Reality Ontario’s Mental Health Care System isn’t working

A report by the Ontario Public Service Employees Union November, 2002

1 © Ontario Public Service Employees Union – 2002 2 Table of Contents Acknowledgements ...... 4 Introduction ...... 5 Background ...... 7 Executive Summary: 10 Systemic Failings of Mental Health Care in Ontario ...... 10 Chapter 1: The Health Services Restructuring Commission29 Chapter 2: Mental Health Implementation Task Forces ....35 Chapter 3: Funding ...... 38 Chapter 4: A Home, a Friend, a Job ...... 43 Housing ...... 44 Employment ...... 47 Income ...... 48 Chapter 5: Bed Numbers...... 50 Chapter 6: The Seriously Mentally Ill ...... 53 Forensic patients ...... 53 Chapter 7: Integration and Streamlining ...... 58 Chapter 8: Regional Reports ...... 62 London and St. Thomas ...... 62 Hamilton and Niagara ...... 66 Toronto ...... 69 Whitby ...... 76 Penetanguishene ...... 80 Kingston ...... 84 Brockville and Ottawa ...... 89 North Bay and Sudbury ...... 94 Thunder Bay ...... 97 Chapter 9: Recommendations ...... 102 Appendix 1: The divestment of Provincial Psychiatric Hospitals...... 103 Appendix 2: OPSEU’s publications on Mental Health ....104 Appendix 3: Participants in OPSEU forums...... 105

3 Acknowledgements

The Ontario Public Service Employees Union would like to thank: The 92 OPSEU members from 20 workplaces around the province including: current and former Provincial Psychiatric Hospitals, general hospitals, community agencies, correctional facilities and probation and parole offices, who participated in the 10 regional workshops that produced the content of this report. Their commitment and passion for working with and for the mentally ill is obvious from their heartfelt comments and observations about a mental health system that is in crisis. OPSEU First Vice-President Smokey Thomas, the local presidents of the current and former Provincial Psychiatric Hospitals, and the OPSEU Mental Health Division Executive for inititating this research project, and for guiding it to its completion with their ideas, knowledge and experience of the mental health system. Janet Solberg for researching and writing the report. Megan Park for facilitating the workshops and editing the report. Katie FitzRandolph for editing and design. I am proud of this union’s on-going and sustained advocacy on behalf of a sound system of mental health for Ontario. Our record speaks for itself. The tragedy is that so many governments have failed to listen to the heart-felt pleas of front line workers and the clients they serve. May this be the last time we have to convey this message.

