, health and other sectors.  The overall goal is to identify flexible, multi-dimensional solutions for the complex problems facing Aboriginal peoples through genuine community participation and shared power to implement change.

In 2003, the First Ministers directed their Health Ministers to consult with Aboriginal peoples on the development of an Aboriginal Health Reporting Framework.[217]  Through the use of indicators permitting comparisons between Aboriginal and non-Aboriginal Canadians, the report is to provide information on the progress achieved and key outcomes. It is intended also to inform Canadians on current programs and expenditures, and provide a baseline against which new investments, service levels and outcomes could be tracked over time. This “report card” information is essential to the success of any wellness and healing strategy.

The strategy must include specifics about who will control its implementation, how to measure wellness, what goals can be established, when actions are to be implemented, and by what criteria the outcomes will be judged.  It is essential to include a specific time frame for implementing actions and evaluating outcomes, as well as a sustained and sufficient funding mechanism.

The Committee recommends:

 

 

93

That, as a priority, the Canadian Mental Health Commission (see Chapter 16), with the full involvement of its Aboriginal advisory committee, develop a strategy for mental health wellness and healing among Aboriginal peoples.

That the strategy set goals, including a timetable for implementation, and recommend ways to evaluate outcomes.

That the strategy adopt distinct approaches for First Nations, Inuit and Métis.

14.5      ACTION ON HEALTH DETERMINANTS FOR EACH GROUP

Text Box: Key factors in the broader environment — income and social status, social support networks, education, employment, social and physical environments, personal health practices and coping skills, healthy child development, biology and genetic endowment, health services, gender and culture — are relevant to good mental health.  Witnesses emphasized that a successful strategy will rely on full recognition of the range of conditions or health determinants that contribute to the poor health status of Aboriginal peoples. They illustrated how key factors in the broader environment income and social status, social support networks, education, employment, social and physical environments, personal health practices and coping skills, healthy child development, biology and genetic endowment, health services, gender and culture — are relevant to good mental health.  But most importantly, they talked about how, if the positive effect of each of these determinants can be made available to Aboriginal people, many negative mental as well as physical health outcomes could be prevented.

14.5.1   Culture- and Group-Specific Approaches

Text Box: Witnesses envisioned traditional healing, language and culture as critical in overcoming negative attitudes and behaviours.As noted earlier, Aboriginal peoples are diverse.  Even among those who identified themselves as North American Indians (almost 65%), Métis (30%) or Inuit (5%), there are many different cultural practices, relationships, languages, and social, economic, and geographical situations within Canada’s jurisdictional boundaries.

For First Nations, the 2001 Census indicated that over half (52%) of North American Indians with legal status lived on reserves. Witnesses emphasized how the very existence of reserves affected the mental health of North American Indian populations, a fact frequently exacerbated by their remote location.

AsJames Morris, Executive Director, Nodin Counselling Services in northern Ontario, commented:

I do not need to talk about the environment in which these people live; they live in debilitating poverty in remote communities. It is the same story in any remote area where people are poor. The environment is the same in all First Nations communities. I never think of a reserve as the normal environment for First Nations people.[218]

For Inuit, geographical location points to certain needs with respect to program and service delivery.  Five of the largest Inuit communities (with populations from 1,500 to 3,000) are clustered above or near the 60th parallel in western territories and eastern provinces. The Committee was reminded that it was only within the last 50 years, as the federal government established a significant presence in the Arctic, that Inuit were moved away from seasonal camps and relocated into permanent settlements.

According to Jennifer Dickson:

During the 1950s, Inuit in seasonal camps and in smaller communities were compelled to resettle at other existing communities when church, health and government officials decided that their social and economic welfare would be improved by living in larger centres. However, this program seriously disrupted the historical and cultural organization of the people and had long-lasting negative consequences for resettled families.[219]

For the Métis as well, history has determined their current status — particularly the fact that, to date, their relationship with other Canadians has not been governed by treaties or land claims. In 2001, almost one-quarter of all Métis lived in Alberta, and the province is unique in having Métis settlement legislation that delegates to them authority to develop limited bylaws and policies in specific northern areas.  However, nearly 70% of the total Métis population across Canada live in cities (outside of specific settlements), together with more than seven in ten (73%) of those North American Indians who do not have legal Indian status.

Witnesses envisioned traditional healing, language and culture as critical in overcoming negative attitudes and behaviours.  Tarry Hewitt called for community-based decisions about conventional or traditional healing practices, but noted that:

….acknowledgment of the efficacy of traditional practices to promote healing is critical to overcoming the habits of dependency and to restoring Aboriginal self-esteem and confidence in their own cultural imperatives.[220]

In a similar vein, Jennifer Dickson supported culturally relevant approaches:

Unique traditional knowledge and culture is central to Inuit health and well‑being.  Inuit wisdom and ways must be incorporated into all programs if we are to affect individual and community health positively.[221]

14.5.2   Family and Community Supports

Many witnesses emphasized that strong families and communities are essential to achieve overall wellness.  They acknowledged the need for individual choices, but stressed how collective social factors exert a major influence on many decisions that Aboriginal peoples make about their lives.

Bernice Downey observed how healthy families make strong communities:

When you talk about mental health, you look at healthy families.  You see they have ways to support themselves, a sense of purpose in their life, and a job that they feel they can make a contribution to.  They can undertake their ways of life and not be restricted by restrictions on hunting, as an example, so that they can teach those traditions to their youth and their youth then can go forward.  That is what mental health is all about for communities.[222]

Other witnesses stressed that caring social relationships and supportive networks provide stability for people and help them solve problems and deal with adversity.  Individuals lacking a sense of control over their life circumstances have decreased overall well-being.  Bill Mussell proposed a concept of “community of care” as one way to protect against potential problems:

I like the notion of “community of care.” Our young people feel that they are homeless people even though they have a house with a roof, walls and so on. They have a house but not a home. Their caregivers are not there, their loved ones are not there, and the people they would like to have care about them are absent.

The better question is this one: What do we need to do with limited resources to contribute to the creation of that community of care?

I do not think you can buy it, but I certainly think you can do things to contribute to its development.[223]

The fact that Aboriginal peoples frequently change their place of residence is a concern. It leads to a lack of continuity in social connections as well as the subsequent loss of a sense of community.  Census data indicated that the on-reserve population was relatively stable, but one-third (33%) of the North American Indian population with legal Indian status in large cities moved every year.  As well, 25% of the North American Indian population without legal Indian status and 23% of the Métis population moved each year — twice the mobility of non-Aboriginal people (14%).

14.5.3   Children and Youth

Text Box: The population of all Aboriginal groups is much younger than the non-Aboriginal population.  The population of all Aboriginal groups is much younger than the non-Aboriginal population.  Inuit have the youngest population, with a median age of only 20.6 years, compared to the non-Aboriginal population’s 37.7 years. This means that 40% of Inuit are children under 15 years of age. Of the Métis population, 30% are children under 15 years of age. Of the North American Indian population, 25% of those with legal status and 35% of those without legal status are children under 15 years of age.

Text Box: Setting up youth internships; creating youth employment opportunities; promoting traditional values and teachings; consulting with the Winnipeg Police Service and the RCMP; providing workplace safety education; and focusing throughout on suicide prevention.

Children are particularly affected by social supports, physical environments, family stability and socio-economic status. James Morris shared his experience and observations on the critical importance of adequate support for young people:

I know kids who are hungry. I know kids who are not well clothed. I know kids who have no place to sleep. I went to a place in one community, which consisted of just a little trailer. There were 18 people living in there, with three beds. Everybody had to take turns sleeping. If it was not the kid’s turn to sleep that night, he did not go to school the next day. He had to go to bed when everybody else got up.[224]

Gloria Laird, Co-Chair, Alberta Mental Health Board, Wisdom Committee, talked about the difficulties of having a large number of Aboriginal children and youth in the social service system in which only a tiny percentage of staff members are Aboriginal.  She also suggested that a high percentage of child prostitutes in Alberta are Aboriginal and that they have special needs that are not met by the current system:

For a number of years I have been advocating for a holistic healing centre.  That has not been supported.  You can talk until you are blue in the face, but there is no change.  The young people are saying that they want to go out to the country and they want to have elders present.  They say they want to do sweats and they want to clean themselves up.  They need something different.  They need to get out of the cities.

Who will open a holistic healing centre for those young people who do not have a voice?  These children are getting younger and younger, 10 and 11 years old.  It is difficult to get out of that lifestyle if you are addicted to drugs such as crystal meth.[225]

There was a strong plea to support young adults as they develop a greater understanding of the world and their place in it.  Jason Whitford, Coordinator, Youth Council, Assembly of Manitoba Chiefs, recounted work in a range of important areas:  setting up youth internships; creating youth employment opportunities; promoting traditional values and teachings; consulting with the Winnipeg Police Service and the RCMP; providing workplace safety education; and focusing throughout on suicide prevention.  The broad goal was to encourage and promote the concept of youth involvement and youth leadership in creating change:

We are telling the youth if they do not like the way things are there are enough of them that they can take over their communities and re-create them the way they want to see them.  Through volunteerism and youth councils, youth organizations, they can start to take ownership of the issues and create opportunities for the other youth around them.  They want to see change in their own communities, but there are a lot of youth out there who just do not have the means to express themselves positively.[226]

14.5.4   Socio-Economic Conditions

Text Box: For too many Aboriginal people, unemployment or underemployment are prevalent factors contributing to poor health.

Text Box: Factors such as housing and community infrastructure influence psychological well-being. It is particularly significant that Aboriginal households (Indian, Inuit and Métis) are much more likely than non-Aboriginal populations to live in housing below an acceptable standard of adequacy.

Witnesses identified a range of socio-economic conditions that have affected their overall health and well-being.  In general, amelioration of income inequalities for Aboriginal peoples was linked to improved access to education and to employment that, in turn, affected access to housing, food and other physical and social necessities.

Among the Aboriginal groups, Métis reported the highest median income in 2000 at about $22,000, a level below that of the non-Aboriginal population by nearly $8,000. Various factors affect the ability of Aboriginal populations to generate income. For example, education is directly linked to employment opportunities, and the Aboriginal population with incomplete high school is almost twice as high as their non-Aboriginal counterparts. In addition, the youthfulness of the Aboriginal populations means that only about 40% of the Inuit are in the working-age population aged 25 to 65 years.

Employment provides not only income for necessities like housing and food, but also a sense of identity and purpose, social contacts and opportunities for personal growth. For too many Aboriginal people, unemployment or underemployment are prevalent factors contributing to poor health. As Elsie Bastien testified, not only is employment limited, but, because of social assistance rules, individuals are restricted from participating in other meaningful activities:

Most of our people are unemployed because there is no work.  Our unemployment rate is at 85 per cent.  The community looked at funding people to take training so that they could then volunteer to work in some of the programs.  However, at the beginning of this year, the federal government changed the Welfare Act to reflect, I believe, what the province has, and so many of those people who would have, could have, been doing some of the community work, because we do not have the dollars to pay them, now cannot do that because they have to be looking for gainful employment.  They need to demonstrate that they have been seeking gainful employment before they get their welfare cheque at the end of the month.[227]

Factors such as housing and community infrastructure influence psychological well-being. It is particularly significant that Aboriginal households (Indian, Inuit and Métis) are much more likely than non-Aboriginal populations to live in housing below an acceptable standard of adequacy (measured by houses in need of major repair) and suitability (measured in terms of crowding of the residents).

Larry Gordon reported that:

In many regions, housing shortages have reached crisis proportions in our area.  The mental impact on families so crowded that people must sleep on the floors and in shifts cannot be underestimated in our region.  Homeless people drift from relative to relative to find a spot for the night.[228]

14.5.5   Gender

Text Box: Current roles, behaviours, and power relations often place women in a doubly disadvantaged position — as women and as Aboriginal people.  To support the mental health of both men and women in Aboriginal communities, changes in practices and priorities are required. Several witnesses stressed the need for greater gender awareness and balance in families and communities as well as in organizational and governmental structures and actions.

Current roles, behaviours, and power relations often place women in a doubly disadvantaged position — as women and as Aboriginal people.  Witnesses noted that the number, quality and effectiveness of services available to Aboriginal women and related supports to their children do not compare to those services provided to Canadians as a whole.

