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PROCEEDINGS HONG FOOK MENTAL HEALTH ASSOCIATION PRESENTS MONDAY, JUNE 6, 1988 CLARKE INSTITUTE OF PSYCHIATRY FUNDED BY THE MINISTRY OF HEALTH Edited by Dr. Peter Chang
TABLE OF CONTENTS
HONG FOOK MENTAL HEALTH ASSOCIATION 1 BOARD OF DIRECTORS 2 CONFERENCE OBJECTIVES/ORGANIZING COMMITTEE 3 SUMMARY OF RECOMMENDATIONS 4 INTRODUCTION - CARMELINA BARWICK 7 ONTARIO MINISTER OF CITIZENSHIP - HONORABLE G. PHILLIPS 8 MESSAGE FROM PRESIDENT - RAYMOND CHUNG 13 ADJUSTMENT TO MIGRATION - DR. VIVIAN RAKOFF 16 ONTARIO MINISTER OF HEALTH - HONORABL8 E. CAPLAN 17 GREETINGS FROM MINISTRY OF COMMUNITY & SOCIAL SERV 23 COMPREHENSIVE COMMUNITY MENTAL HEALTH CARE: AN OVERVIEW -DR. DONALD WASYLENKI 24 PENARY SESSION/SUMHATION - DR. PETER CHANG 34
HONG FOOK MENTAL HEALTH ASSOCIATION 1988- 1989 BOARD OF DIRECTORS PRESIDENT RAYMOND CHUNG VICE-PRESIDENT SYDNEY TANG SECRETARY RAYMOND ANG TREASURER STANLEY KWAN CHAIRMAN, PROGRAM COMMITTEE ELLEN LIU CHAIRMAN, EDUCATION COMMITTEE BLANCHE HODDE CHAIRMAN, ADMINISTRATION COMMITTEE RAMON TAM CHAIRMAN, MEMBERSHIP COMMITTEE PETER CHANG CHAIRMAN, PUBLIC RELATIONS TASK GROUP RON SMITH
MEMBERS AT LARGE: CELESTINE CHAN WENDYCHAN TED LO SUSAN LUNG SAN NGUYEN BOB SIMMONS
HONG FOOK MENTAL HEALTH ASSOCIATION The Hong Fook Mental Health Association stated informally in the form of grassroots meetings in 1978, by people who were concerned about the lack of mental health services to the Chinese and Southeast Asian Canadians living in Metropolitan Toronto. It was later incorporated as a voluntary, non-profit organization.
The objectives of the Association are: -To promote a heightened awareness and understanding of mental health issues in the Chinese and Southeast Asian communities. -To promote better access to mental health services by the identified population.
Activities of the Association include:-Administering the Hong Fook Mental Health Service which is funded by the Ministry of Health to provide consultation-liaison and case management services to the target population -Public education: forums, radio, TV, newspaper articles, and videotape productions -Professional conferences to highlight the issues related to multicultural mental health -Meetings with other ethnocultural organizations for better coordination and information sharing -Publicat1on of newsletters to keep members informed of multicultural activities in the community -Proact1ve program planning
Membership: Anyone 1nterested in multicultural mental health 15 welcome to join. Contact Hong Fook Mental Health As5ociation for further 1nformation: 41 Cecil Street, Toronto, Ont. M5T 1N1 Telephone - 595-1103
OBJECTIVES OF THE CONFERENCE: 1. To bring together the key players in the planning, development, funding and delivery of mental health services for Toronto's diverse ethnocultural communities: including consumers, service providers and funders. 2. To facilitate the exchange of ideas and information. 3. To identify and discuss issues of concern to the groups involved in the provision of community mental health services. 4. To formulate recommendations to the Government of Ontario to improve mental health services to the ethnocultural communities.
ORGANIZING COMMITTEE:CARMELINA BARWICK - CHAIRMAN PETER CHANG JENNIFER FLEMING CHRISTINA LEE ROSE LEE TED LO TIMOTHY NGUY SAN D. NGUYEN SYDNEY TANG ANNIE TSE
SUMMARY OF RECOMMENDATIONS (I) Policy and planning 1) Funders and planning bodies need to develop specific policies regarding service delivery to the multicultural population. Such policies need to recognize the complementary roles of mainstream and ethno-specific agencies in the provision of a range of services in our increasingly diverse multicultural society. As well, the funding and planning of mental health programs should reflect this policy. - The Ministry of Health needs to provide incentives to improve access to mental health services for ethnocultural communities. To this end, funding must be allocated to support innovative programs, pilot projects and the study of linguistically and culturally appropriate service delivery models. As well, funding criteria need to be developed to evaluate the multicultural content 0£ program proposals. - Planning and coordinating bodies need to foster the collaboration of "mainstream" and "ethno-specific" agencies to maximize resources and improve the coordination of services. 2) Information on government multicultural policies and funding criteria needs to be centralized and made readily available to the public.
3) The proposed Community Mental Health Services Act (Bill 50) needs to recognize the special needs of the culturally and racially diverse population in Ontario.
4) Mainstream agencies need to develop multicultural policies regarding board representation, hiring practices, job assignments and staff development/training.
(II) Services and Programs 1) The feasibility of the following services and programs needs to be investigated. - The applicability of the Hong Fook model to other ethnocultural communities; - Residential facilities specialized in serving members of ethnocultural groups with long- term psychiatric disabilities; - Home treatment for multicultural clients; - Day programs for the ethnic elderly population; - Research projects on linguistically and culturally appropriate treatment approaches including examination of indigenous methods.
2) Community agencies serving ethnocultural groups need to be strengthened to provide services and/or work with mainstream agencies in the following areas. - Crisis intervention; - Discharge planning (early involvement of community agencies is important); - Family support, thereby increasing the involvement of the family in treatment and rehabilitation.
3) Hospitals and community mental health programs need to develop and specialize in programs for major ethnocultural groups in their respective catchment areas.
4) Funding to be made available for the establishment of an interpreter pool and the purchase of interpreter services by hospitals and mental health programs.
(III) Prevention and education
1) Funding to be made available for organizing community-based educational and preventive programs: - community education to improve mental health awareness; - Development and dissemination of educational materials - Family life education; - Self-help groups; - Groups for isolated seniors.
2) Colleges and universities need to: i) introduce specific measures to train more bilingual and bicultural health care and social service professionals; ii) place more emphasis on cross-cultural training in their professional and continuing education programs; and iii) offer re-training to foreign-trained professionals.
3) The staff development/training program in mainstream agencies needs to increase its multicultural content and extend such training to administrative and support staff.
INTRODUCTION by Mrs. Carmelina Barwick
My name is Carmelina Barwick. I have been associated with Hong Fook right from the time of its inception and I feel very privileged to be your MC for today, because we have a number of very important speakers this morning. I am also looking forward to the workshops, hoping that we can come up with some interesting and innovative approaches to the problems that are confronting all of us in this field of multicultural and cross-cultural work.