Leah Casselman, President

4 Introduction

On November 26, 2000, a search team found Barbara Skultety’s body behind a Collingwood Lumber yard, a day after she went missing from Collingwood General and Marine Hospital. Eighteen months later, a coroner’s jury concluded that Skultety, 49, had committed suicide after being admitted as an involuntary patient at the Hospital. She had spent four days on a stretcher in an emergency room cubicle as doctors searched in vain for a psychiatric bed. Collingwood General and Marine Hospital has no psychiatric facility so staff tried to arrange for Skultety to be transferred to the Mental Health Centre in Penetanguishene or to the psychiatric ward at Barrie’s Royal Victoria Hospital. “She had lost her right to freedom, but there was no bed for her to go to,” said “She had lost Coroner James Kovacs. her right to freedom, but The coroner’s jury agreed. The jury members called for “immediate action, in particular to provide adequate funding to ensure that all persons requiring there was no bed mental health services have immediate access to prompt, safe, and secure for her to go to.” medical treatment.’’ In the months before her death, Collingwood hospital officials pleaded with the Ministry of Health to open more psychiatric beds in Simcoe County, the inquest heard. The ministry added five additional beds to the health centre in Penetanguishene, but not until several months after Skultety’s death. “How could this happen in our society? ... It makes you wonder what’s happened to health care, said Kovacs, adding psychiatric care has been “hardest 1 hit” under the Ontario government’s health care restructuring. 1 “Inquest tries to see how Barbara Skultety was a casualty of the restructuring. So, too, were Wayne system failed woman,” Collingwood Connection, Cutler, 31,Cory Wibberley, 20, and David Lumgair, 32, all of whom killed Roberta Avery, May 8, themselves at the Grand River Hospital in Kitchener over a four-month period 2002. from November, 2000, to March, 2001, while waiting for treatment for mental 2 “54 steps urged to prevent health problems. 2 suicides; Victims’ families like jury proposals; hospital OPSEU members are on the front lines of mental health services in Ontario. says it can’t afford them”, They have witnessed the suffering that the dismantling of yet another vital The Kitchener-Waterloo public service has caused consumers and their families. Record, Frances Barrick, February 16, 2002. 5 The union represents 7,000 front line staff in Ontario’s Provincial Psychiatric Hospitals, general hospitals and community agencies who work with the mentally ill. OPSEU members are registered nurses, registered practical nurses, social workers, maintenance workers, vocational rehabilitation counsellors, housekeeping attendants, psychometrists, occupational therapists and cooks. They work in a variety of settings: in acute-care wards, out-patient clinics and community outreach teams known as ACT (assertive community treatment) All this teams. restructuring The dismantling and restructuring process has been heartbreakingly familiar. created so much First, the Conservative government proceeded to cut corporate and income tax turmoil and thereby depriving the government of billions of dollars of revenue. disruption and Then they declared a shortfall in the budget and moved to cancel vital programs administrative in education, health, housing, environment, transportation, social services and busyness – at employment – all the while vowing that the public sector must learn to do more every level – with less. that thoughtful At the same time – and this is key – the Conservative government moved to and informed restructure whole facets of public life. They forced the amalgamation of city analysis could councils, fire departments, libraries and boards of education. They downloaded barely be the responsibility for transportation, social services and public housing to cities mustered. already starved of cash. They passed legislation that fundamentally changed how the education system would be financed. They restructured hospital care and homecare and moved to deregulate energy and electricity. All this restructuring created so much turmoil and disruption and administrative busyness – at every level – that thoughtful and informed analysis could barely be mustered. The same Conservative government template is now being applied to the area of mental health with predictably disastrous results. OPSEU held workshops with our members across Ontario to find out from them the effects of the restructuring of mental health services. They told us that mental health services are in a critical state. Sure, there were gaps and faults in the ‘system’ previously. But the current hodgepodge of funding arrangements, and governance arrangements, and divestment, and re-investment, and bed closings, and bed transfers, and program closures, and program start-ups, and proposed hospital closings and proposed hospital building, all of this has put treatment, care and services for people with mental illness in chaos. That state of chaos is the impetus for this report. Front line staff are deeply concerned that the well-being of people with mental illness is being lost in a hastily conceived, shoddily implemented and sadly underfunded plan to reform the mental health system.

6 Background

Reform of Ontario’s mental health system has been in the works for more than four decades. Historically, people with serious mental illness were cared for and treated at the 10 Provincial Psychiatric Hospitals (PPHs) owned and operated by the government. In the 1950s, with the advent of psychotropic medicine, many of these patients were moved into the community, spawning the growth of alternative or complementary care by a wide range of community-based and general hospital services. The multiplicity and There the tension was created and there it remained. What is the appropriate role and place for specialized psychiatric facilities? What’s the appropriate mix fragmentation of hospital and community services? How should the mental health budget be of community divided? How can we ensure that consumers get the support they need in the mental health community – and have access to appropriate hospital care when the occasion services has arises? made it more These are important questions. But generally speaking, they’ve been lost in the difficult for overarching policy decision to shift patients into the community – and the consumers and subsequent debate about the capacities and failures of the community-based families to get sector. what they need. The contribution of community agencies to the care and well being of consumers cannot be overestimated. But, in some measure, their success has led to their own undoing. The multiplicity and fragmentation of community mental health services has made it more difficult for consumers and families to get what they need. Similarly, mental health workers have experienced increasing frustration in their attempts to provide a continuity of care for their clients so that they may live and participate in their own communities.