But women were also seen as instrumental in effecting real change and successful outcomes for Aboriginal communities. Bill Mussell pointed out that strong women hold the key to their own mental health and that of their families and their communities.  Jennifer Dickson stressed that:

Inuit women are truly the agents of change in Canada’s Arctic.  If motivated, included, franchised and supported, they can and will contribute substantially to strong, stable, healthy and happy communities.[229]

14.5.6   Recommendation for Action

The Committee listened carefully as witnesses presented evidence related to key health determinants and concurred as to their centrality to mental health, whether of individuals, families, communities, or Aboriginal peoples in general.  It agrees with the need for an action plan to focus on multiple determinants of health and on the complex interactions among them.  Given the numerous root causes of the mental health problems of Aboriginal peoples, any strategy to address them must be based on clear evidence, both about particular problems and about the dimensions of effective measures to address them.

The Committee recommends:

 

 

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That the Canadian Mental Health Commission (see Chapter 16), in consultation with its Aboriginal advisory committee, develop, as an integral component of the wellness and healing strategy for mental health, a plan that would:

·         identify key health determinants;

·         assess the influence of these determinants on mental health;

·         detail measures for implementation; and

·         establish timelines and funding levels needed to promote wellness and healing.

14.6      ACTION ON JURISDICTIONAL RESPONSIBILITIES

The Committee heard frequently that lack of clarity on the jurisdictional responsibility for Aboriginal peoples is one of the major challenges in building a coherent, integrated system to plan and deliver mental health and mental wellness services.

First Nations who are registered Indians on reserve are provided with a number of programs and services relevant to mental health; but when these same people leave the reserve, the situation changes. Lorraine Boucher, Director of Health Programs, North Peace Tribal Council, observed that:

First Nations people are always being thrown back and forth like a political football concerning accessing services. When we are on reserve, we are under the federal government; when we are off reserve, we are under the provincial government.[230]

For the Inuit, the situation is similar. Onalee Randell emphasized that, in the unresolved dispute over jurisdictional responsibilities, it is the people who need services that are suffering:

There continues to be discussions around responsibility — whether the federal, provincial or territorial governments have responsibility.  The outcome is that those discussions are taking precedence over the delivery of services to Inuit communities and preventing those well‑needed services from being delivered.[231] 

Text Box: Lack of clarity on the jurisdictional responsibility for Aboriginal peoples is one of the major challenges in building a coherent, integrated system to plan and deliver mental health and mental wellness services.Like North American Indians without legal status, Métis face mental health concerns comparable to those of First Nations and Inuit but are continually battling for jurisdictional recognition within the Canadian federation.  The federal government does not acknowledge specific responsibilities for Métis or non-status Indians, while the provinces and territories are reluctant to seek legal clarification of the issue.  Many Métis simply want clarification about the jurisdiction applying to them, either federal or provincial, so that access to needed services can be made easier.

Under the jurisdiction regarding Metis, they need an increase in services provided to them.  They also need to resolve the jurisdictional situation so that they are no longer denied access to Aboriginal federal or provincial mental health and related programs.  —Donna Lyon[232]

14.6.1   Defining the Federal Role

Currently, all levels of government are ambivalent about their responsibilities with respect to the health of Aboriginal peoples. The Constitution Act, 1867, which provided (in section  91 and 92) a legislative division of powers between the federal Parliament and provincial legislatures, allowed for a division of responsibility for Aboriginal peoples into categories, some of which are accorded status through federal recognition while others are not.

For the federal government, the Indian Act has provided a baseline for services to registered status Indians on reserve and to certain Inuit. Following a 2004 commitment to develop an Inuit Secretariat within the Department of Indian and Northern Affairs, the federal government has begun to take a more publicly identified role in its approaches to Inuit-specific issues. Since 1985, except under programs aimed at the general Canadian population, Métis and non-status Indian issues have been dealt with by a federally appointed interlocutor for Métis and non-status Indians rather than by a specific federal department.

Provincial and territorial governments are reluctant to provide Aboriginal-specific funding or services, fearing that they will be perceived as accepting jurisdictional responsibility. This pervasive ambivalence is particularly serious with respect to mental health, where the applicable programs and services must certainly encompass education, housing, employment, and social assistance, as well as health — all areas generally accepted as provincial/territorial responsibilities.

There was no ambivalence among the witnesses who appeared before the Committee and called for a clearly defined relationship with the federal government. The Canada-Aboriginal Peoples Roundtable process in 2004 was seen as a useful beginning for First Nations, Inuit and Métis in their call for self-determination based on indigenous rights.[233]  At the end of May 2005, the organizations representing various groups signed a number of statements that outlined specific measures to define further relationships with the Government of Canada.[234]

Witnesses spoke to the Committee of a new special relationship with the Government of Canada outside the current, often multiple-departmental interactions.  Irene Linklater stressed the need to re-establish the special relationship with the Crown. She went on to say that First Nations want:

…a direct relationship to, if not the Prime Minister then to the Privy Council; to primary decision-making bodies that have a fiscal arrangement directly with First Nations, and a direct First Nations-to-federal government relationship, a nation-to-nation relationship…[235]

14.6.2   Focusing Federal Departmental Efforts

At the federal level, responsibilities for the areas that determine positive mental health for Aboriginal peoples fall under the mandates of several departments.  The picture is one of extreme fragmentation as multiple departments offer selective programs or services to particular groups of Aboriginal peoples.  In most instances, the provision is exclusively to First Nations on-reserve; in others, only to First Nations off-reserve; some include Inuit and a few have a broader Aboriginal focus.

In 2005, 16 federal departments and agencies offered programs for Aboriginal people with total expenditures of approximately $9.1 billion. Approximately two-thirds of all funds (about $6 billion) are spent by Indian and Northern Affairs Canada. Health Canada accounts for close to $2 billion, while other departments and agencies account for slightly more than $1 billion.[236] To date, there are no estimates of the total federal funding spent on mental health, mental illness and addiction among Aboriginal peoples.

Text Box: At the federal level, responsibilities for the areas that determine positive mental health for Aboriginal peoples fall under the mandates of several departments.  The picture is one of extreme fragmentation as multiple departments offer selective programs or services to particular groups of Aboriginal peoples.Except for certain obligations specified in the Indian Act and administered by the Department of Indian and Northern Affairs, the federal government has permitted the development of a different foundation for each set of programs and services offered to Aboriginal peoples.  Neither the Constitution Act, 1867 nor the Constitution Act, 1982 provide legislative authority to, or impose legal obligations on, the relevant federal departments or agencies.

 

 

Text Box: To date, there are no estimates of the total federal funding spent on mental health, mental illness and addiction among Aboriginal peoples.The need to deal with several departments is viewed as a major, crippling impediment by Aboriginal peoples.  For First Nations, the split of social programs and subsequent funding between two departments has created a gap in health and in the relationship of First Nations with the Crown and the Government of Canada:

 

Text Box: The need to deal with several departments is viewed as a major, crippling impediment by Aboriginal peoples.I would point out that there is a gap…in the relationship between the constitutional arrangements as set out by Canada, having established an administrative body called Indian Affairs, whose powers in this regard are now delegated to a federal department called Health Canada, to FNIHB, and that structure filters the money.  —Irene Linklater[237]

For the Inuit, Onalee Randell emphasized that, because there are so many departments involved, departmental silos are reinforced, perpetuating unresolved disputes over jurisdictional responsibilities:

It is also resulting in poor communication and coordination between not only health service providers from one region to another or from one community to another, but also from the intergovernmental departments.  The housing people do not ever want to talk about how housing impacts mental wellness.  The education people do not ever want to talk about how to revise or change curriculum to assist students to have the self‑esteem and coping skills they need.[238]

For Métis, the problem is that there is simply no departmental focus or concentrated governmental attention.  Neither Indian and Northern Affairs Canada nor Health Canada assume specific responsibility.  According to Gloria Laird, however, Co-Chair, Alberta Mental Health Board, Wisdom Committee, people are beginning to look at ways to develop a departmental focus in relation to the health and health service needs of Métis people.[239]

 

14.6.3   Recommendation for Action

Text Box: If any strategy and action plan are to be successfully implemented, this jurisdictional ambivalence needs to be sorted out, or at least replaced with clear statements of where responsibilities lie.

Text Box: Moving on and off reserve as well as between provinces and territories should not occasion a loss of continuity in the delivery of services which can lead, in turn, to a loss of the programs essential for mental health.The Committee recognizes that if any strategy and action plan are to be successfully implemented, this jurisdictional ambivalence needs to be sorted out, or at least replaced with clear statements of where responsibilities lie.  The present reality is that Aboriginal peoples are very mobile and cross jurisdictional boundaries frequently.  Moving on and off reserve as well as between provinces and territories should not occasion a loss of continuity in the delivery of services which can lead, in turn, to a loss of the programs essential for mental health.

 

Text Box: An unprecedented level of both federal leadership and intergovernmental collaboration is necessary to address the epidemic of mental health problems, including suicide and addictions, in Aboriginal communities.The Committee was told that all levels of government have consistently denied full responsibility for the deterioration of the overall health status of Aboriginal peoples.  Such denial has led to the offloading of responsibilities, obscuring of factual information, and failure to develop methods for assessing progress toward better health, including mental health.

Witnesses indicated clearly that they want a more direct relationship with the Crown, through the Government of Canada, that enables them to take direct responsibility for their own health. But they want to do this as part of a relationship with the Government of Canada that recognizes the ability of Aboriginal peoples to control their lives if provided with sufficient resources and support.

The Parliament of Canada and the federal government have long-term responsibilities for the state of well-being of all citizens of Canada, including all Aboriginal peoples.  An unprecedented level of both federal leadership and intergovernmental collaboration is necessary to address the epidemic of mental health problems, including suicide and addictions, in Aboriginal communities. Beyond the work to be undertaken by the proposed Canadian Mental Health Commission, it is imperative that the federal government initiate action immediately to address the mental health needs of Aboriginal peoples. 

The Committee has considered several potential federal foci that would complement and support the work of the proposed Canadian Mental Health Commission. Despite parliamentary oversight provided through standing committees in both Houses and through occasional reports by the Auditor General, Aboriginal peoples’ issues have not been examined sufficiently rigorously or continuously by Parliament. One option might involve the establishment of a Parliamentary Officer, similar to the Auditor General or the Commissioner of Official Languages, who would report directly to Parliament (rather than to the federal government or to an individual minister).

Text Box: The Committee believes, that the most pressing need is to coordinate federal efforts directed at improving the health and well-being of Aboriginal peoples in Canada.A second option, based on the Prime Minister’s initiatives for the Canada-Aboriginal Peoples Roundtable process, would be to establish a permanent structure similar to the National Round Table on the Environment and the Economy.  Constituted as an independent advisory body, this National Round Table functions as a coalition builder, working to reconcile the often opposing governmental, industry, and community positions.

The Committee believes, however, that the most pressing need is to coordinate federal efforts directed at improving the health and well-being of Aboriginal peoples in Canada. The establishment of a Cabinet Committee on Aboriginal Issues and a secretariat at the Privy Council Office, combined with the 2003 commitment to develop a report card on Aboriginal peoples, opens the door to greater direct recognition of the federal relationship with all Aboriginal peoples.

The Committee recommends:

 

 

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That the Government of Canada create an interdepartmental committee composed of deputy ministers in departments with responsibility for Aboriginal peoples, chaired by the Privy Council Office.

That the interdepartmental committee prepare a report to be tabled in Parliament every two years on the impact of the work of these departments on the wellness of Aboriginal peoples, including but not limited to their mental wellness.

That this Aboriginal wellness report include an inventory of all federal programs and services specific to each group of Aboriginal peoples, with information on spending and the impact on actual health outcomes achieved, including but not limited to mental health outcomes.

 

 

That the interdepartmental committee support working groups composed of First Nations, Inuit and Métis representatives to provide information, advice and verification of the report.

14.7      ACTION ON DELIVERY OF PROGRAMS AND SERVICES

Programs and services that are designed to maintain health, prevent ill-health, and/or restore health and function, also constitute a determinant of health for Aboriginal peoples. As noted earlier, specific federal programs and services relevant to the mental health of Aboriginal peoples are provided primarily to First Nations clients living on reserve.  Often, by extension, they are provided also to Inuit clients, but seldom to non-status Indian and Métis clients.