Our first speaker this morning has been very active in both public and community life in the last 20 years. He has served as a school trustee, as chairman of the Metro Toronto School Board,as well as the Scarborough Board' of Education. He vas chairman of the Board of Governors of Scarborough General Hospital, as well as the past president of the Bridlewood Community Association. He vas first elected to the Legislature of Ontario in September, 1987 and was soon sworn in as Minister of Citizenship.
He is a member of Executive Council of Ontario and Chairman of The Cabinet Community of Race Relations. As Minister, he is responsible for programs and policies that foster full participation of all Ontarians in the economic, cultural, political and social life of this province. His ministry also has a critical role in the implementation of the multicultural strategy which vas announced by the Honorable Lily Munro in 1987. He is responsible for the Ontario Human Rights Commission. Indeed the initiative from his Ministry has major impact on all the activities that we are involved in.
It is my privilege to introduce to you the Minister of Citizenship Mr. Gerry Phillips.
THE HONOURABLE GERRY PHILLIPS - MINISTER OF CITIZENSHIP Carmelina, ladies and gentlemen. First I thank you very much for inviting me here today to share with you some of my thoughts in the area of multicultural health care. I can't help noticing this cartoon here referring to stress, because periodically I put myself under that kind of stress.
Last Friday I was to have breakfast with a supreme court judge from Pakistan at the Guild Inn, which is a neat little place in Scarborough, so my wife and I were there right at 8 a.m. I told my driver that he was not needed until 9:15 or so, so he left. (This was changed from the original plan which was to meet the supreme court judge at the Ramada Renaissance.)
At about 8:20 they were not there yet, I figured there had been a mistake. I phoned the Ramada Renaissance and sure enough they were waiting for me there. Suddenly this stress started to rise. I didn't have the car so I phoned a cab. I said, "Listen, I'm in a big hurry, we have to get over to the Ramada Renaissance". "Well, this is no time to be in a rush, this is rush hour".
It was a lesson in my stress level going up, and I appreciate the work that many of you do in this room to help people deal with stress.
I would like to start by thanking the Hong Fook Mental Health Association and particularly the Conference Planning Committee for organizing this symposium.
We all know that the administration of health care in the province is of vital concern to all of us. It involves the CO-ordination of a terrific number of people in services. By having information sharing sessions like this we provide, I hope, even better and more effective services. I am very dedicated to ensuring that we service the multicultural community; and I am pleased to see Dr. Ralph Masi here today, who is chairing an Advisory Council on Multiculturalism, reporting to the Minister of Health, and she will talk about that later.
The multicultural theme of this symposium is of particular interest to me. The population of Ontario is now made up of over 100 different ethnic culture groups, one of every four Ontarians were born outside of Canada, and that number is increasing. Twenty years ago most of immigration came from the United States and Europe. That has changed dramatically in the last ten years. Now 75% of immigration Comes from Asia, Central and South America, the Caribbean and the Middle East.
There is a commitment by the federal government to increase the levels of immigration for a whole variety of reasons, not the least of which is the need for talented young people. Without them our population will actually decline. So, the federal government is committed to increase the level of immigration to perhaps as many as 200,000 sometime, five or six years down the road.
In my opinion people will continue to come from the same areas they came from in the last ten years, namely, Asia, Central and South America, the Caribbean, Middle East and probably from Africa. These people as you know will be talented, well educated people who are choosing to come to Canada to help build a better life for themselves and also help build a better country for us.
We need to ensure that we have across the province in every institution, an environment that welcomes that kind of diversity.
Canada has been fortunate that we have been able to attract the quality immigration that we have in the past and surely one of our goals has to be to have an environment in which we can continue to do that. I think all of us are proud that Canada has taken the multicultural approach rather than the melting pot that the U.S. seems to pursue. It is the policy of your government in Ontario to celebrate the diversity of cultures. We think they are a source of strength and enrichment, and we will ensure that in our government programs, services and policies, we reflect the diversity. Our ideal is to build a society that is based on tolerance, understanding and mutual appreciation. I hope all of us can share in the pride and progress that we have made towards achieving that ideal, while never forgetting that we still have much to do.
I believe that Ontario has an opportunity to build a role model for the world. Our challenge is to create a society in which all of us have the opportunity to express our uniqueness, and our differences are not just tolerated peacefully but celebrated as our strength, enjoyment and pride.
My role in the provincial government is that of the Minister of Citizenship. It is a brand-new Ministry that was created after the last election when the new government was formed. The Premier believed there was a need for the Ministry that would focus single-mindedly on the key issues of citizenship in the province. My role is quite specific. I have on your behalf the responsibility for making sure that our multicultural policies are implemented, that our race relational policies are implemented that in the areas of immigration that the province helps immigrants feel welcome, settled, be exposed to services that we offer.
Plus, I have responsib1lity for working with the native community, and the Human Rights Commission reports to me. As you can see, it is quite a specific focus that I have responsibility for and frankly, I believe it is right at the heart of the future of what this province is about. So I am delighted to have been given that responsibility.
I would like to emphasize that while I all responsible for multi-culturalism, it is a government-wide approach and my key job is to be the advocate of multiculturalism, to ensure that in every ministry we are reflecting multiculturalism. In fact, I would think that probably about 90% of my work is actually with other ministers and ministries. We very much realize as a government, the success of that policy depends on the ability of each ministry to respond. I think it is fair to say that so far, we are making good progress. In fact, there is not a ministry in the provincial government that does not have significant initiative underway to ensure that they are changing to reflect the diversity of the province.
There are the obvious ones of course, that you would naturally think of, the Solicitor General, who has a responsibility for policing in the province, is working with all the police forces to make sure they are changing to reflect the diversity. She has recruited someone out of the Metro Toronto Police Force to work with her. She is sponsoring a major two-day policy conference in the fall with all the police organizations in the province. The Minister of Education unveiled a very comprehensive policy to school boards and communities across the province, which is seeking consultation on a broad basis and is in the process of being finalized. Community and Social Services, as many of you work with that organization, are looking at how community service groups and the mainstream agencies can ensure that they are providing service to the multicultural communities.
You can think of all the traditional ministries and how they respond. The Ministry of Tourism, for example, is contracting quite a major research study to ensure that tourism in the province reflects the diversity. If you followed the enumeration - process that is going on right now, we advertise in about 40 different languages. A form that the enumerators are using now, is in 8 languages for their door to door follow-up. There is a toll-free number that you could phone and have questions answered virtually any language. The point I am making is that there is not one single ministry that does not look at and respond to the diversity of cultures in the provinces.
The Minister of Health will be talking with us this morning about things that she is doing because clearly the whole area of health care and how it responds to the diversity is crucial. The responsibility in the Ministry of Health in providing culturally sensitive services are particularly important. The Ministry of Health has made really excellent progress in addressing the needs of the multicultural community. A good example is the Advisory Council I just mentioned with Dr. Ralph Masi and a broad cross-section of the community. This Council will help the Minister in Overcoming the barriers to full access that could result from linguistic or cultural differences.