Over the last 20 years, four different governments (and three separate political 3 G.F. Heseltine, Blueprint parties) felt it necessary to respond to this perceived ‘crisis’ in the provision of For Change: The Next Ten mental health services in four separate documents: Years. 1983 4 Robert Graham, Building Blueprint for Change3 • Community Support for 4 • Building Community Support for People People. 1988 5 • Putting People First 5 The Ministry of Health, • Making It Happen6 Putting People First. 1993 6 The Ministry of Health, Making It Happen. 1999 7 When you pare them down to their essentials, each report is remarkably similar, identifying many of the same systemic problems and continuing difficulties in meeting the needs of people with serious mental illness. There seems to be two overriding concerns. The first is a sense that the mental health ‘system’ isn’t a system at all: • Psychiatric hospitals, general hospitals, family practitioners, community mental health agencies, and homes for special care operate with very little coordination. • The large number of separate agencies and institutions makes access to How can the mental health services confusing and time consuming. ‘silos’ of mental • There are serious gaps in services for people with complex needs, for health be example, people who have a mental illness and addiction, or a mental broken down? illness and developmental disability. What should be • There is no established continuum of care, that is, access to different done to effect levels and intensity of treatment where and when it’s needed. seamless • There is little attention paid to the need to integrate the services treatment? provided by health, housing, education, employment and social services. How can we get The second concern seems to be more about the quality of care and the agencies to work need to have care providers be accountable for high standards: more closely • There is a need to establish ongoing models of ‘best practices’ as a with each other? standard for treatment, delivery of service and continuum of care. • Likewise, there is a need for common intake, assessment and discharge tools to be used across the mental health system. • Both the system and the services provided must be made accountable through monitoring and evaluation of patient outcomes. Here too, important questions were raised. How can the ‘silos’ of mental health be broken down? What should be done to effect seamless treatment? How can we get agencies to work more closely with each other? What kinds of community supports are needed? How can we ensure that agencies provide the best care possible? How much is all this going to cost? And what would it look like in the end? Generally speaking, the role of psychiatric hospitals – as the home of last resort – has been taken for granted. But that very characterization has unfairly diminished, even ignored, the important role psychiatric hospitals have played in providing services outside the confines of institutions. Psychiatric hospital employees have worked in the community to help establish supportive housing, appropriate therapeutic interventions, vocational training, peer support groups, outpatient care, social and recreational programs. Even so, OPSEU’s mental health workers have been put on the defensive for over 20 years, fighting a continuing battle over the transfer of mental health funding and beds from the hospital to the community sector.

8 The election of the Conservative government in Ontario brought all this to a head. With very little consultation, the government moved quickly to divest the The sense of province of its psychiatric hospitals and shift the governance, funding and chaos, confusion programs to public hospitals and community agencies. and anxiety in When the Conservatives came to power in 1995, there were 10 Provincial the mental 7 Psychiatric Hospitals, all directly operated by the provincial government. Six health sector of them have since been divested, so they are now operated and controlled by general hospitals.8 Over the same period of time, public services were subject to has never been unprecedented cutbacks and layoffs. The sense of chaos, confusion and anxiety greater. in the mental health sector has never been greater. The Ontario Public Service Employees Union represents 7,000 staff in Ontario’s Provincial Psychiatric Hospitals, general hospitals and community agencies who provide care to people with mental health illness. We have been vitally involved in the issues around mental health reform for 25 years. We have a long history of constructive, informed debate both at the provincial and local level.9 Our views flow from an informed perspective and, in all conscience, we must state the following: • The continuing threat and reality of massive restructuring, conceived mainly behind closed doors, is damaging the quality and delivery of mental health services both in hospitals and community agencies. • The Conservative government’s ideological commitment to balanced budgets and tax cuts has put the financial survival of mental health facilities and agencies at risk. • Grand interventions and even grander plans are diverting time, money and effort away from people who need it the most. As mental health workers, as members of OPSEU, it’s not our job to throw up our hands because the ‘system’ is in trouble. On the contrary. No one knows the system better than we do. But make no mistake. For us, the system is not about funding, or beds, or models of integration. It never has been. For us, the system has always been populated by real people, real lives and real 7 They were: London relationships made over time. That is our starting point. Psychiatric Hospital, St. Thomas Psychiatric Hospital, Hamilton Psychiatric Hospital, Queen Street Mental Health Centre, Penetanguishene Mental Health Centre, Whitby Mental Health Centre, Kingston Psychiatric Hospital, Brockville Psychiatric Hospital, North Bay Psychiatric Hospital, Lakehead Psychiatric Hospital. 8 See Appendix 1. 9 See Appendix 2. 9 Executive Summary: 10 Systemic 6ailings of Mental Health Care in Ontario