Of the 16 federal departments and agencies that offer programs for Aboriginal people, primary responsibility rests with Indian and Northern Affairs Canada and Health Canada.  Indian and Northern Affairs Canada is responsible for the administration of the Indian Act and is the major provider of basic services such as education, social assistance, housing, and community infrastructure to status Indians on reserve, and some Inuit communities. With respect to specific health services, Health Canada is responsible for the provision of primary care through nursing stations and health centres to First Nations and Inuit clients on reserves and in many remote and isolated communities. The Non-Insured Health Benefits Program offers assistance with drugs, crisis intervention and mental health counselling to eligible First Nations and Inuit clients regardless of residency when no other insurance coverage is available.

Witnesses emphasized a number of underlying premises essential to successful outcomes from any program and service relevant to mental health, including: community authority and control; cultural accommodation; and equity of access.  Incorporation of these elements into program and service delivery would help build what Bill Mussell referred to as “promising practices”:

We talk about our weaknesses, problems and issues, but seldom do we ever talk about our resources and what our strengths are and the good ways of our life. What are the promising practices that we live with? I tend to hesitate to use “best practices” because I think there is so much that we do not know. If we were to buy into the notion of best practices, I think we would be cutting ourselves off before we had a chance to truly identify, explore and discover what truly works.[240]

14.7.1   Community Authority and Control

Most witnesses testified that community authority and control over programs and services is essential to successful outcomes.  They insisted that Aboriginal communities must take control of their own destinies through oversight of the design of mental health programs and services, their delivery and cultural appropriateness.  Valerie Gideon argued that unless First Nations have a sense of ownership and control over a comprehensive set of mental wellness programs, any new investment or initiative would inevitably work against itself.

Others stressed the need for capacity building to identify the strengths and expertise within each Aboriginal family and community. For Bill Mussell, “the foundation of the approach is to build community capacity that is reliable, safe and helpful within the context of regional and provincial support.”  He indicated:

Text Box: Witnesses insisted that Aboriginal communities must take control of their own destinies through oversight of the design of mental health programs and services, their delivery and cultural appropriateness.  Capacity needs to be built at all levels of the system: the individual; family communication and problem solving; peer-to-peer helping; support group models that reflect the reality of community networks and existing relationships; peer and other professionals to help staff at the community level who offer services based in the range of mainstream cultural and complementary approaches of healing and helping; regional resources, including highly skilled professionals such as psychologists willing to bring their skills to engage in a creative and collaborative process to develop new programs and services; and provincial services that provide a high level of specialized services to support the capacity-building needed in the communities.[241]

Ian Potter, Assistant Deputy Minister, First Nations and Inuit Health Branch, Health Canada, also recognized that communities are seeking empowerment and control:

Text Box: With regionally identified, regionally based and regionally delivered programs and services, Aboriginal peoples report difficulties in achieving full consultation and participation.I am absolutely convinced that better health outcomes will not be achieved unless we can support the communities in taking a more active role. Our strategy is to try to work with the provinces and the communities, using the federal government resources, to see if we can design a health system in which communities can play that role. I do not think that we will get the results, as technically proficient as we may be, unless we can build a health system that is seen to be driven by the community, supported by the community and, often, delivered by community members. [242]

He also noted that Health Canada is pushing for greater integration of federal services with provincial services to reduce duplication and problematic overlap, arguing that:

Most of the services we fund are delivered by First Nations and Inuit. Part of that process is to support them so that they can play an active and essential role in the fundamental health care system in Canada, which is provincial or territorial. [243]

Aboriginal peoples raised some concerns, however, about being pushed into the provincial (often regionally based) sphere. With regionally identified, regionally based and regionally delivered programs and services, Aboriginal peoples report difficulties in achieving full consultation and participation.

As Valerie Gideon pointed out:

Especially in provinces where much of the decision-making is devolved to fairly independently operating regional health authorities, First Nations communities have to take on their responsibility to push the regional health authorities to be accountable to them for the type of services they provide to their members. The reality is that they do not have the capacity for that. Very few of the regional health authorities reach out to First Nations communities in their areas to develop relationships. [244]

Onalee Randell emphasized that regional funding is not supportive of community-based programs:

We seem to be in an era of federal funding that is not community-based; it is regional funding involving specific communities. In areas of mental wellness, this funding is insufficient. How do you define which community requires mental wellness programming? Is it the community that does not have the suicides or the community that has had four, five, six or seven suicides in that year? [245]

14.7.2   Cultural Accommodation

Text Box: Witnesses called for cultural awareness training and orientation for mental health staff as well as other service providers, including teachers, police, and officials for social services and children’s services.Witnesses called for access to culturally appropriate health care and services that recognize the internal cultural diversity, even within each group.  They called for cultural awareness training and orientation for mental health staff as well as other service providers, including teachers, police, and officials for social services and children’s services.

Elsie Bastien stated that understanding and accepting the diversity of Aboriginal peoples was central:

Mental health providers can only create an environment of culture safety for Aboriginal people if they have been trained to understand and accept the cultural, linguistic, tribal, geographical, economic, political and community context of the various Aboriginal communities.  Failure to grasp the significance of these contextual factors often leads to stigmatization, misdiagnosis, and inappropriate treatment.[246]

Tarry Hewitt and others provided a recurring focus on traditional healing practices as a significant factor in moving forward:

Healing circles, culture-based and guided by an experienced, and in our case, academically trained Aboriginal who engages in traditional healing, are far more than a cosmetic overlay to “group sessions.”  They are rooted in ceremonies and traditions that can only be performed by those from the Aboriginal community who possess a depth of knowledge and who are recognized within that community as being capable of leading healing circles.[247]

Although witnesses agreed that more authority should be delegated to Aboriginal communities to customize services and foster solutions that are more culturally appropriate, they recognized some challenges. Tarry Hewitt acknowledged that supporting traditional skills:

involves not only overcoming a non-Aboriginal bias in favour of conventional treatments and methods of delivery, but also the challenge of Aboriginal perceptions that, as a result of decades of paternalistic intervention, non-Aboriginal practices are superior.[248]

As Sheila Levy pointed out, cultural traditions need to be blended with social realities:

Looking backward in rose-coloured glasses has not helped. Inuit want the best of both worlds in which they live. Many Inuit with whom I work and whom I know well have pointed this out to me. They want evidence-based methods and approaches integrated with Inuit beliefs, ways and cultural knowledge.[249]

Clearly, the differences in identity, in size and in geographical location of each group must be factored into any mental health strategy. Officials from Correctional Service Canada were asked if programs and services for Aboriginal offenders considered adjustment issues:  for example, an individual who displays signs of mental health problems may simply be experiencing social adaptation problems arising from the fact that he or she comes from a different cultural and geographic background. Dr. Michael Bettman of Correctional Service Canada indicated that the issues involved are very complex and good solutions are difficult to find:

If you are looking at specific cultural treatments, and you are adding the dimension of urban versus rural, it becomes more complicated. That is why we embarked on, not so much recreating but building from the ground up, many of our programs for Aboriginal populations specifically — designed by Aboriginal people, often delivered by Aboriginal people for the overrepresented Aboriginal population in our federal system.[250]

14.7.3   Equity of Access

Text Box: Although the federal government asserts that there are reasonably comparable levels of service for Aboriginal peoples throughout the country, many witnesses insisted that this is not the case.Although the federal government asserts that there are reasonably comparable levels of service for Aboriginal peoples throughout the country, many witnesses insisted that this is not the case. They described an overall patchwork of programs and services for Aboriginal peoples depending on whether they are Indian, Métis, or Inuit, and whether they live on or off reserve, at a remote northern or a southern urban setting, in a specific province or territory. Furthermore, witnesses argued that providing provincial services comparable to those available to the general population to people whose overall health and wellness status is so much lower does not make sense.  To achieve real health comparability, programs and services must be designed to enhance and build positive health status among Aboriginal peoples specifically.

The Committee was reminded by Donna Lyon that the Métis are generally excluded:

Within the Metis Centre, some 30 per cent of the Metis people make up the target of our Aboriginal population [but] they are not included in many of the initiatives available to First Nations people and possibly Inuit people as well.  They are not included in the National Indian Health Board program.  They have no access to the National Native Alcohol and Drug Abuse Program.[251]

Text Box: To achieve real health comparability, programs and services must be designed to enhance and build positive health status among Aboriginal peoples specifically.Even for First Nations, there are problems with continuity depending on whether an individual is on reserve or off reserve in an urban setting. Irene Linklater pointed to residency requirements for reserve benefits:

There is a residency issue there, that once you have been away in hospital for three months, then you no longer have that benefit; you must then go to the province.  There are other complications that can arise, such as if you go away to school, or you leave and then you have palliative care requirements, you cannot go back to your community because medical services does not pay for your trip back home to die with dignity.[252]

Within each jurisdiction, the delivery of health services to Canada’s Inuit population varies with place of residence. Inuit argue that there are differences between those who live in the territories, where the federal government still assumes some jurisdiction, and the provinces with larger Inuit populations such as Quebec or Newfoundland and Labrador where the federal government sees a provincial obligation to provide northern services.  As Onalee Randell explained:

The First Nations and Inuit Health Branch provides prevention and promotion programs and in some cases, limited care and treatment programs to Inuit communities through the two territorial governments: for Inuit living in Nunavut and Inuvialuit, through the Nunavik Health and Social Service Board for Inuit in Quebec, and through the Labrador Inuit Health Commission for Inuit in Labrador.  In Nunavik, for example, in northern Quebec, if someone requires significant mental health services, they are transported by Medivac to Montreal, to a provincial hospital, where they have developed a partnership or an agreement.  In fact, Nunavik has one bed dedicated for Inuit in Montreal for mental health services.[253]

14.7.4   Recommendation for Action

Text Box: The Committee recognizes the need for “outside the box” thinking and innovative ideas that lead to programs with clear goals and clear ways of measuring progress or the lack of it.

 

Text Box: The Committee agrees with the need for a seamless system to promote well-being, not only for First Nations and Inuit, but for all Aboriginal people.The Committee recognizes the need for “outside the box” thinking and innovative ideas that lead to programs with clear goals and clear ways of measuring progress or the lack of it. It is looking for some specific results from the $200 million allocated for an Aboriginal Health Transition Fund following the September 2004 special meeting of the Prime Minister, First Ministers and Aboriginal leaders.[254] This federal fund is to enable governments and communities to devise new ways to integrate and adapt existing health services to better meet the needs of Aboriginal people.

Text Box: The Committee believes that programs and services delivered to all Aboriginal peoples will lead to more successful outcomes if the principles of cultural accommodation and equity of access are respected.The Committee agrees with the need for a seamless system to promote well-being, not only for First Nations and Inuit, but for all Aboriginal people.  The Committee is aware that many First Nations have accepted responsibility for the direct delivery of health care services.  It further recognizes the need for greater community involvement in the design and implementation of all programs and services directed to Aboriginal peoples, including, where possible, direct community authority and control over them. Moreover, the Committee believes that programs and services delivered to all Aboriginal peoples will lead to more successful outcomes if the principles of cultural accommodation and equity of access are respected.

The Committee does not expect the federal government to deliver all the required programs and services, but it does expect it to live up fully to its responsibility to ensure their provision.  The federal government can do this either through direct delivery or by providing funding to the provinces specifically earmarked for Aboriginal peoples on a per capita and health status basis.  Regardless of who is involved in the delivery of needed programs and services, the key is to have clear lines of authority and to monitor outcomes carefully.  Adequate checks and balances and appropriately objective evaluation measures must be in place.

Text Box: The Committee does not believe, therefore, that it is appropriate to propose any new entity or structure solely on the basis of the testimony heard during this mental health study.The Committee acknowledges that the logical consequences of the preceding arguments and evidence about jurisdictional responsibilities and program and service delivery strongly suggest the need for a completely different model of governance of the broad affairs of Aboriginal peoples in Canada. This new model must recognize that the time is ripe for serious consideration of a mechanism to include Aboriginal peoples in the decisions that affect their lives.  The Committee also knows, however, that this new model cannot be a simple administrative reconfiguration. Nor can its development be proposed in the context of a report whose primary focus is the mental health and well-being of Canadians in general.

The Committee does not believe, therefore, that it is appropriate to propose any new entity or structure solely on the basis of the testimony heard during this mental health study. It is prepared, however, to add its voice to support further work on the issues of governance and of administration for Aboriginal peoples. In particular, it acknowledges the need for greater autonomy for Aboriginal peoples in the design and delivery of programs and services that meet the needs identified by their communities.