I really compliment my colleague Mrs. Caplan who I suspect has the most difficult job in the government when you realize that she has a third of the provincial budget of 12.7 billion dollars. It went up about 1.2 billion dollars just to sustain the health care system, and it is a real challenge to manage the health care system.
In spite of all of those financial issues that she faces, whenever I talk to her, she is interested, responsive, and she always finds time to put a high prior1ty on the multicultural issues.
There is one area that I would like to mention specially and that is the area of language. One of the greatest barriers to government services is of course the language barrier. I know the Ministry of Health is talking significant steps to provide staff who are fluent in third and even a fourth language at Community Health Centres throughout the province. Our Ministry, the Ministry of Citizenship is looking very carefully at this question of language and interpreter services. We published the newcomer's gu1de to Ontario in nine languages, in addition to French and English.
Even more challenging than the language: barriers perhaps are the, cultural barriers. In my Ministry, we are also working to lover these barriers through our culture interpreter project. We really saw the need for that most clearly, in the wife assault program. We have across the province, three pilot projects underway. We saw in these projects the need for, and the importance of, culturally sensitive interpreters and I am very much aware that this is also apart of the Hong Fook project.
I know you have been working closely in that project and Jerri Critchley who is here today, will be participating in the workshops. Jerri knows this area backwards and forwards. I urge you to ask her about her extensive experience in culture and interpretation and to make use of her experience.
More importantly perhaps, I urge you to share your experiences and concerns with them. We are right now looking at that project and Jerri, I know would welcome comments that will help us establish our programs and our priorities.
I very much appreciate the opportunity to be here today to say that the area you work in is fundamental to the future of the province.
The theme of this symposium is very appropriate: it is a challenge to provide comprehensive community health care in our multicultural society with the financial constraint that we are all under. Thank you very much.
CARMELINA BARWICK – M.C. Thank you very much, Mr. Phillips. I was particularly interested in your comment about your role as an advocate with the other Ministries. We realize that although we are concerned with mental health issues which is under the jurisdiction of Mrs. Caplan, there is no possible way that we can expect positive mental health for the population we serve unless they have adequate housing, good quality day-care services, good job opportunities, learning skills, etc. It is very encouraging to hear all these initiative and particularly your efforts in these regards.
I would like to call on Mr. Raymond Chung to address us this morning. Mr. Chung the President of the Hong Fook Mental Health Association, which is the association that is responsible for the Hong Fook Mental Hea1th Service.
I have been privileged to work with Mr. Chung right from the time that he and a number of other Chinese professionals have asked me here from the Clarke if I would be interested in helping them in looking at how they can improve the quality of services to the Chinese-speaking community here in Toronto. Of course very shortly thereafter we had the boat people who came to Toronto from Vietnam. They are, comprised of the ethnic Chinese and the Vietnamese people. It made sense at the time for us to also include in our proposal to the Ministry of Health not just services for the Chinese but also for the Vietnamese, the Cambodian and the Lao.
We have been fortunate that as of last year we got funding for a full-time Cambodian worker, in addition to the Chinese and Vietnamese workers. We also hope that in a short period of time, we wi11 also be able to get a Lao speaking worker, because this is indeed a community that is not getting any services at all in the area of mental health. Mr. Chung.
MR. RYAMOND CHUNG – PRESIDENT, HONG FOOK MENTAL HEALTH ASS. Honorable Ministers, distinguished guests, dear friends and members. Imagine yourself just arriving in China and you have a severe stomach pain. You walk into my clinic, hoping to get some help. You begin to tell your symptoms but all you hear my say is, "Nei bin do mm shu fok ah?". Unfortunately you do not understand it and I can’t understand you either. As a result you cannot get the treatment you need and I feel frustrated because I cannot help you.
Ladies and Gentlemen this situation happened frequently in the past 10 to 15 years in Toronto and it is stl11 happening today. We all know that an assessment cannot be done accurately if there is no direct communication between the patient and physician. Adding to the language barrier there are also the differences in cultural be1iefs and traditional practices. With Canada being the haven for immigrants and Toronto being a major reception city, an effective health delivery system has been a major focus of concern and discussion in the past decade.
There are those who firmly believe that services could only be delivered by the qua1ifled professionals in the mainstream organizations and institutions. There are those who feel very strong1y that one could be better served by one's own people, regardless of qualification. The discussion and the search for a workable system has been going on while those non-English, non-French speaking immigrants who need services desperately continue to be deprived of their rights to the required treatment.
We at Hong Fook are not so much concerned as to who should give the service, but rather, we are anxious to see those in need of the service receive it, in the language and with the cultural understanding that they feel comfortable with. To us the question of equal access should be addressed as soon as possible.
Ten years ago, Hong Fook was stated informally because of the growing need of the Chinese and Vietnamese immigrants for mental health services, with very limited community resources. With the firm belief that mainstream agencies have an important role to play in serving the immigrants in the multicultural society, the group adopted the consultation-liaison model. The whole concept lies in brid9ing the service providers and the consumers with the appropriate language and cultural interpretation.
For almost five years, services were provided by volunteers who have both language and professional qualifications. The approach was accepted by service providers and welcomed by the comaun1ty. In 1982, our proposal for a full-time service was finally approved for founding by the Ministry of Health. The funding was very small, yet very significant. It signified that the funder recognized the growing needs of the new immigrant communities and also, the funder accepted the importance of culture-specific service providers.
We were extremely delighted with the decision by the Ministry of Health, not because we got the money, but rather, we saw the move reflect the commitment of the Ministry in offering quality service to the large number of new immigrants. We saw it as a first step towards equal access. It is rewarding to see that, over the past six years the Hong Fook Mental Health Service has been successful in doin9 both liaison and consultation with the target communities and various professional service providers.
However, we would like to emphasize that the model should be seen as a first step in serving the much neglected mental health needs of the immigrant population. It is effective for new communities with an urgent need and limited resources. It should be used as a short-term solution until a long term comprehensive system is developed.
With the success of our service in the past six years, we have demonstrated two things: one, the effectiveness of the consultation-liaison model in delivering service to new immigrant communities, and two, the culture-specific service can compliment the mainstream agencies. In fact we feel strong enough to say that culture-specific and mainstream agencies are not actually exclusive and should work hand-in-hand towards an improved service delivery. We hope that w1th our experience, we can now go one step further to look at a more comprehensive system with the needs of the different immigrant groups in mind. It is for this reason that we or9anized the conference. We hope by bringing together the funders and the concerned individuals like you, we can look at some options, explore different approaches and examine the possible steps which would bring us together for the search of a comprehensive system so as to meet the challenge.
Apart from our experiences, our enthusiasm and our firm belief that equal access to quality mental health services is a key ingredient in the multicultural society, we do not pretend to have the answers or a prepared package to share with you. Rather we are hoping that you have brought with you your experiences and ideas. Together we can formulate some directions and recommendations as guidelines for us to plan and fund our future programs to meet the challenge of the different immigrant communities.
Your presence is a big encouragement to us. It confirms that, we are not alone in wanting to improve our services, and that there are people like you who care as well. It is not going to be an easy task, but let's hope today marks the beginning of many more opportunities in the future for us to work together in setting up the best mental health service delivery system in Toronto.