Members of the Ontario Public Service Employees Union (OPSEU) have been on the front lines of the restructuring of mental health services in Ontario. They have witnessed the suffering that the closure of beds and programs have caused for consumers in the past several years. The testimony Staff at the 10 Provincial Psychiatric Hospitals (PPHs) have been at the centre of frontline of the changes. Between 1998 and 2001, six Provincial Psychiatric Hospitals workers reveals were transferred from the direct operation of the province to the operation and a continuing control of general hospitals. Four of them remain under provincial operation, deterioration in but the province has plans to divest at least two of them in the near future. the services Staff at the former and current PPHs asked OPSEU to research and write a offered people report on the devastating effects of mental health care restructuring. with mental OPSEU held workshops with members from 20 workplaces from across the illness or province between October, 2001, and August, 2002. Nurses, social workers, disabilities. cooks, vocational counsellors, laundry workers, psychologists and maintenance workers told their stories. They work in the current and former Provincial The reality is Psychiatric Hospitals, in general hospitals and in community agencies.10 that both OPSEU correctional officers and probation and parole officers also participated consumers and in the workshops because, sadly, the mentally ill are all too frequently involved ex-consumers in the justice system. are being short Their vivid comments and analysis form the centrepiece of this OPSEU Mental changed in Health Report. virtually every Over and over again, their shared experiences reflect similar concerns and aspect of their issues. It soon became apparent that these issues are critical failings in the lives. provision of mental health care. It’s true that mental health restructuring is far from over and so its shape and outcome are vague at best. But the testimony of frontline workers reveals a continuing deterioration in the services offered people with mental illness or disabilities. The reality is that both consumers and ex-consumers are being short changed in virtually every aspect of their lives.