At this time, then, the Committee recommends:

 

 

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That the Government of Canada work closely with the provinces/territories and representatives from the different Aboriginal communities to develop programs and services deemed necessary by Aboriginal peoples.

That criteria for the design and delivery of identified programs and services take into account the importance of enhancing community involvement, and of ensuring cultural accommodation and equity of access.

 

 

That any delivery mechanism for these programs and services include ongoing oversight and public evaluation of outcomes by the funding body.

That the criteria for funding and accountability provisions be made public.

14.8      SPECIFIC INITIATIVES

14.8.1   Renewal of the Aboriginal Healing Foundation

Many witnesses stressed the need to build on the efforts of the Aboriginal Healing Foundation and called for its long-term renewal.  The Aboriginal Healing Foundation was established in 1998 with a 10-year mandate to address issues of physical and sexual abuse related to residential schools.[255] It has a special place as the first national Aboriginal organization representative of all groups working on Aboriginal-initiated and Aboriginal-implemented community projects.  According to Gail Valaskakis, it played a critical role in providing partnerships, in identifying and filling the gaps in services, and in involving survivors and those who are intergenerationally affected.[256]

Representatives of First Nations and Inuit spoke about the need for long-term renewal of the Foundation’s funding in order to expand and sustain community healing projects. For Shean Atleo, Chief A-in-chut, B.C. Regional Chief, its funding of healing efforts at the community level were crucial to increased emotional wellness in his community:

Through the 1990s, we saw a decline in suicide attempts and completions amongst the Nuu-chah-nulth. While there is no one factor that we can point to, I know that the work of the Aboriginal Healing Foundation was tremendous for our people. The foundation allowed for community-based design and delivery of healing.[257]

For the Inuit, although late in coming to the process, the programs that resulted from the Aboriginal Healing Foundation filled a gap:

Inuit reviewing the Aboriginal Healing Foundation program see the need to expand it, to have it not only focus on residential schools and the negative impact of those schools relating to abuse but also the negative impact relating to language loss, cultural loss and the loss of parenting skills. This information is from Inuit who have provided information that they were not abused in residential schools; they believe the schools were a positive experience. However, they did lose their language. They feel some loss of culture.  —Onalee Randell[258]

The Foundation’s funding ends in 2007 and, for many groups, this constitutes another example of the instability created by short-term funding.  By the time that communities develop the capacity to apply for funding through the Foundation, none will be available:

For the first three years of that funding, communities tried to figure out what they needed and how to implement it, and even to get assistance with writing the proposals, which the Aboriginal Healing Foundation provided. 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. —Onalee Randell[259]

Gail Valaskakis confirmed that the Inuit were late in accessing the programs of the Aboriginal Healing Foundation.  She also noted that:

Metis have been even more difficult to reach and are a target. Many areas of society that are invisible to all of us, such as the homeless and the incarcerated, have been difficult to reach as well…[260]

Data from two studies related to the costs of abuse and the value of healing were used by Valaskakis to provide evidence that “healing is cost effective, personally effective and socially effective.”  According to the Canadian Incidence Study of Reported Child Abuse and Neglect, child abuse is extremely costly and when “applied to the residential school issue, it shows that Canadian society pays about $440 million per year on incarceration, social services, special education and health.”[261]

The second study cited by Valaskakis looked at healing in relation to incarceration on the Hollow Water Reserve.  It found that healing is more cost-effective than incarceration, and actually lowers its rate:

For every $2 spent on the community holistic healing circle program at Hollow Water, the federal and provincial governments save $6 to $16 on incarceration fees. That is a conservative estimate that was done by holding the cost of the system constant and adding the cost of one person to the system.[262]

The Aboriginal Healing Foundation is credited with providing the type of integrated approach that has a better chance of working than the stove-piped, or silo-structured, model currently in existence.  As Gail Valaskakis testified:

To date, the Aboriginal Healing Foundation has invested $437 million in community-based projects, ranging in type from awareness and prevention to actual healing services, including long-term healing services in residential treatment in trauma centres and programs for addiction.[263]

She called for support for the Aboriginal Healing Foundation on a long-term basis:

An endowment of $600 million would support a 30-year healing strategy with a 2.5 per cent inflation rate and a 5 per cent return on that investment. Thus, $28.7 million per year would be available for community-funded projects. This would mean that by year 30, the Aboriginal Healing Foundation would have invested $1.2 billion in healing. [264]

The Committee commends the work done by the Aboriginal Healing Foundation and agrees with those who call for a long-term commitment to its work. It recognizes the need to continue to address the legacy of abuse and the intergenerational and other impacts of social, psychological, cultural and spiritual injuries. It supports the goals of acknowledgement, redress, healing and reconciliation.

The Committee recommends:

 

 

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That the Government of Canada renew the mandate of the Aboriginal Healing Foundation and provide funding for another three years.

That, on a priority basis, the Canadian Mental Health Commission (see Chapter 16) and its Aboriginal advisory committee undertake an evaluation of the efficiency and effectiveness of the Aboriginal Healing Foundation.

That the results of the assessment include recommendations concerning the future of the Aboriginal Healing Foundation and be made public.

 

 

14.8.2   Increase of Health Human Resources

All witnesses acknowledged that mental health and the prevention and treatment of mental illness depend upon integrated, interdisciplinary care from a variety of health care providers. In Aboriginal communities, the acute shortage of family physicians, nurses, psychiatrists, psychologists, social workers and other professionals seriously affects the delivery of appropriate care and services.

Many emphasized the need for mental health professionals who are themselves Aboriginal, or at least are knowledgeable about Aboriginal cultures.  Arnold Devlin recounted a story of how psychiatrists educated and oriented to a different culture and life experience reacted to Aboriginal peoples living in northern Ontario:

Text Box: Many emphasized the need for mental health professionals who are themselves Aboriginal, or at least are knowledgeable about Aboriginal cultures.  Providers who are Aboriginal can counter cultural biases that can affect diagnoses.At one time psychiatrists in the Nishnawbe-Aski area were educated in Scotland and England. They would arrive from the University of Toronto to work in the area. They classified people with many strange multiple personality disorders and exotic mental illnesses. One time I spoke to a lady after she had seen the psychiatrist and asked what she had said to him. She said that she had simply told him about her life and he gave her medications to take. That is the reality and, often, the worldview and the sense of values and beliefs is very different so the psychiatrist’s paradigm missed it all together and did not click on what was happening to that person. [265]

According to Rob Wipond, providers who are Aboriginal can counter cultural biases that can affect diagnoses.  In refuting the claim that Aboriginal communities suffer significantly higher rates of mental illness, he asserted:

Ample research has shown that culture, lifestyle and spiritual difference are crucial factors in diagnoses and forced treatment.  If you start seeing gods and demons and believe you are approaching a mystical breakthrough, it is not at all likely that a psychiatrist is going to support your exploration.  He is going to call you “delusional,” probably “schizophrenic” and tranquilize you.[266]

Text Box: Several witnesses emphasized the need for innovation in addressing the shortages of Aboriginal people in the mental health field, pushing for thinking “outside the box.”The number of Aboriginal workers actually working in the field of mental health, and their particular concerns, have not been fully quantified.  For example, one Aboriginal psychiatrist, Cornelia Wieman, who returned to her Six-Nation reserve to practise medicine, found that the community could not afford to pay her a salary commensurate with her training and expertise because it lacked the money to do so.

Dr. Arthur W. Blue noted that the Native Psychologists of Canada is a small organization with less than 20 members. He identified the need for a supportive institution responsible for training native clinical psychologists to achieve successes similar to the movement “from 51 native physicians 20 years ago to 250 today.” He went on to emphasize the important role for psychologists:

It is not only treatment but it is also prevention. Not only do they do psychometrics, psychotherapy, group psychotherapy, abuse treatment, both physical and substance, they are the best educated mental health professionals available in Canada, and should be working hand in glove with mental health workers, social workers, physicians and the band council. [267]

Many Aboriginal people do not succeed in education and in pursuing careers as health workers.  Several witnesses emphasized the need for innovation in addressing the shortages of Aboriginal people in the mental health field, pushing for thinking “outside the box.” Tarry Hewitt described a legal training program for 10 students in Nunavut at Akitsiraq Law School in collaboration with the University of Victoria Law School, the University of Ottawa, the Government of Canada and the Government of Nunavut.  She also mentioned the collaboration of the University of Cape Breton with First Nations communities in Nova Scotia to bring the university classroom to the communities:

Some of the obvious benefits to the communities include not having to leave home and family responsibilities to pursue post-secondary education and the ability to be educated in familiar versus intimidating surroundings.  This leads to higher rates of retention.  The educational institution benefits from this collaboration by giving visiting professors a chance to become more knowledgeable about First Nations communities and customs.[268]

Debbie Dedam-Montour, Executive Director, National Indian and Inuit Community Health Representatives Organization, pointed out that the training for a community health representative (CHR) has changed as part of the health transfer process from one offered by Health Canada to one under band jurisdiction.  She noted that: “Some colleges have CHR programs, such as the course at Portage College. Alberta and Manitoba offer courses but they are fragmented.”[269]  The current goal is to set up core competency training programs for the CHR in each of the provinces.

The issue of accreditation, of determining who is authentic and qualified to provide effective healing, was also addressed by Tarry Hewitt:

There is capacity within the Aboriginal communities to identify men and women who engage in traditional healing practices, who routinely seek guidance from elders and medicine men and women and who would be appropriate facilitators of healing circles and other traditional methods.  Structures already exist within the Aboriginal communities to vet the recognized ability of healers who would provide services in an accountable manner.[270]

The accreditation process is important for traditional healers who seek funding by Health Canada as health workers in Inuit and First Nations communities.  According to Ian Potter, some system of standardization is needed:

We have some limitations with respect to funding traditional medicine because there is no system in place that defines who is a traditional medicine specialist.  In other countries — and it is something we have tried to encourage First Nations and Inuit people in Canada to look at — the people who practice traditional medicine have organized themselves to certify who is a legitimate provider of these services.  So far, we have not been able to achieve that.  There is a difficulty, as liability issues arise; if we pay for something, we should know what standard we are paying for. [271]

Text Box: The Committee believes that a special effort must be made to increase the number of Aboriginal people pursuing health care careers in the mental health field.  Culturally sensitive approaches for training and retaining Aboriginal individuals as psychiatrists, psychologists, mental health nurses, social workers and others are needed urgently.The Committee knows that successes in the area of Aboriginal health human resources have been achieved over the last few decades.  It is aware of the efforts of both Health Canada’s Indian and Inuit Health Careers program and the National Aboriginal Achievement Foundation.  It also recognizes the positive step represented by the announcement of $100 million for an Aboriginal Health Human Resources Initiative as a result of the September 2004 special meeting of the Prime Minister, First Ministers and Aboriginal leaders.

The Committee believes, however, that a special effort must be made to increase the number of Aboriginal people pursuing health care careers in the mental health field.  Culturally sensitive approaches for training and retaining Aboriginal individuals as psychiatrists, psychologists, mental health nurses, social workers and others are needed urgently.

The Committee recommends:

 

 

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That the Government of Canada work with the provinces and with universities and colleges to establish clear targets for Aboriginal health human resources.

That the Government of Canada finance specific access for Aboriginal students seeking careers in mental health.

 

 

That the Government of Canada increase its financial and social support for Aboriginal students engaged in these studies.

 

14.8.3   Suicide Prevention

Text Box: Inuit regions had rates of suicide “which are 11 times the national average.”