I would like to take this opportunity to thank the Honourable Elinor Caplan, Minister of Health and Honorable Gerry Phillips, Minister of Citizenship and Dr. Vivian Rakoff, Director and Psychiatrist-in-Chief of the Clarke Institute for spending their valuable time with us this morning as our guest speakers.
I also would like to thank Dr. Donald Wasylenki, for sharing his insight and experiences with us by being our keynote speaker.
Hong Fook and the Clarke Institute have been partners working together close in the past decade. Today again, the Clarke Institute has offered the use of its premises and facilities and we sincerely appreciate their co-operation and generosity.
No event could be organized smoothly without a great leader and a group of dedicated volunteers. At Hong Fook we are fortunate to have such people all the time. I will not name them all here now, but would like to mention the great job done by the Chairperson of the conference planning committee, Carmelina Barwick, and her two co-ordinators, Jennifer Fleming and Annie Tse. To the three of you, a big thank you. Lastly I would like to acknowledge that today's Conference is funded by the Ministry of Health. Thank you.
CARHELINA BARWICK - M.C. Our next speaker is someone that I have such a tremendous respect and admiration for, because without his continuing support and encouragement, there is no possible way that I would have been able to do the work that I have done with the various community groups in Toronto in the last 18 years.
When I go around the Institute here, people do not always know what I do. One day they hear me talk about the work I do with the Filipino community, the next day the work I do with the Korean community (I'm glad to see there is somebody from the Korean community here today). Of course they have heard me talk about Hong Fook for the last ten years.
I would like to introduce to you Dr. Vivian Rakoff who is the Psychiatrist-in-Chief of the Clarke Institute of Psychiatry as well as the Head of the Department of Psychiatry at the University of Toronto. Dr. Rakoff.
DR. VIVIAN RAKOFF - PSYCHIATRIST AND CHIEF OF THE CLARKE INST. Honourable Ministers, Mrs. Caplan, Mr. Phillips, Ladles and Gentlemen. It is no accident that today's meeting is at the Clarke Institute. We are interested here in the broad range of mental health and psychiatric problems in general. It would be irresponsible for a place like this not to be involved with the problems of immigrant groups.
One always begins one of these occasions with a quote from the most ancient source you can find. There is in fact a quote from Hippocrates, which goes: "The movement of peoples is always accompanied by great perturbation". Immigration is impossible without some pain.
It may seem odd to you if I begin with a autobiographical note. to say that I am an immigrant too. You say, you are a Caucasian, you are English speaking, you are a professional. What sort of immigration did you have? Difficult, because even for those of us who share aspects of the culture, share some of the racial characteristics and share the language, the transition from home land to another place, the change in climate, in food, in architecture, in politics, in popular culture, is an extra-ordinary thing to do. So it is not a great leap of the imagination for me to say that if I had difficulty with all these privileges, how much more difficult it must be for people who don't share these fundamental links to a community.
People live not just in their private lives, they also live in their public lives. It is in the area of the public life in particular that there is a profound disruption. So that for academic, humane, medical, political, social, and for all sorts of reasons, it is essential that a research institute with a clinical base, like the Clarke Institute, would have to be involved with multiculturalism, and specifically with Hong Fook.
I know that the poor Minister gets a pitch from every person she comes by as though she were a walking bank instead of a human being. Madam Minister, I make my pitch to you in other ways and at other times. It is essential that the country knows that the Clarke Institute is not just concerned with laboratory Studies with fancy new machinery, but it is also very much involved with the real world of people.
I think that this particular energy, with which Carmelina Barwick and others have been involved, attempts to create access to health care and particularly to mental health care, because this is often where the pain of immigration manifests itself. I think this has been an essential and I hope a continuing part of the Clarke Institute.
Let me end with a paradox. I hope that 40 years hence, I won't be here, we will not need a Hong Fook and that what we share will be as important as those things that make us particular, and the universal access to health care will be predicated not upon creation of separate agencies but on a society that will continue to be open and celebratory of its variety.
One needs to be at home, one needs a place that is responsive to one's own history, so that one has as it were a balloon, submarine, that allows one to move into the new society and truly adapt with little harm, very little pain, with as little difficulty as possible. I thank the ministries involved for making these transitions possible and for supporting these important manifestations of the kind of place in which we live. Thank you.
CARMELINA BARWICK - M.C. Thank you Dr. Rakoff. Mr. Phillips spoke earlier about the stress and trying to go from an appointment to another and I know that Mrs. Caplan has to leave a1so for another appointment. It is my privilege to introduce to you this morning Mrs. Caplan who has been introduced by about three different people already. I will not spend much more time in telling you all of her accomplishments, as well as all of the plans that are underway from her Ministry. I will let her do that. The Honourable Elinor Caplan.
THE HONOURABLE ELINOR CAPLAN - ONT. MINISTER OF HEALTH I am delighted to be here this morning, to have the opportunity to talk about a subject which is very important to me. Dr. Rakoff, let me tell you, I think you have said it about as well as I could say as to your vision for the future. I want you to know that I share that vision. I want to thank the Hong Fook Mental Health Service and organizers of this important Conference for the opportunity to address this meeting on multicultural health. I want to tell all of you that multiculturalism in this province is in good hands and acknowledge my colleague the Honorable Gerry Phillips, who as advocate wlth1n the system, is doing an outstanding job in raising the consciousness both around the cabinet table and in the communities of this province.
When I was first elected to the provincial legislature, I mentioned in my maiden speech that my riding was unique. I described it as having five percent of everyone, with 40 different languages, and all the different foods of the different countries are sold side by side in the malls and plazas. What struck me was that every member of the legislature, described his/her riding as unique in its multicultural nature.
So the challenge is before us. A number of people have referred in their remarks to the boat people. Dr. Rakoff used the vision of the submarine. In fact it's an analogy that I have often used. I see one of our finest achievements in this province has been our ship of health care.
There are those who would suggest different names for this ship but I start by saying we are all in the same boat. Some of us are passengers, some of us crew members and the suggestion has been made that as Minister of Health, I'm the captain. The cynics would call this ship the Titanic. Then there are those I who would argue that it is in fact the luxury liner the Q.E.II and if it is not, it should be. Then there are those who suggest that I'm in some way captain of the famed Bounty or the modern day Captain Blye and I reject that out of hand.
With the reports that are before the Ministry, from Dr. John Evans, Dr. Robert Spasoff and his group, and Steven Padborski who would tell us that in fact we are in changing times, Ontario is about to embark on a voyage on our ship and I prefer the analogy of the Starship Enterprise because we are in fact charting a new course in unknown waters. Some even suggest we are somewhere out of this world, I like to believe we are on that leading edge and that the challenge is presented to us by the very diverse nature of our society. It offers us an opportunity to go to where no man has gone, to seek and to find and to use the experience of our neighbours worldwide as to how we can respond to the challenges of providing equality in access.