10 See Appendix 3 10 And there’s little reason to expect it will get any better. Given the priorities of this Conservative government, it’s impossible to believe they will provide the money that’s needed for therapeutic counselling, for rehabilitation, for vocational training, for supportive housing, for affirmative employment, for schooling, for recreation – or even for emergency and acute mental health services in public hospitals already running on deficit budgets. In short, their record in the public sector speaks for itself. The following are 10 system-wide failings that were identified by OPSEU members across the province. How can 1. Psychiatric hospitals do not admit patients even someone who is though beds are available. obviously in OPSEU members reported that severely ill patients – patients who were need of help be suicidal, or wildly hallucinating, or completely out of control – could not be turned away? admitted into the psychiatric hospital even though there were empty beds in admitting and throughout the facility. This is especially true of first-time admissions. How can this happen? How can someone who is obviously in need of help be turned away? In some cases, it’s because there is a lack of attending psychiatrists or registered nurses to staff the wards. That’s one result of an uncertain future, say OPSEU members. Restructuring and divestment has been going on for so long, that professional staff leave when other, more secure employment becomes available. But that’s not the only reason. Over and over again, we heard from OPSEU front line workers that empty beds are being frozen in the psychiatric hospitals. One registered nurse who works at Regional Mental Health Care, London, formerly the London Psychiatric Hospital, put it this way: “Look, the Conservatives promised not to close any psychiatric hospital beds. But when patients are discharged, their beds stay empty. We’ve got 100 empty beds in our hospital and a waiting list a mile long. This is all part of implementing the Health Services Restructuring Commission’s recommendations to reduce bed numbers. It’s a lot easier to reach those lower bed targets by closing empty beds – even though there are a lot of critically ill patients who could use our help.” Increasingly, patients who would normally be admitted directly into a psychiatric facility are being funnelled into the emergency wards of public hospitals. That’s what happens when the provincial psychiatric hospitals get closed – and their funding; programs and governance get transferred to designated public hospitals in the community. Those hospitals then become responsible for receiving, assessing and treating consumers in crisis. Does that policy serve the patients’ needs? Front line workers say not for a minute. Ex-consumers, especially when they are in crisis, need the reassurance of familiar surroundings, staff and procedures. None of that occurs when they are admitted to the emergency ward of a public hospital. It’s even worse for first-time consumers. We heard time and time again of patients becoming increasingly agitated, violent and/or depressed as they were 11 forced to wait – in the maelstrom of an emergency department – for hours and even days to be seen by qualified personnel and referred to an appropriate facility. In the Spring of 2002, a coroner’s jury concluded that Barbara Skultety, 49, had committed suicide after being admitted as an involuntary patient at the Collingwood General and Marine Hospital. She had spent four days on a stretcher in an emergency room cubicle as doctors searched in Most general vain for a psychiatric bed. hospitals don’t “She lost her right to freedom, but there was no bed for her to go to,” have the trained said Coroner James Kovacs. The coroner’s jury agreed. The jury psychiatric members called for “immediate action, in particular to provide adequate funding to ensure that all persons requiring mental health services have emergency immediate access to prompt, safe, and secure medical treatment.’’ nurses to triage effectively a In the months before her death, Collingwood hospital officials pleaded with the Ministry of Health to open more psychiatric beds in Simcoe person with County, the inquest heard. The ministry added five additional beds to mental illness. the health centre in Penetanguishene, but not until several months after 11 Nor do they have Skultety’s death . the physical The truth is that most general hospitals don’t have the trained psychiatric space to keep emergency nurses to triage effectively a person with mental illness. Nor do they people in crisis have the physical space to keep people in crisis safe so that they don’t become frightened by the hectic environment in the emergency ward, frighten others or safe. do harm to themselves. Wayne Cutler, 31, Cory Wibberley, 20, and David Lumgair, 32, all committed suicide while patients at the Grand River hospital. Inquest jurors heard that Cutler hanged himself the day he was scheduled to be discharged. They were told Wibberley was in the psychiatric ward for 10 days before he killed himself and Lumgair hanged himself in the emergency department while waiting to see a doctor.12 The coroner’s jury was so upset by the absence of a psychiatric acute-care unit at Grand River, that they recommended a study be done to determine 11 “Inquest tries to see how system failed woman” in whether the Kitchener-Waterloo region needed a Provincial Psychiatric the Collingwood Hospital. Connection, Roberta Avery, May 8, 2002 Front line staff talked about patients having to be restrained by security guards 12 Frances Barrick, “54 steps or hauled off to jail. urged to prevent