Text Box: Data collection and analysis, knowledge translation and dissemination of accurate information are considered essential for early detection and effective intervention.The rates of suicide among Aboriginal peoples are significantly higher than for the general population in Canada. In 1995, the Royal Commission on Aboriginal Peoples estimated that suicide rates across all age groups of Aboriginal people were on average three times higher than in the non-Aboriginal population. For registered Indians, the suicide rate was 3.3 times the national average; for Inuit, it was 3.9 times. Among Aboriginal youth aged 10 to 19 years, the suicide rate was five to six times higher than among their non-Aboriginal peers.[272]

Text Box: For young people, suicide prevention was seen as an area that needed urgent attention.Witnesses told the Committee that the statistics do not provide the complete picture and that many incidents have gone unreported. According to Debbie Dedam-Montour, most suicide statistics do not account for suicides wrongly reported as accidental deaths, nor do they include incomplete suicides (suicide attempts).  Witnesses stated that by 2005, the reported rates of suicide were much higher. Larry Gordon pointed out that Inuit regions had rates of suicide “which are 11 times the national average.”[273]James Morris, speaking about the 32 isolated First Nations served by the Sioux Lookout First Nations Health Authority in northern Ontario, reported the extremely high incidence of suicide in the region:

The national rate for suicide for young people in Canada is 0 to 14.9 per 100,000. In some of our communities, the rate is 42.5 per 100,000. The suicide rate is 398 per 100,000 in the age group 15 years to 19 years. The national average is 12.9 per 100,000. [274]

For all groups, surveillance, data collection and analysis, knowledge translation and dissemination of accurate information are considered essential for early detection and effective intervention.  Onalee Randell explained:

The lack of Inuit‑specific data makes it difficult for Inuit to work together across Canada.  We have community‑level data provided by regional boards on suicide incidence.  There is no national reporting for Inuit suicide.  It is anecdotal from the communities.  We do not have the same level of data on incidence of attempts or incidence of mental illness[275]

For young people, suicide prevention was seen as an area that needed urgent attention.  Jason Whitford reported that:

…of the close to 300 people we have met with and talked to about suicide prevention, probably 95 per cent had had suicide directly impact their family or a close friend. 

When working with the mainstream, it was the reverse.  It was probably 10 per cent who had a family member or a close friend die by suicide.[276]

Text Box: The majority of witnesses talked about suicide as the end product of a series of very fundamental problems, all of them incorporated within the broad compass of the determinants of health.Many factors contribute to suicide. A 1995 report by the Royal Commission on Aboriginal Peoples identified situational, socio-economic and culture stress as the major risk factors for suicide among Aboriginal peoples.  Mental illnesses related to psycho-biological factors such as anxiety disorders or schizophrenia were documented infrequently.[277]  This was reiterated by Arnold Devlin:

If you look at suicide in First Nation communities, I am not sure that you can use the mental illness model. I think that depression and substance abuse contribute, but there are other factors that are integral to that desperation, that despair, and that loss of hope that actively contribute to suicide.

The 10 year-old or 14 year-old who commits suicide is not suffering from a mental illness. They have given up. If we look at it from a mental illness model, we miss that sense of historical dynamics. [278]

The majority of witnesses talked about suicide as the end product of a series of very fundamental problems, all of them incorporated within the broad compass of the determinants of health. They argued that resources should be devoted at an earlier stage toward stopping or easing the problems contributing to the high rates of suicide in Aboriginal communities.Ron Evans, Chief of Norway House Cree Nation, insisted:

We do not wish to recite the devastation visited upon our peoples.  We do wish that you understand that our peoples continue to suffer from what our Elders and healers say is unresolved grief over the generations.  Some refer to this situation or condition as historic trauma or collective grief,  and it manifests itself in the high proportion of our people addicted to alcohol, drugs, gambling or other forms of addiction and in high suicide rates, especially among our young people. [279]

James Morris, Executive Director, Nodin Counselling Services, in reference to some root causes of suicide, observed:

Some of the causes are oppression and colonization, going back 100 years. The problem cannot be understood by anybody who has not been colonized or oppressed. We understand because we have experienced it.

 Part of the problem is the residential school system. Once again, if you have never been a residential school victim, you do not know how it is because you do not know how it feels. It is the same with racism. Racism is everywhere. Once again, if you have never been a victim of racism, you do not know what it is. If you are not affected by it, if you are not hurt by it, you do not respond to it. When you see somebody victimized by racism, you do not do anything because it does not bother you. We experience racism every day, everywhere. It is a fact of life.[280]

Text Box: People talked about the need to integrate physical and mental health programs and services to reduce the tendency to define issues in silos and to “stove-pipe” services.People talked about the need to integrate physical and mental health programs and services to reduce the tendency to define issues in silos and to “stove-pipe” services. Sheila Levy emphasized that suicide cannot be separated from other issues:

There is a tendency to view suicide, violence, addictions, abuse and mental health as separate issues. These problems receive separate funding while we should address the underlying commonalities in these issues. [281]

Onalee Randell supported greater integration of programs at the community level for more positive outcomes:

Individuals sent out for addictions treatment are returned to the communities without health or social services being notified of their return or any follow-up of the outcomes of their treatment. Children and youth who have had suicide attempts and are sent out of their communities for medical attention are returned to the communities with no follow up and, in some cases, no notification of health centre nurses who sent them out.[282]

The Committee is extremely concerned about the high rates of suicide among Aboriginal peoples. It is more than a decade since the Royal Commission on Aboriginal Peoples highlighted this and the resultant devastation for Aboriginal communities in its special report. Instead of improvement, the Committee heard about deterioration.

Text Box: The Committee is extremely concerned about the high rates of suicide among Aboriginal peoples.Text Box: The Committee wants concrete action to address the appalling suicide rate among Aboriginal children and adolescents.The Committee observes that, starting in 2005, Health Canada is to allocate $65 million over five years to a new National Aboriginal Youth Suicide Prevention Strategy; the money flows at a rate of $15 million per year from year two to year five.  It includes funding for First Nations on reserve and Inuit to support communities at risk, through crisis response and stabilization.  Some additional funding for research will look at off-reserve Aboriginal youth.

The Committee sees a role for the proposed Canadian Mental Health Commission in helping to develop consistent standards and protocols, in understanding risk factors and in organizing a national suicide research agenda. But, most importantly, it wants concrete action to address the appalling suicide rate among Aboriginal children and adolescents. The Committee believes that this work would best be undertaken by the Canadian Mental Health Commission in close cooperation with other organizations such as the Canadian Institutes of Health Research and the Canadian Institute for Health Information.

In view of the clear need for immediate culturally appropriate actions, the Committee recommends:

 

 

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That the Canadian Mental Health Commission (see Chapter 16), as a high priority, identify measures to reduce the alarming suicide rates amongst Aboriginal peoples.

That identification of these measures be a component of its priority action on an Aboriginal wellness and healing strategy.

That the Government of Canada allocate a designated suicide fund that accommodates the distinct needs of each group of Aboriginal peoples.

That the fund include specific allocations for implementing any measures identified by the Canadian Mental Health Commission as well as for increased research by the Canadian Institutes of Health Research and for specific data collection by the Canadian Institute for Health Information in collaboration with the National Aboriginal Health Organization.

 


14.8.4   Reduction of Alcohol and Substance Addiction

Text Box: The Assembly of First Nations supported the need for appropriate funding to develop and administer regional treatment facilities for those who abuse solvents and those with drug addictions.  As with suicide, witnesses talked about the interrelationship between alcohol and/or substance abuse and other social problems.  James Morris reiterated that “All these social problems, suicide, sexual abuse, family violence, alcohol and drug abuse, are manifestations of deeper problems.”[283] Debbie Dedam-Montour argued that “the broad term of ‘family violence,’ which is sexual, physical, emotional and psychological abuse, and neglect…has had a domino effect because it leads sufferers to self-medicate with alcohol or any other harmful substances and to involvement with correctional institutions.”[284]

Text Box: Inuit communities have a need for specific alcohol and addictions programs that are culturally based and use both harm reduction and abstinence models.The Assembly of First Nations supported the need for appropriate funding to develop and administer regional treatment facilities for those who abuse solvents and those with drug addictions.  Valerie Gideon told the Committee about proposals:

…to look at developing or creating new treatment centres that would have a broad mandate beyond strictly alcohol, for example, or some of the more well-known drugs to look at some of the emerging addictions, such as crystal meth, for example, that play a pivotal role in mental health and suicides in our communities. [285]

Donna Lyon noted the lack of sufficient funding by Health Canada for addiction services:

There are long waiting lists to attend counselling and insufficient funding for patient transportation. Much of the funding is prioritized toward acute care operations and short-term crisis intervention. [286]

Inuit communities have a need for specific alcohol and addictions programs that are culturally based and use both harm reduction and abstinence models:

There needs to be an increased number of Inuit addiction counsellors and early interventions. We need to have after-care and follow-up services in communities. No longer are people happy with going to six-week treatment centres and then coming home to the same situations; the same overcrowding, the same high costs and no supports.  —Onalee Randell [287]

Text Box: The connected nature of alcohol and other substance abuse and suicide, along with other social problems, requires a coordinated population health approach.The Committee supports the message that the connected nature of alcohol and other substance abuse and suicide, along with other social problems, requires a coordinated population health approach.  Careful evaluation of what works best to achieve positive outcomes is essential. It is extremely important, therefore, that the proposed Canadian Mental Health Commission work very closely with other organizations such as the Canadian Institutes of Health Research and the Canadian Centre for Substance Abuse.

The Committee recommends:

 

 

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That the Canadian Mental Health Commission (see Chapter 16) identify measures to reduce the alarming alcohol and substance addiction rates amongst Aboriginal peoples.

That identification of these measures be a component of its priority action on an Aboriginal wellness and healing strategy.

That the Government of Canada allocate a designated fund for addiction that accommodates the distinct needs of each group of Aboriginal peoples.

That the fund include specific allocations for implementing any measures identified by the Canadian Mental Health Commission as well as for increased research by the Canadian Institutes of Health Research and for specific data collection by the Canadian Centre for Substance Abuse in collaboration with the National Aboriginal Health Organization.

14.9      ASSESSING DATA AND DOLLARS

Two things are important to the success of any strategy — money and data on what is happening.  Money alone will not fix the poor health status of Aboriginal peoples, although there is no doubt that more must be spent.  It is critical to have comprehensive data on where and on what money is currently being spent and what outcomes are the result.  New approaches to the collection of information and evidence are needed both to improve care and to inform new approaches about how best to distribute the money to achieve the greatest results.


14.9.1   Expanded Data

Text Box: There is no ongoing data collection on the prevalence of mental illness and addictions among Aboriginal people.

Text Box: The most definitive source of data about persons with disabilities in Canada (Participation and Activity Limitation Survey, PALS) provides no information specific to Aboriginal peoples.  The foundation of any effective strategy or action plan is data.  Over the last decade, many reports — from those emanating from the Royal Commission on Aboriginal Peoples to those issued following the recent First Ministers’ meeting with Aboriginal leaders — have called for development of a framework to collect and report comparable information across all Aboriginal groups.

Although the Government of Canada, as part of the Canada-Aboriginal Peoples Roundtable process in 2004, committed itself to the development of an Aboriginal report card, there is no ongoing data collection on the prevalence of mental illness and addictions among Aboriginal people.  Witnesses acknowledged that federal departments have difficulty in getting comprehensive data relating to mental health on all Aboriginal populations. For First Nations and Inuit, Indian and Northern Affairs Canada, Health Canada and Correctional Service Canada all offer specific programs and services, but the data analyses relating to them are limited.

At Social Development Canada, the most definitive source of data about persons with disabilities in Canada (Participation and Activity Limitation Survey, PALS) provides no information specific to Aboriginal peoples.  Although suggesting that rates of disability — including mental disabilities may be much higher among Aboriginal persons than in the rest of the population, Cecilia Muir, Director General, Office of Disability Issues, explained:

In terms of data, we do not have specific data. I have talked about the population size, but it is not specific to Aboriginal persons. They were not over-sampled, so we do not have greater detail about the [incidence] in the Aboriginal population.[288]

Text Box: Witnesses called for baseline data from which specific targets could be established.Witnesses stressed the need for better data to support informed decisions that would contribute to wellness.  They called for baseline data from which specific targets could be established.  They urged greater accountability and transparency by governments, providers and others so that progress toward established goals could be tracked and measured over time. Elsie Bastien pointed out:

We need to develop baseline data of program and service delivery usage by Aboriginal populations.  It is important that mechanisms be developed to systemically collect and analyze longitudinal Aboriginal health information.  A centralized focussed approach will be helpful to coordinate, foster comparability, and create linkages among Aboriginal health and data sources.[289]

Text Box: Witnesses emphasized the need for data specific to each group.Witnesses emphasized the need for data specific to each group.  The First Nations regional longitudinal national health survey was held out as a potential vehicle for ongoing collection of mental health data and monitoring of the equality of access to mental health services in First Nations communities.  Housed within the First Nations Centre at the National Aboriginal Health Organization, the regional health survey is community-based, the only survey that goes on reserve and collects data directly from First Nations people.

There is a limited amount of Inuit- and Métis-specific data on mental health, as in other areas of health. It is very difficult to measure progress when data are absent or not available in sufficient detail.