It is a challenge that I consider an opportunity and I thank you for welcoming me aboard. The fact that this group of health care providers and consumers are here today is living testimony to one of the major changes that has taken place in Ontario in the past 50 years: the growing multicultural diversity of our population.
There can be no doubt that this diversity has enriched us enormously and has had a positive and a profound impact on our lifestyles, on our attitudes and on our social structures our province has flourished with the influx of ideas and talents and traditions that have been brought here by people from every corner of the globe. They have made Ontario their home, often fleeing strife, adversity, war and violence.
At the same time, this new cultural diversity presents us with those special challenges that I refer to. One of those challenges is to create an environment that allows our multicultural reality to infuse and permeate government services and programs. That's what my colleague does. Raising the sensitivity internally is the challenge to us in government.
In health care, our government has made a commitment to ensure that health care services will be available arid accessible to everyone in this province regardless of economic status, geographic location and ethnic origin.
I can say with pride that we have taken action to honour that commitment even though we have a long way to travel on our ship. We have ended extra-billing and have removed any financial barriers to health care. We are moving to improve services for people in the north and we are expanding services for the elderly. We are creating a whole new range of services for women and we are broadening financial support for physically disabled people who need assistant devices.
Just last week I introduced the Independent Health Facilities Act. This new legislation will allow a wide range of medical procedures to be carried out in community-based settings, in an environment that is safe, effective, accessible.
We know that our work is not yet over, there are still people ~n this province, people that we must reach out to, to realize our objectives in health services. They were acknowledged by Raymond, I think by Dr. Rakoff as well. We know that some people are not using services because of language barriers. For others it may be lack of understanding of services available and for some there may be ideas or attitudes which make them hesitate to come. I forward and receive needed care.
If we are to expand the frontier of making health services more accessible we must be ready to respond to the cultural and ethnic sensitivities 0f every group in these provinces. In support of multicultural health concerns I've undertaken the following I actions. I've asked 28 district health councils to increase Their representation from local multicultural communities and to review the number of culturally sensitive and culturally focuses in their districts. I've also asked them to advise local community and health care agencies, that multicultural health care needs, must be considered when proposals for new programs are developed. I have written to senior managers in the Ministry, emphasizing the importance of considering multicultural issues in program planning and development. 12 of our 13 community health centres now have staff fluent in languages other than French and English and we have provided grants to three of these community health centres for special programs from people from South-East Asia.
We are also committed to establishing 600 nursing home beds in culturally sensitive settings. The location of these beds is now being developed and I expect calls for proposals will be issued by my Ministry soon.
In the spring I launched a far-reaching information campaign to encourage greater multicultural awareness in the health care community. An information kit and questionnaire was sent to over 400 agencies, including district health councils, community I health centres, health services organizations, hospitals and public health units. The kit contained information about our government's multicultural strategy and race relations policy, the provinces ethnic cultural data basis and a list of health publications available in languages other than English and French.
It also provided contacts for follow-up information. I believe these initiatives are all good and they are all positive but I: also thought that the Ministry needed a special focus, to plan strategically for multicultural health services. Just over a month ago, I appointed a special advisory committee on Multicultural health, a committee to advise me on multicultural issues and concerns, and to provide recommendations on how health services can reach across language barriers and reach across cultural differences, to those people in need.
I have asked the committee to accept the following responsibilities: to advise me on ways to ease access to health care for multicultural communities across Ontario; to establish a communication network with multicultural groups across the province; to receive and share information on how to achieve more culture-sensitive health care services; to work with the Ontario Council on Multiculturalism and Citizenship, on issue5 related to health care delivery; and to recommend specific action to the Ministry for making new and existing health care programs more responsive to the needs of our ethnic and multicultural group.
Our government has adopted a set of principles to ensure that individuals of all cultural backgrounds have equal access to health care services and we have pledged action to support those principles. I would like to thank Dr. Ralph Masi for agreeing to be the Chairman of the Advisory Committee on Multicultural Health.
There is perhaps no area of health care where culture and ethnic: sensitivities are more important than in the care and treatment of people with psychiatric disabilities. Proper assessment, diagnosis, therapy and effective support programs all require ah understanding of a person's cultural and ethnic traditions, social values and their belief structures. That's why I believe this Conference today is so important in furthering awareness and understanding of those cultural factors that are so essential in proper mental health care.
For a moment let's consider the broad dimensions 0£ the challenge that we face here in Ontario. One in eight people can expect to be hospitalized for mental illness, at least once during their life time. Suicide is the second most frequent cause of death among Canadians, aged 15 to 39. Mental illness is the second leading category in general hospital use for those aged 20 to 44. It is estimated that some 1.5 million people in Ontario have some form of mental Illness and that 38 thousand are severely disabled by schizophrenia, affective disorders and other mental disabilities.
When we look into the future, we are told that we can expect a doubling of mental disorders among the elderly, a 40% increase in chronic functional disorders and little change in the number of acute cases. Lying behind each and everyone of these numbers, these statistics, are real human beings with a variety of psychiatric difficulties. Human beings who look to our health care system and to our communities for the support and the care that they require.
That is the reason for shifting the emphasis on mental health I treatment from institutions to community settings, because with the right treatment program, the right supports, we know that in most cases mental health can be restored. Over the years a flexible and responsive network of community mental health pro9raas have been developed in the province. Supportive housing, geriatric services, self-help and p5ycho-social rehabilitation programs, voluntary col1munity support, drug and alcohol dependency programs, are just some of the different, methods that have been developed to help people from every walk of life and every strata of society.
Providing this care is a partnership. That partnership includes government, usually as the funder, health professiona15, social workers, volunteers, interest groups, and we must not forget the friends and the families.
This morning I would like to talk to you about the government’s role 1n this partnership, because I 5ee it as more than just funding. Government5 are measured and evaluated by the goals they set for themselves. Alternately, in the public mind, governments are judged on how well they achieve these goals.
The care of the psych1atrically ill is one of our highest goals. I want us to become known for achiev1ng the new direction for mental health in this province. The groundwork has already been laid. Last summer my Premier and yours, Premier David Peterson, announced that funding for community mental health programs be doubled from 65 million to 130 million annually over the next three years. With th1s funding we would more than double the number serviced by these programs. This com.1tment presents us with a major opportun1ty to bring change and new direction to mental health care and treatment here in Ontario.
We must be absolutely sure that the programs that are developed will generally improve quality of life and increase the potential for restoration to health. We must therefore have standards and evaluation procedures as we proceed. To answer these questions and prepare for this expansion, last fall I appointed a working group to develop a comprehensive community mental health model for thi5 province. The group under the direction of the former Chairman of the Rideau Valley District Health Council, Robert Graham, is taking an extens1ve look at what we have 1n place right now arid what we will need to realize a fully inte9rated, balanced, flexible and accessible network of mental health services.
I should point out that the Graham report will emphasize the importance of programs that are culturally sensitive. In the future, where programs are being considered for funding, they will be expected to demonstrate that they have considered the cultural needs of the people that they will be serving. I think. That is a major step forward. We also want to ensure that this expanded network remains a true partnership. We recognize that community mental health services must be more closely integrated with other health and social agencies in the community including the general and psychiatric hospitals.