suicides. One North Bay OPSEU member put it this way: “All this is leading to a crisis Victims’ families like jury because the holding beds and emergency wards use low-paid, low-skilled proposals; hospital says it can’t afford them” in The security guards to oversee the holding beds – this scares the mentally ill patients Kitchener-Waterloo Record, and the rest of the hospital.” February 16, 2002 13 “Son faces charge of Even more common is the fact that hospitals, under pressure to reduce in- attempted murder; Father patient stays, end up medicating people with mental illness and releasing them stabbed in the head with a back onto the streets where they often get caught up in the corrections system. screwdriver” in the One Kitchener hospital kept a difficult patient in lock-up for four days. Hamilton Spectator, John Burman, September 7, A recent situation in Hamilton illustrates, tragically, what can happen when a 2002, p.3 general hospital releases a patient not ready to return to his home13. 12 Joey Tobin was diagnosed with schizophrenia five years ago after a troubled life as a child. Refusing to take his medication, he went into crisis and was admitted to McMaster University Medical Centre. After a week’s stay, the 21-year-old was released into his parents’ care despite his mother’s protest that he wasn’t ready to come home. Just hours later, Joey Tobin was arrested for attempted murder after stabbing his father, Ron Tobin, in the head with a screwdriver. Some time later, Ron Tobin died of his injuries. 2. The revolving door of mental health care: patients are transferred from one hospital to another If there was one underlying theme, the raison d’être of mental health reform – it was to end the fragmentation in mental health services and provide a continuum of care. Patients would be able to gain access to the services they need, where they need it and when they need it. Seamless transitions from the hospital to the community and, if necessary, back into the hospital. There aren’t enough mental These days, that’s a pipe dream. Patients with mental illness are transferred from place to place, usually after unconscionable delays, no matter where they health beds in are in the ‘system.’ the general In the London area, it starts from the very beginning. First-time patients or hospitals. And patients who have not recently received care from Regional Mental Health management is Care, London, formerly the London Psychiatric Hospital, must first go to the freezing beds in admissions department of London Health Sciences Centre, (LHSC) the general the psychiatric hospital. hospitals. But when there are no acute care beds available for consumers at London So, first-time Health Sciences Centre, they are sent to Regional Mental Health Care, London and remain there until an acute care bed becomes available at LHSC. Patients patients, or are assessed and treated while they wait for a bed. patients who haven’t been in When a bed becomes available at LHSC, the patient is transferred. the system for a The revolving doors would make anyone dizzy. long time, have The situation is this: there aren’t enough mental health beds in the general to wait. hospitals. And management is freezing beds in the psychiatric hospitals. So, first-time patients, or patients who haven’t been in the system for a long time, have to wait. And the waiting period can be for days, weeks and months. “We would never do that to a person in distress with a physical crisis, like a heart attack,” said one social worker. “A heart attack is considered a real emergency. But if a person shows up in psychological crisis, they’re treated like second class citizens.” Continuity of care is also supposed to mean that a patient leaves the hospital with a carefully designed discharge plan. But that’s not how it works these days. Staff are under enormous pressure to vacate beds, either because there is a waiting list or in order to meet the bed reduction formula. OPSEU front line workers say that these days the criterion for discharge is: ‘what’s the worst thing this patient can get up to if we put him in the community.’ 13 Psychiatric hospitals used to discharge patients with a whole team of professionals following the progress of the patient. Now it’s up to community agencies to do the follow-up. But, of course, community agencies have the right to refuse to take on patients, whether it’s for supportive housing, case management, ACT teams or vocational training. Or they can assign entrance criteria that effectively exclude the seriously mentally ill. Patients who have a Disjointed, ‘bad history,’ or who ‘aren’t willing to work,’ or ‘who don’t fit in’. overlapping The truth is that the community sector is under siege because of the lack of services and funding and the increase in the numbers of people needing assistance. A long- organizational time registered practical nurse in southwestern Ontario says change has been confusion is the more rapid in the last few years that at any time in his career. rule. “Rapid, constant changes have made it more difficult to access services. Yet the requests for community services are up and everybody who is working anywhere in this field is noting phenomenal increases in the statistics of ill people they’re seeing.” Disjointed, overlapping services and organizational confusion is the rule: “It’s confusing to know who’s responsible for what, so it’s even harder for a person off the street.” In the Niagara region, front line staff report “there is no way of knowing where services are. Some patients never qualify and they are never referred to a proper service. There is no single patient file. You can be kept on four