For Inuit in particular, our information is missing or mixed in with the data that includes other Aboriginal peoples.  Without the correct Inuit health stats, development and evaluation of programs and services will not be based on reliable evidence.  —Larry Gordon[290]

Text Box: The Committee believes that, without a clear, complete and accurate picture of the current situation facing Indian, Inuit and Métis populations, it will be extremely difficult to set standards and targets and provide the required resources for programs and services that will be effective in improving the overall wellness of Aboriginal peoples.  Across the board, while we are gathering data and accumulating an evidence base for First Nations and Inuit, Metis lag far behind in gaining initial basic baseline data.  —Bernice Downey[291]

One witness stressed the need for careful analysis of data, taking into account factors such as culture.  Elsie Bastien noted that an evaluation of service delivery can measure outcomes as poor based on an imperfect theory:

An error or poor outcome is an indicator of incomplete data or an inadequate hypothesis that did not result in a successful completion of a certain purpose and/or intent.  It is imperative that culturally appropriate program indicators are included within the proposed environmental scan.

[…] An accurate picture would be data not generated from a Western medical model, which is our current practice, but generated from an Aboriginal world view on health and wellness.[292]

The Committee believes that, without a clear, complete and accurate picture of the current situation facing Indian, Inuit and Métis populations, it will be extremely difficult to set standards and targets and provide the required resources for programs and services that will be effective in improving the overall wellness of Aboriginal peoples.  In particular, the Committee recognizes the importance of developing data that will provide the baseline against which new investments can be tracked over time and the outcomes of new programs and services measured.

Text Box: The Committee does not understand how federal departments, knowing the abysmal health status of Aboriginal peoples and the fact that this population is universally considered to be at risk, could have failed to collect, or to support others in collecting, the data required to develop a strategy to address the problem in a meaningful way and to measure progress subsequently with respect to outcomes.The Committee does not understand how federal departments, knowing the abysmal health status of Aboriginal peoples and the fact that this population is universally considered to be at risk, could have failed to collect, or to support others in collecting, the data required to develop a strategy to address the problem in a meaningful way and to measure progress subsequently with respect to outcomes.

 

 

 

The Committee recommends:

 

 

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That the Government of Canada work with the National Aboriginal Health Organization to assess the appropriateness of the First Nations regional health survey for use as a model for data collection for other Aboriginal peoples.

That the Canadian Institute for Health Information be encouraged to provide analysis of health determinants data related to each of the Aboriginal peoples.

That the Canadian Mental Health Commission (see chapter 16) work with the Canadian Institute for Health Information to improve understanding of mental health causes and outcomes.

 

 

14.9.2   Transformed Funding

Text Box: Multi-year sustainable funding is essential to counter the past experience of communities that devoted resources to set up a program only to discover that the available funding would support it for only a year or two.Witnesses stressed repeatedly that the key to capacity is adequate, flexible and ongoing funding.  In particular, multi-year sustainable funding is essential to counter the past experience of communities that devoted resources to set up a program only to discover that the available funding would support it for only a year or two.  Onalee Randell emphasized that:

The short-term unstable and uncertain funding causes incredible barriers to the delivery of mental wellness programs. […]Multi-year flexible funding is required. It is difficult for small communities to develop programs and not know if those programs will be funded the next year.[293]

Valerie Gideon urged that funding and reporting structures be transformed:

…so that they are enabling tools rather than barriers to the implementation by communities of holistic approaches to mental wellness. An example of that transformation is multi-year flexible funding arrangements and reporting based on outcomes versus administrative data. [294]

Irene Linklater noted that integrated models of funding between federal agencies are being introduced that allow for the support of comprehensive programs with long-term sustained funding and rigorous accountability requirements:

…there is a new contribution model between First Nations and Inuit Health Branch and Indian and Northern Affairs Canada that looks at block funding, multi-year arrangements.  We are encouraged by that process.[295] 

 

Text Box: Needs-based funding formulas that would provide stable, predictable funding to facilitate financial planning are necessary.  The First Nations reporting requirements established by the federal government were criticized by the Auditor General of Canada as being onerous; she commented that they “are a significant burden, especially for communities with fewer than 500 residents. We estimated that at least 168 reports are required annually by the four federal organizations that provided the most funding for major federal programs.”[296]

Needs-based funding formulas that would provide stable, predictable funding to facilitate financial planning are necessary.  Valerie Gideon supported the movement to more targeted and consolidated funding for First Nations health, a focus on block funding and the development of a “system of healing centres and lodges under First Nations control to bridge jurisdictions and individual ministries, and to pool both health and social resources from all sources.”  She maintained that this funding would be most effective with:

…an increased transfer of funding to First Nations communities to develop and maintain their own health centre facilities and, underneath that, the mental health services with strategic linkages to provincial and territorial jurisdictions.[297]

The overall allocation of money for mental health purposes was challenged by several witnesses.  Donna Lyon called into question the current funding focus on “affordability and not need,” when the need is so great for mental health services.[298]

According to Ron Evans, funding can be a source of wellness. He linked research from Harvard University on socio-economic development and from British Columbia on suicide prevention in First Nations to demonstrate the interconnected nature of economic and cultural stability in communities:

The Harvard project on Native American tribes found, through several years of onsite work with First Nations in U.S. and Canada, that business success in First Nations in Canada and tribes in the United States depend upon a few factors such as a stable government and regulations, adequate funding, and, importantly, the cultural match of the business to the community.  Similarly, the ongoing 14-year study of Chandler and Lalonde, “Cultural Continuity as a Hedge Against Suicide,” found that First Nations who had control of essentially government functions such as education, health, community services, who worked to resolve land claims and who actively practised their cultural traditions, had little to no suicide.[299]

14.9.3   Funding for Youth

Irene Linklater was one of several witnesses to talk about the lack of youth-specific funding and the problems created when program funding is delayed. Referring to the importance of youth councils that represent young people in communities, she stated:

One of the problems that they have is access to funding.  There is really no specific funding for youth engagement at the community level for, say, the youth suicide strategies. 

In Manitoba here, we have funding for youth through the Assembly of Manitoba Chiefs, but every year we fight for funding.  We sometimes do not get our funding until October.[300]

While Jason Whitford, Coordinator, Youth Council, Assembly of Manitoba, acknowledged that it does not always take a lot of money to do positive things in a community, any discontinuity in funding makes it more difficult to operate. Even the Keewatin Winnipeg Youth Initiative, recognized as best practice and funded by the Urban Multipurpose Youth Centres Initiative out of Heritage Canada, experiences funding problems:

We are waiting for funding once again for the year.  We will probably end up losing about five months out of the year.  However, based on past experience, we are going to just continue to deliver programs and services for urban Aboriginal youth and convince the management of AMC to support us in operating that project.[301]

For the Inuit as well, although the presence of and participation by youth is seen as crucial to community wellness, particularly to suicide prevention, the funding is erratic.  Larry Gordon recounted how the National Inuit Youth Council has been active in role modelling and in suicide prevention:

The funding provided to Inuit youth for these important initiatives is provided year to year with no guarantees, despite the success the work had in outreach to Inuit youth who are the most at-risk population for suicide in all of Canada.[302]

As part of the September 2004 federal, provincial and territorial Health Agreement, the federal government announced new funding of $65 million allocated over five years for an Aboriginal youth suicide prevention strategy.  Ian Potter indicated that discussions about its distribution were ongoing:

We are working on the program jointly with the Assembly of First Nations, the Inuit Tapiriit Kanatami and with input from other national Aboriginal organizations, provinces and territories and federal departments.  This strategy will support communities in stopping youth from becoming suicidal, reaching youth who are at risk of committing suicide and preventing suicide clusters in the aftermath of a completed suicide. [303]

For Arnold Devlin, funding for a serious problem like suicide that ends after a five-year period is a major concern:

One of our greatest concerns is the sustainability of the program; it needs to be linked with some long-term planning and this will be the key to success. If we just think this will be our solution, it will not be effective.[304]

14.9.4   Recommendation for Action

The Committee believes it self-evident that long-term suffering will require long-term funding.  Aboriginal peoples have endured a lengthy period of alternating indifference and piecemeal attention from the federal and other governments entrusted with their well-being. The Committee is aware of the November 2005 commitments for an Aboriginal Blueprint on health.  However, it recognizes that previous announcements such as the $200 million for an Aboriginal Health Transition Fund in September 2004 did little to alleviate the health needs of Aboriginal peoples. Discussions relating to the distribution of that money remained “ongoing” some 14 months later. In the meantime, the problems are not getting any better and are probably worsening. There are no data to inform us.

The Committee heard the urgent calls for multi-year, sustained funding appropriate to the magnitude of the problems facing Aboriginal peoples.  It has already recommended that the proposed Canadian Mental Health Commission, in consultation with its Aboriginal advisory committee, establish timelines and funding levels to implement wellness and healing programs.  It urges prompt movement on this overall strategy and action plan.

The Committee has already recommended the creation of an interdepartmental committee to report to Parliament every two years with a clear inventory of ongoing federal programs and services and the money spent on them.  It has also recommended that the federal government work with Aboriginal peoples to identify necessary programs and services combined with appropriate oversight and evaluation criteria.

The Committee further recommends:

 

 

102

That the Government of Canada undertake immediate analyses of the current level of federal funding for Aboriginal peoples.

That the analyses assess how much funding would be required to change key health determinants for Aboriginal peoples.

That the analyses include a short, medium and long range assessment for funding needs.

That the first report to Parliament by the inter-departmental committee recommended in section 14.6.3 include the results of the analyses.

14.10    CONCLUSION

Text Box: In a country proud of the rich personal opportunities available to most citizens and the wealth of its human and natural resources, the situation facing Aboriginal people on a daily basis is a shameful blot on the public record.  Text Box: There is great human potential among Aboriginal peoples, especially given the youthfulness of the population.In a country proud of the rich personal opportunities available to most citizens and the wealth of its human and natural resources, the situation facing Aboriginal people on a daily basis is a shameful blot on the public record.  Still, there is reason to hope. The Committee heard that Aboriginal peoples face high levels of mental distress but experience a low incidence of mental disorder. This suggests strongly that many of the current negative outcomes, whether suicide or addiction associated with despair, can be reversed. There is great human potential among Aboriginal peoples, especially given the youthfulness of the population.

The Committee was encouraged by the repeated testimony that the mental distress facing Aboriginal peoples is preventable and that the effects of decades of fragmented and often negative treatment could be alleviated. It agrees that efforts on the part of governments, communities and individuals can produce positive effects on wellness, especially wellness derived from mental health.

Text Box: The Committee believes that Canada’s long tradition with population health initiatives offers significant promise for improvement in the mental and physical health status of Aboriginal peoples, primarily through practical changes to their social and physical environments.  Actions in education, housing, employment and community support can produce significant long-term benefits to Aboriginal peoples.The Committee believes that Canada’s long tradition with population health initiatives offers significant promise for improvement in the mental and physical health status of Aboriginal peoples, primarily through practical changes to their social and physical environments.  Actions in education, housing, employment and community support can produce significant long-term benefits to Aboriginal peoples.

The Committee is aware of many initiatives of Aboriginal communities across the country to change their social and physical environments.  It also recognizes the ongoing collaborative efforts among all groups — First Nations, Métis, and Inuit. The Committee commends all participants for these shared endeavours.

The Committee strongly supports the development of a national strategy that is holistic, culturally appropriate, community-based, equitable for all Aboriginal peoples, and supported by sustained funding.  It calls for the preparation of an action plan based on the determinants of health, one that incorporates specific goals and timelines to achieve measurable beneficial outcomes and that fosters collaboration among all those working to achieve these objectives.

The Committee supports increased, stable, multi-year funding agreements to provide long-term support for long-term goals for a population experiencing serious but preventable problems.  It knows that all Canadians are looking for progress on key outcomes that will improve the overall well-being of Aboriginal peoples.



[1]     20 April, 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/13eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[2]     21 April 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/13evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[3]     20 September 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/27eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[4]     Indian Act, R.S. 1985, c. I-5, http://laws.justice.gc.ca/en/I-5/, Tonina Simeone, Federal-Provincial Jurisdiction and Aboriginal Peoples, TIPS-88E, Library of Parliament, 2001.
Mary Hurley, The Indian Act, TIPS-17, Library of Parliament, 2004, http://lpintrabp.parl.gc.ca/apps/tips/printable/tip17-e.pdf.