A key element in the successful implementation of this network will be our volunteer district health councils, who will be planning for the provision of mental health services across their regions. We will offer our full support to the district health councils in this exciting and complex undertaking.
For my part I am certain that we will develop a community mental health model for Ontario which will allow us to effectively and- efficiently expand our existing network of 465 programs. I expect that you will be hearing more about this in the weeks ahead.
The changes that we are planning for mental health care are part of my personal commitment to seek innovative new directions across the length and breadth of our health care system. With the creation of the Premier's council on health strategy our government has brought together representatives from a cross section of Ontario to develop proposals and to make recommendations on how we can improve quality of health and quality of life in this province. The mission of the Premier's council on health strategy is to provide leadership and guidance to the whole government in achievin9 the goals of health for every citizen of Ontario.
The council has accepted the World Health Organization definition that health is not only the absence of disease or illness anymore than happiness is the absences of pain. Health is a positive and liberating capacity that allows people to cope, to adapt, to influence their surroundings. Health is not on1y an objective to be sought but an asset to be nurtured, so that we might realize our dreams and aspIrat1ons and for newcomers to this country, those who have chosen Canada and Ontario as their home, I think this def1nit1on of health is very important.
I know that I can count on our ideas, on your co-operation and on your support. I believe that we are entering a new era of health and mental health here in Ontario. I believe that we share the same goals, I think that we recognize that the changes are great and that there are some difficult and tough decision ahead. I believe that we will meet those challenges together and that a decade from now our children, and in some cases, our grand- children, will look back and say they planned well for us.
We know that one of the pressures for change in the society 1s: not only the change in technology, which is allowing us to move: out of the institutions and into the community, but the aging society.
We are spending just slightly more per capita on health care than Sweden and we are second only in the world per capita spend1nq to our ne1ghbour to the south, the United States. We know that their system is cruabl1ng. We know as well, that there are models, opportunities and choices that will be influencing the directions II that we go. I want you to know that I have developed tremendous sensitivity for the needs of the aging population. I have aged rapidly in the past seven months.
I want to thank you for this opportunity to come to the Clarke 11 Institute, to address the Hong Fook Association and to pledge to you that we will meet these challenges together. Well, we may not always agree. That's why I need to have those who will tell me what their needs are, challenges to respond to, and to do so in an environment of healthy and creative tension because that is what keeps us moving forward.
In closing, that's the reason that what we have today as we chart this new course, is the envy of the world. Because we are always trying to improve upon it and make 1t better. Thank you.
CARMELINA BARWICK - MC I assure you there will be no lack of ideas from this group, because it is not just people who are working with Chinese, Vietnamese, Cambodian, but in this room are people working with many of the ethnocultural communities in Toronto. In fact you and Mr. Phillips can expect that we w1ll be sending you the proceedings, perhaps outlining innovative ideas from this group that will go out today. We have with us today Eva Allman who is working as a seconded person from the Citizenship Ministry to work with the Ministry of Community and Social Services. I would like to call on Eva, to give us a few words from COMSOC.
EVA ALLMAN I bring you the greetings of my Minister, the Honorable John Sweeney, Who had a previous engagement and could not be here today. He sends his greetings, and he also wants me to share with you that the Ministry as you probably know by now is actively involved in a number 0£ initiatives, stemming from the same purpose and the same goals that have been mentioned by Mr. Phillips and Mrs. Caplan.
The commitment of the Ministry has been very clearly stated in I its strategic planning that was put out last year to provide a range of accessible, lingu1stically and culturally appropriate services which promote independence, family support, and service choice. The issue is no longer whether such services are needed but how to do it. The Ministry is actively workinq together with other Min1stries, particularly with the Ministry of Health in proposing ways that we can do things together, because our work is so interrelated, particularly in the area of mental health and rehabilitation and so on.
I don't want to go into details about all the different projects right now, but I wi11 be available. I will be going to the different workshops during the morning and I would be more than happy to discuss it with you. Thank you.
CARMELINA BARWICK – MC Our keynote speaker this morning probably does not need a lengthy introduction because many of you who are working in the; fi community may have worked with him or heard of him. I have known him for a very, very long time.
He is somebody who is always keen on pursuing innovative approaches, trying out different ways of delivering services, perhaps in a more efficient manner. He is at the moment the its Director of the Continuing Care Division at the Clarke Institute of Psychiatry. Up until last year he was the psychiatrist-in-chief of Whit by Psychiatric Hospital. He has a very wide range of interests. He was involved in setting up the West Park Psycho Geriatric Service, for instance, because of his interest in I geriatrics. He has been instrumental in starting the Active Care I Clinic here at the Clarke Institute which indicates his interest in longterm care. Without further ado I would like to give you Dr. Donald Wasylenki.
DR. DONALD WASYLENKI - M.D. DIRECTOR, CONTINUING CARE I would like to begin by thanking the conference organizers for inviting me, and also to congratulate them on getting not just one but two Ministers. It attests not only to the importance of, the topic but also to the energy of the organizers.
I've been asked to provide for you a generic framework for organizing mental health services for people who are disabled by severe mental disorders. I understand that you will look more carefully at this framework as part of the workshop program, from the point of view of cultural relevance.
I was particularly happy to hear the Minister of Citizenship talk about the importance of coordination in providing services, and also to hear the Minister of Health talk about the important role of the District Health Councils, because this framework I'm going to talk about was really developed while working with the Metropolitan Toronto District Health Council in helping them to pursue an important objective - to coordinate mental health services in Metropolitan Toronto.
COMPONENTS OF COMPREHENSIVE COMMUNITY CARE 1. Medical and Psychiatric Services a Family Physicians b Psychiatrists c Hospitalization i Brief Hospitalization ii Part1al Hospitalization iii Home Treatment iv Regional Hosp1tallzation
2. Community Housing Services a Alternative Community (Supportive) Housing b Approved Homes c Homes for Special care d Commercial Boardinq Homes
3. Psychosocial Services a Rehabilitation Assessment b Case Management c Social and Recreational i Rehabilitation Assessment ii Family Interventions iii Social Therapeutic Clubs 1v Social Network Therapy v Self-help Groups d Vocational and Educational e Financial Services f Individual Psychotherapy
4. Co-ordination and Advocacy a Co-ordination b Advocacy
In thinking about needs for services, it is useful conceptually to separate two different kinds of services. The first are treatment services. These are relatively straightforward, are frequently provided in hospital or hospital-like settings, and I usually encompass only short episodes in the ongoing development of problems associated with severe mental illnesses.
The other dimens1on is rehabilitation. In dealing with people who are significantly disabled, this is where the real work needs to be done. This is often carried out in non-institutional or non-hospital-based programs. It is only within the last five to ten years that we have really begun to develop in the mental health field a technology for understanding these needs, measuring them and developing effective interventions. This is the whole developing field of psychiatric rehabilitation.
In thinking about what I am going to be presenting here, it would be useful if you could think (in terms of these two dimension: treatment and rehabilitation. It is this rehabilitation area where we are just beginning to learn what to do and to organize ourselves around the issues.
You will see in this presentation that we have organized some of this framework around a particular illness, schizophrenia. That's because we want to be as specific as possible in evaluating various interventions that have been tried and written about. All of these interventions apply to people suffering from major mental disorders, who have ii degree of disability as a result. This is a way to begin to organize thinking about a framework for the kind of components of care that such people require.
I want to emphasize three important principles developed by Leona Bachrach because they are crucial if planning is going to be relevant.
The first one is the idea of functional equivalence. This simply means that you do not have to have every kind of service everywhere. Within areas such as housing, if you have a lot of one kind of service, you may not need is much of another. For example, if you have a highly effective case management system that provides a lot of support to people living in commercial boarding homes, you may need fewer high support group homes in your area. That's the idea of functional equivalence – that there is some balancing off of things.
Cultural relevance, which is of particular importance to you, simply means that in planning services you have to be sensitive to the aims, values and objectives of a given specific community or a given specific cultural group. You cannot just take model programs or a model framework and attempt to impose it. Communities and cultural groups will have their own objectives with regard to this patient population and their own ways of achieving these objectives. When you are planning it is important to be as sensitive as possible to those issues.
The last planning principle, trading off of services, is really an extension of the first. This simply means that it's possible that one would require fewer of one type of service if one had more of another. For example, an active psycho-social clubhouse program might result in less need for acute care general hospital beds in a given area.
Making a commitment to these principles is making a commitment to an incremental approach to planning and service development. That is, rather than espousing and attempting to apply a given plan at the beginning, the idea that the systems that we are I trying to create are evolv1ng, growing, expanding and self-correcting. It is important to put things in place slowly to look at the impact, and then to move to the next step on the basis of what is learned from the first step. I think that exemplifies, for example, the development of Hong Fook and other culturally sensitive mental health services in Toronto.
Let me begin by talking about the first component area: medical and psychiatric services. The issue of the role of the family physician in the treatment and rehabilitation of people who are disabled is a contentious one. There are some people who feel strongly that family physicians have in general, neither the interest, nor the expertise, to be significant participants in the care of people who are severely mentally ill. Other people feel they are a key resource, especially if we are going to try to integrate the care of people with mental disorders with the care of people with physical disorders. The family practitioner becomes the keystone.
There provide a reasonable degree of backup to a family, physician, or more frequently to are some very interesting model programs demonstrating that if you can a group of family physicians then it is quite possible to achieve this objective. I would think, in terms of cultural relevance, that there are usually More family practitioners available to serve a culturally identifiable group than there are psychiatrists. A very important way of multiplying the effectiveness of psychiatrists would be to build careful liaison systems and relationships with family physicians so that the mental health expertise could be more easily transferred. Most of the models in the literature are rural or semi-urban. There are fey good models that have been reported so far of family physician functioning in systems of mental health care in urban settings.
If you have a shortage of psychiatrists, and that applies to most areas in Canada north of St. Clair Avenue and west of Bathurst and east of Yonge Street, then you want to figure out the best way to use psychiatrists. I should say it probably applies to many cultural groups living within those boundaries as well. It's important to think about what you want your psychiatrist to do and one of the things you do not want him to do is to sit in his office seeing individual patients eight or ten hours a day, because that is the least effective way to take advantage of his training and expertise.
What you want are multiplier effects. How can you connect your I psychiatrist to other people to multiply his effectiveness. This may be done by developing the educational role and increasingly, a kind of physician manager role in relation to case management services.
What about hospital beds? How should they be used? In a modern system, I think it's now becoming fairly clearly understood that the role of a general hospital psychiatric inpatient unit is to provide relatively brief, relatively intensive management of disturbed and disturbing behaviour for all people in the community who require the service.
That's the expectation you should have of inpatient psychiatric units. The issue, I'm sure, for many of you, has to do with achieving accessibility and making these services more relevant. It is important to understand this, so that you can appreciate when a general hospital is functioning efficiently and effectively. When it is not, the usual thing that happens is that accessibility begins to become impossible, and you just cannot I find a bed.
Partial hospitalization programs are extremely important in freeing up 24-hour psychiatric inpatient beds. If you have a good partial hospitalization program operating at your general hospital, it's much easier for you to be flexible in the use of your 24-hour inpatient beds and for those beds to become really available as a crisis intervention resource.
I would encourage you, in working with hospitals, to build systems of care to help hospitals to either develop on their own, or develop in collaboration with you as joint ventures, partial hospitalization programs. A good partial hospitalization program can have a tremendous impact on a system of care.
Home treatment 1s an interesting modality. It is really a form of crisis intervention, the way I am talking about it here. It refers to the fact that you can take people who come to the emergency department of a general hospital and who require admission and instead of admitting them to the hospital, you can manage them at home. There are huge benefits to this, particularly in terms of avoiding excessive reliance on hospital care.
What most people say when we talk about this is that what relatives and families of these people really need when they become disturbed and disturbing is some relief, and that's what hospital care provides. Yet in three studies of home treatment - one conducted in Montreal, one in Australia and one in Wisconsin - the finding was the same: that is, families expressed much more satisfaction with home treatment than they did with standard hospitalization. That is thought to result from a growing sense of mastery on the part 0f family members. Working with the treatment team they can learn to manage difficult situations.
The reason I said this was interesting is because although there is a strong scientific basis for the effect of this approach, it is seldom implemented. We have very few home treatment teams in North America. Again with the new monies being developed and the ability to rethink how we are doing things, it will be interesting to think about these models and again to think about them in relation to multicultural issues.
If we have all the things we need, i.e. family physicians doing what we think they should do, psychiatrists doing what we think they should do, general hospital beds, partial hospitalization programs and home treatment plus the other commun1ty support services that I'll be talking about, do we really need mental hospita1s?
It appears that we do. One jurisdiction in Boston, where there really is a comprehensive community support system in place, reports that there still is a need for a regional resource, to deal with five different patient populations. These include the elderly patient who 1s demented and psychotic, the patient who is developmentally handicapped and has a major mental disorder, two groups of schizophrenic patients, i.e. the assaultive group and the group who are very regressed, and the brain damaged young adult with psychotic behaviour.
It has been suggested that those five patient groups require some sort of hospital-like regional resource to attempt to meet their needs. The state of the art in community programming has not reached the point where we can comfortably manage those patients in alternative ways.
The importance here again is in building your system to have a clear idea of what the role of the mental hospital is, if there is a mental hospital in your system. It 5hould not be a place where someone who develops an acute episode finds himself the next morning, 30 miles from where he lives. That's not what mental hospitals are for. If they have a function it's a highly specialized one. It should be difficult to get into these hospitals unless you have very specific kinds of severe long-term disabilities. There is a lot of confusion in the province about this 1ssue at the moment.