[5]     Indian Affairs and Northern Development Canada, Performance Report for the period ending March 31, 2005, p. 21, http://www.tbs-sct.gc.ca/rma/dpr1/04-05/INAC-AINC/INAC-AINCd45_e.pdf.

[6]     Health Canada, Performance Report for the period ending March 31, 2005, p. 6, http://www.tbs-sct.gc.ca/rma/dpr1/04-05/HLTH-SANT/HLTH-SANTd45_e.pdf.

[7]     Health Canada, Federal Indian Health Policy 1979, http://www.hc-sc.gc.ca/fnih-spni/services/indi_health-sante_poli_e.html.

[8]     20 April 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/13eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[9]     20 September 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/13eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[10]    Correspondence from Ian Potter, Assistant Deputy Minister, First Nations and Inuit Health Branch, Health Canada to Senator Michael Kirby, Chair, Standing Committee on Social Affairs, Science and Technology, The Senate,7 September, 2005.

[11]    20 April 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/13eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[12]    20 April 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/13eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[13]    Correspondence from Ian Potter, Assistant Deputy Minister, First Nations and Inuit Health Branch, Health Canada to Senator Michael Kirby, Chair, Standing Committee on Social Affairs, Science and Technology, The Senate, 7 February 2006, p. 2.

[14]    Health Council of Canada, The Health Status of Canada’s First Nations, Inuit and Métis, January 2005, http://healthcouncilcanada.ca.c9.previewyoursite.com/docs/papers/2005/BkgrdHealthyCdnsENG.pdf.

[15]    According to Linklater, the statistic was from research conducted by the Assembly of Manitoba Chief in 2001; 1 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/16evc-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[16]    1 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/16evc-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[17]    21 April 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/13evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[18]    20 September 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/27eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[19]    21 April 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/13evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[20]    1 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/16evc-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[21]    20 September 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/27eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[22]    20 September 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/27eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[23]    20 September 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/27evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[24]    1 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/16evc-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[25]    20 September 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/27eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[26]    20 September 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/27eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[27]    20 September 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/27eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[28]    21 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/23evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[29]    11 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/15evf-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[30]    20 April 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/13eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[31]    21 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/23evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[32]    Auditor General of Canada, Health Canada — First Nations Health, Chapter 13, October, 1997, http://www.oag-bvg.gc.ca/domino/reports.nsf/html/ch9713e.html#0.2.L39QK2.4FNW9F.4QDJQE.ZG.

[33]    Auditor General of Canada, Indian and Northern Affairs Canada — Social Assistance, 1994, http://www.oag-bvg.gc.ca/domino/reports.nsf/html/9423ce.html#0.2.L39QK2.6NA0GI.V1SJQE.ZL.

[34]    Health Canada, Blueprint on Aboriginal Health:  A 10-Year Transformative Plan, Prepared for the Meeting of First Ministers and Leaders of National Aboriginal Organizations,
24-25 November 2005, a Work in Progress, 2005,http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/2005-blueprint-plan-abor-auto/plan_e.pdf.

[35]    Ibid.

[36]    6 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/18eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[37]    Canada Health Act, 1984, Chapter C-6, Section 2 — Interpretation, http://laws.justice.gc.ca/en/C-6/17077.html#rid-17084.

[38]    Corrections and Conditional Release Act, 1992, c. 20, http://laws.justice.gc.ca/en/C-44.6/.

[39]    Correctional Service Canada, Commissioner’s Directive, “Health Services,” Number 800, 2004, http://www.csc-scc.gc.ca/text/plcy/cdshtm/800-cde_e.shtml.

[40]    Correctional Service Canada, Performance Report for the period ending March 31, 2005, p. 12, http://www.tbs-sct.gc.ca/rma/dpr1/04-05/CSC-SCC/CSC-SCCd45_e.pdf.

[41]    23 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[42]    7 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/19eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[43]    7 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/19eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[44]    For additional material on mental health, see Dr. Brent Moloughney, “A Health Care Needs Assessment of Federal Inmates in Canada,” Canadian Journal of Public Health, Vol. 95, Supplement 1, March/April, 2004, http://www.cpha.ca/english/cjph/inmates/CJPH_95_Suppl_1_e.pdf.

[45]    23 February, 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[46]    Office of the Correctional Investigator, Press Release, “Reports Highlights Dramatic Increase in Numbers of Inmates Mentally Ill — Implementation of National Strategy Urged to address Crisis,” 4 November 2005, http://www.oci-bec.gc.ca/release-20051104_e.asp.

[47]    Correctional Service Canada, Commissioner’s Directive, “Health Services,” Number 800, 2004, http://www.csc-scc.gc.ca/text/plcy/cdshtm/800-cde_e.shtml.

[48]    Ibid.

[49]    7 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/19eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[50]    7 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/19eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[51]    7 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/19evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[52]    23 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[53]    11 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/15evf-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[54]    15 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/22evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[55]    23 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[56]    11 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/15evf-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[57]    7 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/19eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[58]    20 April 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/13eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[59]    16 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/06eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[60]    7 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/19eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[61]    7 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/19eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[62]    7 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/19eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[63]    16 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/06eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[64]    7 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/19eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[65]    16 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/06eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[66]    23 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[67]    2 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/17eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[68]    23 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[69]    7 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/19eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[70]    15 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/05evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[71]    14 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/22eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[72]    23 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[73]    National Defence Act, R.S. 1985, c. N-5, http://laws.justice.gc.ca/en/N-5/.

[74]    23 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[75]    National Defence, Performance Report For the Period ending March 31, 2005, p. 115, http://www.tbs-sct.gc.ca/rma/dpr1/04-05/ND-DN/ND-DNd45_e.pdf.

[76]    Ibid., p. 88; The Primary Reserve is made up of the Naval Reserve, the Army Reserve, the Air Reserve, the Communication Reserve, the Health Services Reserve, the Legal Reserve, and the National Defence Headquarters Primary Reserve List.

[77]    National Defence, Statistics Canada CF Mental Health Survey, “A milestone,” http://www.forces.gc.ca/health/information/op_health/stats_can/engraph/MH_Survey_e.asp.

[78]    Correspondence from Brigadier-General Hilary F. Jaeger, Surgeon General, National Defence to Senator Michael Kirby, Chair, Standing Senate Committee on Social Affairs, Science and Technology, The Senate, 2 February, 2006 pointed out that, as the survey did not measure all types of mental illness, the true lifetime prevalence is likely higher.

[79]    23 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[80]    23 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[81]    23 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[82]    National Defence, News Room Backgrounder,“Canadian Forces Mental Health Programs — Update,” BG 05.037, 10 November 2005, http://www.dnd.ca/site/newsroom/view_news_e.asp?id=1804.

[83]    National Defence, Canada’s Military Health System, “In-Garrison Health Services,” http://www.forces.gc.ca/health/about_us/engraph/in_garrison_e.asp.

[84]    Operational Stress Injury Social Support, Information for Canadian Military, Former and Serving, “What are Operational Stress Injuries?” http://www.osiss.ca/sitePage.txp?ud_siteSectionId=14347&tx_target=main1131814980596.

[85]    Mark Zamorski, Evaluation of an Enhanced Post-Deployment Health Screening Program for Canadian Forces Members Deployed on Operation OPOLLO (Afghanistan/SW Asia):  Preliminary Findings and Action Plan, June 2003, http://www.forces.ca/health/information/op_health/op_apollo/engraph/op_apollo_toc_e.asp.

[86]    National Defence, Directorate of Medical Policy, series of booklets titled Preparing for Critical Incident Stress, Preparing for Deployment Stress, Preparing for Reunion Stress, 2000, http://www.forces.gc.ca/health/information/engraph/health_promotion_home_e.asp?Lev1=2&Lev2=5.

[87]    National Defence, Aide Memoire for the Supervisor’s Role in Dealing with Alcohol Misuse, DCOS Force Health Protection, 2004, http://www.forces.gc.ca/Health/Services/health_promotion/PDF/Aide%20Memoire%20for%20the%20Supervisor%27s%20Role%20in%20Dealing%20with%20Alcohol%20Misuse.pdf.

[88]    Correspondence from Brigadier-General Hilary F. Jaeger, Surgeon General, National Defence to Senator Michael Kirby, Chair, Standing Senate Committee on Social Affairs, Science and Technology, The Senate, 2 February, 2006.

[89]    23 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[90]    23 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[91]    23 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[92]    23 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[93]    23 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[94]    23 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[95]    23 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[96]    Canadian Defence Academy, Moving On — A Handbook for Canadian Forces Members Preparing for Release, “Chapter 8 — Disability Benefits and Pension,” 2002, http://www.cda.forces.gc.ca/er/engraph/mss/handbook/pdf/Eng_Chapter_8.pdf.

[97]    23 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[98]    National Defence Ombudsman Office, Annual Report 2004-2005, June 2005, http://www.ombudsman.forces.gc.ca/reports/annual/2004-2005_e.asp#Battle.

[99]    Ibid., section titled “Following up on the CF’s Treatment of Members Suffering from OSIs.”

[100]  Canadian Forces Grievance Board, see case summaries section in index, PTSD did not appear in a search; one drug addiction case was found; http://www.cfgb-cgfc.gc.ca/index-e.php

[101]  23 February, 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[102]  Department of Veterans Affairs Act, R.S. 1985, c. V-1, http://laws.justice.gc.ca/en/V-1/ and Pensions Act, R.S. 1985, c. P-6 http://laws.justice.gc.ca/en/P-6/; Canadian Forces Members and Veterans Re-establishment and Compensation Act, http://www.parl.gc.ca/PDF/38/1/parlbus/chambus/house/bills/government/C-45_4.PDF.

[103]  Veterans Health Care Regulations, http://laws.justice.gc.ca/en/V-1/SOR-90-594/.

[104]  23 February, 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[105]  Veterans Affairs Canada, 2004-2005 Performance Report, p. 10, http://www.tbs-sct.gc.ca/rma/dpr1/04-05/VAC-ACC/VAC-ACCd45_e.pdf.

[106]  23 February, 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[107]  Veterans Review and Appeal Board, Annotated Pension Act, 2005, http://www.vrab-tacra.gc.ca/Documents/AnnotatedAct-March2005.pdf.

[108]  Veterans Affairs Canada, 2004-2005 Performance Report, p. 17, http://www.tbs-sct.gc.ca/rma/dpr1/04-05/VAC-ACC/VAC-ACCd45_e.pdf.

[109]  Government of Canada, Canada Gazette, “Canadian Forces Members and Veterans Re-establishment and Compensation Regulations,” Vol. 139, No. 51, 17 December 2005, http://canadagazette.gc.ca/partI/2005/20051217/html/regle7-e.html.

[110]  Ibid., Service Income Security Insurance Plan (SISIP) is described in the previous Canadian Forces section 13.3.3.2.

[111]  Canadian Forces Members and Veterans Re-establishment and Compensation Act, 2005, c.21, http://laws.justice.gc.ca/en/C-16.8/index.html.

[112]  A “rehabilitation need” is a physical or mental health problem resulting primarily from service in the Canadian Forces that is creating a barrier to re-establishment in civilian life.” Government of Canada, Canada Gazette, “Canadian Forces Members and Veterans Re-establishment and Compensation Regulations,” Vol. 139, No. 51, 17 December 2005, http://canadagazette.gc.ca/partI/2005/20051217/html/regle7-e.html.

[113]  The National Mental Health Clinical Centre of Expertise at Ste-Anne de Bellevue is responsible for advances in mental health clinical care through program development, research, education and outreach; Veterans Affairs, News Release, “National Mental Health Clinical Centre of Expertise Officially Opens,”7 November 2005, http://news.gc.ca/cfmx/view/en/index.jsp?articleid=181199&.

[114]  Government of Canada, Canada Gazette, “Canadian Forces Members and Veterans Re-establishment and Compensation Regulations,” Vol. 139, No. 51, 17 December 2005, http://canadagazette.gc.ca/partI/2005/20051217/html/regle7-e.html.

[115]  23 February, 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[116]  23 February, 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[117]  Veterans Affairs Canada, Volume  II of the Disability Pension Program Evaluation, July 2005, http://www.vac-acc.gc.ca/general/sub.cfm?source=department/reports/deptaudrep/disapen_eval_july2005.

[118]  Veterans Review and Appeal Board, “About Veterans Review and Appeal Board,” http://www.vrab-tacra.gc.ca/AboutVRAB.htm.