The next area is housing. If you are dealing with someone who is disabled and mentally ill, you are not going to get anywhere in terms of treatment or rehabilitation, if that person does not have a safe, secure place to be. This is really the sine qua 1°n of working with this population and in many ways the most difficult problem. The old way of thinking about the housing issue is that we create a series of transitional residential alternatives, and that people will move through these, so they'll start off in hospital and end up owning a condo at Harbour Front.
This model has the idea that as your functioning improves, you move, or as your functioning deteriorates you move. If you are in a level 2 group home you can live there as long as you are functioning at a certain level. If your level of functioning changes you've got to move. Residential instability is a major problem in this patient population and in many ways this kind of thinking has contributed to it.
The new idea is that you should try and separate the programming and the level of support from the bricks and mortar, so that you can live in a house or an apartment and you can have the amount of support you need provided for you there on a day-to-day basis, depending on the level of your need. So, if you need a lot of support for a couple of weeks, you can get a lot of support provided where you live. When you are feeling better and you need less support, then that support can be withdrawn. You don’t need to move to another level of group home. This is the idea of supported housing which is being contrasted to the older idea of supportive housing. I think it's an idea with a lot of promise, and there is a lot of excitement developing about it.
I should say that the situation for us in Ontario now is that there is a lot of money available for bricks and mortar to build houses or even apartment buildings for disabled people. The problem we have is getting agencies who are willing to develop these projects and getting dollars from the Ministry of Health to provide the programming. It is the programming side where we have a problem.
In addition to medical-psychiatric and housing services, there is an array of psycho-social services, which support people in the community. These are the services which focus on social functioning and community adjustment issues.
First of all, in order to implement a rehabilitation framework, people working with these patients have got to know how to do rehabilitation assessment. That is a functional assessment, very different from the traditional psychiatric diagnostic assessment which focuses on signs, symptoms and diagnoses. Here the focus is on what the person's goals are in rehabilitation, what the skills are that the person will need to achieve those goals, and what kind of a program then needs to be developed to help the person either acquire new skills to function in the environment of his choice or to apply skills that he already has.
To create a service plan and a service delivery system, out of the relatively fragmented kinds of non-systems that exist, case management 1s necessary. The case manager is the glue that holds the elements of the service plans together for a disabled person. Basic case manager functions 1nclude carrying out an assessment, developing a plan with the person, then linking that person to the components of the plan, monitoring, and advocating on behalf of the person. These functions need to be provided for people who are disabled if they are going to be able to use the services that are available. Case management is very important to you to gain access to so-called mainstream services.
Among the psycho-social services that people require, skills training is very important. The assessment and the case manager’s work can usually identify major skill deficits but then there have to be programs that provide training in these basic I activities of daily living skills, and particularly in social skills. Social skills just refer to the ability to make appropriate responses in social situations, but if you do not have them its very difficult to build support for yourself. Social skills training programs are very important.
Families do need support. The objective in working with families is to try and provide some education about what these illnesses are. Schizophrenia would be an example of one. We want to move families from a belief that the individual is bad, misbehaving, lazy or hopelessly ill, to an understanding that the person has an illness that can be managed, and then try to help the family to develop skills at managing. That's called family psycho-education. That's the current approach to working with families.
There are still families and family groups that hear this as more blaming. However, at least for this hypothesis we have a fair bit of reasonably solid data, and by and large, individual families are responsive to this approach. They are eager to learn how to manage situations. That's an important component now in this area of service delivery. This has been extended to development of self-help groups for families. Friends of Schizophrenics in Canada and the National Alliance for the Mentally III in the United States.
Social Network Theapy is an extension of the family psycho-educational approach to involve other members of an individual's social network and it is particularly important in working with people who are more chronic and appear to be more isolated, where there is a need to really rebuild or build new social networks.
I am going to review very quickly a number of very major interventions.
The Therapeutic Social Club is a very important social recreational, quality of life resource, and again I'm sure you are familiar with many of those.
In addition the whole area of vocational and educational rehabilitation is very complex and difficult because there are strong views held by people in the field which are often in contradiction to one another. It tends to come down to the issue of sheltered vocational rehabilitation versus experience in real job situations. I think this is the most complicated field in rehabilitation.
One model that appear to pull much of rehabilitation together both in terms of psycho-social programming and vocational educational rehabilitation is the psycho-social club house model developed at Fountain House in New York. We have a nice model program in Toronto, Progress Place. These programs provide both specific job responsibility at the club house initially, and then may lead to temporary employment programs where members of the club get experience in real jobs.
The reason they are able to achieve this experience is because the staff contracts with the employer, that if the member is unable to be at work on a given day, the staff will come and work for him, so the employer is guaranteed of having someone there to do the job. I think increasingly, like with housing, the idea of supported work rather than sheltered work is developing. Work where the person can go and be in a real job but be supported he needs it, is supplanting the older ideas.
Financ1al services, includ1ng basic budget1ng, and assurance that entitlements are made available to people are very important.
If you look at Metropolitan Toronto you can find most of the services I have d1scussed, but if you talk to pat1ents they'll often look at you in disbelief. Case management sounds wonderful. I've been a patient in the system for 15 years and I've never met a case manager," is not an uncommon response in talking to consumers about some of these 1ssues. Where are all these things? Why are they not available? There are two other I1mportant 1ssues 1n terms of access1billty and availability - coordination and advocacy.
In order for services to be useful to people, they have to be available. People have to have access to them. The idea of coordination emphasizes the need for organizations to adjust to one another. If you want to coordinate your services with someone else you have to be prepared to make some adjustments.
Coordination is a whole topic in itself. I will just point out to you that it is possible to organize your thinking about coordination on a continuum, from a situation where a group of independent entrepreneurial agencies agree to get together from time to time to talk about problems, to fully integrated independent mental health authority which has funding ab1lity as well as planning ability.
What's happening in Ontario is that we have a very entrepreneurial system. We have 400 community mental health programs in the province, each of which does its own thing. The same is true with hospitals. But these people are increasingly saying: "you know, we need some coordination - in fact, maybe we even need some direction - in fact, we might even need a mental health authority." It's becoming clear to people that there is a lot of duplication and inefficiency in the system. I think we are going to be hearing more about approaches to coordination in the future.
I would like to add a final word about advocacy which of course has to be a central concern of yours. There are really three levels of advocacy which are necessary. One is the kind of advocacy that all case managers need to provide for their clients. You have to negotiate for you client. Then there is the Psychiatric Patient Advocate Office in Ontario which has a specific mandate to provide social advocacy, therapeutic advocacy and legal advocacy for patients in the ten provincial psychiatric hospitals. Finally we need to have advocacy carried out by organizations. These include organizations like your own, advocating for greater accessibility for large groups of people.
What I have tried to present is a framework. I think that there is fairly broad consensus internationally now about these kinds of issues. Around the world people have come to recognize the importance of these kinds of programs, and they are on a much more solid scientific base than they have been in the past. One of the big problems we have is how do we take all that we know and transfer it over into what we do.
I hope this is helpful to you, and I'd like to wish you the best of luck in your proceedings throughout the day. Thank you very much.
PLENARY SESSION -RECOMMENDATIONS
DR. PETER CHANG: |