[119]  Ombudsman Ontario, “The Case for a VAC Ombudsman — Esprit de Corps,”July 2005, http://www.ombudsman.on.ca/PR_details.asp?PRID=174.

[120]  Veterans Affairs Canada- Canadian Forces Advisory Council, Honouring Canada’s Commitment Opportunity with Security for Canadian Forces Veterans and their Families in the 21st Century, March 2004, http://www.vac-acc.gc.ca/clients/sub.cfm?source=councils/vaccfac/commitment.

[121]  23 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[122]  23 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[123]  Veterans Affairs Canada, Support for the CF Community, http://www.vac-acc.gc.ca/clients/sub.cfm?source=salute/osi_edition/cf_support.

[124]  10 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/15evc-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[125]  Royal Canadian Mounted Police Act, R.S. 1985, c. R-10, http://laws.justice.gc.ca/en/R-10/index.html.

[126]  Royal Canadian Mounted Police Regulations, 1988 (SOR/88-361) http://laws.justice.gc.ca/en/R-10/SOR-88-361/174146.html.

[127]  Royal Canadian Mounted Police, Departmental Performance Report for the period ending
March 31, 2005, p. 23, http://www.tbs-sct.gc.ca/rma/dpr1/04-05/RCMP-GRC/RCMP-GRCd4502_e.asp#glance.

[128]  Special Duty Service involves designated operations which could include armed conflict, peacekeeping missions, anti-terrorism activities, disaster relief or search and rescue activities.

[129]  Public Service Commission, Guide to the Priority for Members of the CF and RCMP who become Disabled, http://www.psc-cfp.gc.ca/staf_dot/priority-priorite/rcmp-grc_e.htm.

[130]  Royal Canadian Mounted Police Superannuation Act, R.S. 1985, c. R-11, http://laws.justice.gc.ca/en/R-11/text.html.

[131]  Royal Canadian Mounted Police, “Veterans Affairs Canada and the Royal Canadian Mounted Police Partner to Improve Services,” RCMP News Release, 17 February 2003.

[132]  RCMP, “The New Veterans Charter — Chief Human Resource Officers Message,”24 May 2005, http://www.rcmp.ca/vets/new_charter_e.htm#top.

[133]  Royal Canadian Mounted Police External Review Committee, Publications, including research reports and communiqués about individual cases, http://www.erc-cee.gc.ca/english/publications_date.html.

[134]  10 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/15evc-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[135]  6 June 2005,http://www.parl.gc.ca/Content/SEN/Committee/381/soci/18eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[136]  Royal Canadian Mounted Police External Review Committee, Occupational Health and Safety- An Employer Perspective, Discussion Paper 9, 1992, http://www.erc-cee.gc.ca/Discussion/english/eDP9.htm.

[137]  Ibid.

[138]  Royal Canadian Mounted Police External Review Committee, Employee Assistance Programs — Philosophy, theory and practice, Discussion Paper 5, 1990, http://www.erc-cee.gc.ca/Discussion/english/eDP5.htm.

[139]  Health Canada, Profile — Substance Abuse Treatment & Rehabilitation in Canada, “The federal role in substance abuse treatment,” 1999, http://www.hc-sc.gc.ca/ahc-asc/pubs/drugs-drogues/profile-profil/federal_e.html.

[140]  16 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/06eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[141]  RCMP, News Release, “RCMP Named One of Canada’s Top 100 Employers,”18 October 2005, http://www.rcmp-grc.gc.ca/news/n_0524_e.htm.

[142]  RCMP, Departmental Performance Report 2003-2004, http://www.tbs-sct.gc.ca/rma/dpr/03-04/RCMP-GRC/RCMP-GRCd3401_e.asp#Lines.

[143]  Norman Sabourin, “Medical Dischage and Duty to Accommodate in the RCMP,” External Review Committee, March 2002,http://www.erc-cee.gc.ca/english/articles/articles_medicaldischarge.html.

[144]  Veterans Affairs Canada, Putting Our Priorities into Action, Five year Strategic Plan — Update 2004, http://www.vac-acc.gc.ca/general/sub.cfm?source=department/reports/update2004/action04.

[145]  RCMP, “The New Veterans Charter — Chief Human Resource Officers Message,”24 May 2005, http://www.rcmp.ca/vets/new_charter_e.htm#top.

[146]  RCMP Veteran’s Association, Calgary Division, “Notes of Interest,” http://www.members.shaw.ca/rcmpvets.calgary/notes.htm.

[147]  17 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/07ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[148]  23 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[149]  Immigration and Refugee Protection Act, 2001, c. 27, http://laws.justice.gc.ca/en/I-2.5/.

[150]  Citizenship and Immigration Canada, Applying for Permanent Residence, “Appendix D:  Medical Examinations,” 2004,http://www.cic.gc.ca/ENGLISH/pdf/kits/guides/4000E.PDF.

[151]  Correspondence from Dr. Sylvie Martin, Acting Director, Immigration Health Program Elaboration, Medical Services Branch, Citizenship and Immigration Canada to Senator Michael Kirby, Chair, Standing Committee on Social Affairs, Science and Technology, The Senate,
3 February 2006.

[152]  Family class sponsored spouses, common-law partners, conjugal partners and their dependent children, and convention refugees and persons in need of protection and their dependents, will not be refused entry if they have a health condition that places excessive demand on health or social services; CIC, Medical Testing and Surveillance, Fact Sheet 20, http://www.cic.gc.ca/english/irpa/fs%2Dmedical.html.

[153]  Anita Gagnon, Responsiveness of the Canadian Health Care System Toward Newcomers, Discussion Paper no.40, Commission on the Future of Health Care in Canada, November 2002, http://www.hc-sc.gc.ca/english/pdf/romanow/pdfs/40_Gagnon_E.pdf.

[154]  Citizenship and Immigration Canada, Departmental Performance Report for the period ending March 31, 2005, p. 61, http://www.tbs-sct.gc.ca/rma/dpr1/04-05/CI-CI/CI-CId45_e.pdf.

[155]  23 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[156]  Citizenship and Immigration Canada, Agreement for Canada-British Columbia Cooperation on Immigration, “Annex H — Immigration Health,” http://www.cic.gc.ca/english/policy/fed-prov/bc-2004-annex-h.html.

[157]  23 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[158]  21 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/23eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[159]  17 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/07ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[160]  17 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/07ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[161]  17 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/07ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[162]  8 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/20ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[163]  Anita Gagnon, Responsiveness of the Canadian Health Care System Toward Newcomers, Discussion Paper no.40, Commission on the Future of Health Care in Canada, November 2002, http://www.hc-sc.gc.ca/english/pdf/romanow/pdfs/40_Gagnon_E.pdf.

[164]  17 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/07ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[165]  17 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/07ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[166]  Public Health Agency of Canada, News Release, “Michael Wilson to serve as Special Ministerial Advisor on Mental Health,” 4 February 2005.

[167]  Financial Administration Act, R.S. 1985, c. F-1, http://laws.justice.gc.ca/en/f-11/text.html.

[168]  Employment Equity Act, 1995, c.44, http://laws.justice.gc.ca/en/e-5.401/50293.html

[169]  Government Employees Compensation Act, Chapter G-5,http://laws.justice.gc.ca/en/g-5/63537.html.

[170]  Treasury Board, Performance Report for the period ending March 31, 2005, p. 13, http://www.tbs-sct.gc.ca/rma/dpr1/04-05/TBS-SCT/TBS-SCTd45_e.pdf.

[171]  Treasury Board of Canada Secretariat, Public Service Health Care Plan — Benefits Coverage and Plan Provisions, July 2001, http://www.tbs-sct.gc.ca/pubs_pol/hrpubs/TB_862/pshcpb-rssfpp_e.asp.

[172]  Treasury Board of Canada, Public Service Health Care Plan Directive, April 2005, http://www.tbs-sct.gc.ca/pubs_pol/hrpubs/TB_862/pshcp_e.asp.

[173]  23 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[174]  Treasury Board Secretariat, Chapter 3-4, Long-term Disability, http://www.tbs-sct.gc.ca/Pubs_pol/hrpubs/TB_865/CHAP3_4-PR_e.asp?printable=True.

[175]  23 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[176]  23 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[177]  23 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[178]  23 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/08ev-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[179]  Public Service Human Resources Management Agency of Canada, 2002 Public Service Employee Survey, Organizational Report, http://www.hrma-agrh.gc.ca/survey-sondage/2002/results-resultats/00/result-e.htm.

[180]  National Joint Council, 2004 Annual Report of the Disability Insurance Plan Board of Management, http://www.njc-cnm.gc.ca/auxFile.php?AuxFileID=260.

[181]  Treasury Board Secretariat, Policy on the Duty to Accommodate Persons with Disabilities in the Federal Public Service,2002, http://www.tbs-sct.gc.ca/pubs_pol/hrpubs/TB_852/ppaed_e.asp.

[182]  Treasury Board Secretariat, Creating a Welcoming Workplace for Employees with Disabilities, http://www.tbs-sct.gc.ca/pubs_pol/hrpubs/TB_852/cwwed1_e.asp#Definition.

[183]  Brief submitted 30 March 2005.

[184]  Brief submitted 30 March 2005.

[185]  16 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/06eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[186]  15 February 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/05eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[187]  Public Health Agency of Canada, News Release, “Michael Wilson to serve as Special Ministerial Advisor on Mental Health,” 4 February 2005.

[188]  Global Business and Economic Roundtable on Addiction and Mental Health, website, http://www.mentalhealthroundtable.ca/about_us.html.

[189]  Health Canada, Healthy Canadian:  A Federal Report on Comparable Health Indicators, 2004, http://www.hc-sc.gc.ca/hcs-sss/pubs/care-soins/2002-fed-comp-indicat/2002-health-sante4_e.html.

[190]  Canada Health Act, Chapter C-6, Section 2 — Interpretation, http://laws.justice.gc.ca/en/C-6/17077.html#rid-17084.

[191]  20 September 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/13eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[192]  9 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/21evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[193]  Auditor General of Canada, Management of Federal Drug Benefit Programs, Chapter 4, November 2004, http://www.oag-bvg.gc.ca/domino/reports.nsf/html/20041104ce.html/$file/20041104ce.pdf.

[194]   20 September 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/27evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[195]   Throughout the chapter, references to Aboriginal peoples are intended to include individuals who identify themselves as First Nations, status Indians, non-status Indians, Métis, or Inuit.

[196]   21 April 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/13evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[197]  20 September 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/27evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[198]  20 September 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/27eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[199]  20 September 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/27eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[200]   21 April 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/13evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[201]  20 September 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/27evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[202]  20 September 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/27evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[203]  9 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/21evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[204]  20 September 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/27evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[205]  21 April 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/13evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[206]  20 September 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/27eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[207]  20 September 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/27evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[208]  Royal Commission on Aboriginal Peoples. (2005) Choosing Life: Special Report on Suicide Among Aboriginal Peoples.

[209]  16 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/22evc-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[210]  21 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/23evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[211]  20 September 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/27eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[212]  The information is based on data provided by Statistics Canada for the health sectoral table of the Canada-Aboriginal Roundtable, November 2004.  It includes four documents: A profile of Canada’s North American Indian population with Legal Indian Status; A profile of Canada’s North American Indian population without Legal Indian Status; A profile of Canada’s Métis population; The Inuit population in Canadahttp://www.aboriginalroundtable.ca/sect/hlth/index_e.html.

[213]  21 April 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/13evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[214]  20 September 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/27evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[215]  20 September 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/27eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[216]  20 September 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/27eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[217]  Health Canada. (September 2004)  Information: The 2003 Accord on Health Care Renewal. http://www.hc-sc.gc.ca/hcs-sss/medi-assur/fptcollab/2004-fmm-rpm/fs-if_01_e.html.

[218]  20 September 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/27evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[219]  20 September 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/27eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[220]  16 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/22evc-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[221]  20 September 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/27eva-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[222]  21 April 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/13evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[223]  20 September 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/27evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[224]  20 September 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/27evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[225]  9 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/21evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[226]  31 May 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/16evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[227]  9 June 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/21evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

[228]  21 April 2005, http://www.parl.gc.ca/Content/SEN/Committee/381/soci/13evb-e.htm?Language=E&Parl=38&Ses=1&comm_id=47.

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