different waiting lists and end up getting the same service in different agencies.” “Also there are no resources in the regions to implement new initiatives like Community Treatment Orders, now mandated when a client is a danger to himself or the community. The paperwork is unbelievable. Then you have to get the patient back into hospital. If he disagrees, you have to get a psychiatrist to make a decision on competency. Then you still have to have a network of services on board for treatment, monitoring and supervision.” “We have a hard time negotiating this system and we’re immersed in it,” commented an attendant from Penetanguishene. “Our clients have no idea where to go to get the help they need. More people are falling through the cracks than there are people getting proper treatment and the system is more fragmented than it ever was.” 3. 6unding for mental health services is not adequate Is there a hospital in Ontario not running on empty? Just as the Conservative government has starved our schools of funding, so hospitals all across the province have been forced to declare deficit budgets. After their initial positive reaction to the June 2002 budget announcement, the Ontario Hospital Association expressed serious concerns about the $300 million shortfall in hospital funding for 2001/02 that had not been addressed.14 14 Ontario Hospital Association, Bulletin, June On June 18, OHA Board Chair Leo Steven wrote to Health Minister Tony 17, 2002. Clement proposing the formation of a joint advisory group to determine the 15 Letter to the Honorable amount hospitals will be authorized to carry forward in their base budget Tony Clement, June 18, allocations for 2002/03, as a result of hospital under-funding in 2001/02. Mr. 2002. Steven writes:15 14 “We believe that this joint review process should be expedited, given the number of hospitals affected and the size of their under-funding …” In addition, the OHA noted that the government had not implemented their “request that all Ontario hospitals be provided with a minimum of 3 per cent increase in total operating funding to accommodate known economic pressures, such as labour agreements and inflation.”16 The OHA listed provincial underfunding, insufficient capital investment and growing healthcare unfunded liability as three contributing elements to the lack of sustainability in Ontario’s health care system.17 This information is certainly consistent with the reports OPSEU received from front line workers at the psychiatric hospitals. To put it bluntly, the fiscal tail is constantly wagging the mental health dog. In every town It’s almost impossible to track mental health funding anymore. and city, there Since 1998, six Provincial Psychiatric Hospitals that were directly operated by are long waiting the provincial government, have been taken over by general hospitals. There is lists for homes no way to track the funding that’s been transferred from the Provincial Psychiatric Hospitals to the receiving general hospitals. Psychiatric hospitals and programs and receiving hospitals are millions of dollars in the hole. Every year, the that often mean Ministry of Health and Long Term Care rides to the rescue with one-time the difference bailouts. But in every location, programs have had to be cut and jobs vacancies between left unfilled in order to reduce expenditures. homelessness The provincial government continues to directly operate four Provincial and shelter, Psychiatric Hospitals. Two of the four will likely be divested to general work readiness hospitals in the next two years. or The government’s investment in community mental health is no better. Despite unemployment, a promise not to close beds until community resources were available, there has therapy or been little investment in community services for the past six months. And, as institutionalization, you will read, community investment over the last several years has barely met the needs of people with mental illness or disabilities – whether its housing, incarceration or employment, recreation, occupational therapy or applicable supervision. In independence. every town and city, there are long waiting lists for homes and programs that often mean the difference between homelessness and shelter, work readiness or unemployment, therapy or institutionalization, incarceration or independence. Front line workers in southwestern Ontario say that cost cutting rather than rehabilitation is driving the mental health system. 16 Ibid. “Clients find their drug plans cut off, they don’t qualify anymore for ODSP, 17 David MacKinnon, because they can’t get a diagnosis and they can’t get a bed in a hospital to get President & CEO Ontario an appropriate diagnosis.” Hospital Association, “It snowballs,” explains a member of a PACT team in southwestern Ontario, Hospital Care: Capitalizing on Emerging who helps consumers make the transition to living in the community. “It’s hard Opportunities in a to get on the list for subsidized housing. Vocational services are a thing of the Difficult Environment, past. Funding has been cut in these areas but you can’t see anything that’s come Presentation to the Halton up in its place.” Healthcare Services Corporation, August 22, 2002 15 “Politically the hoopla was about deinstitutionalizing and upgrading the quality of life, but the small print was about saving money. It’s been cut, cut, cut.” 4. There is a continuing privatization of mental health services In the province of Ontario, the privatization of health care is moving right along. • The Conservative government has agreed to the creation of 20 private, for- profit outpatient facilities that will be providing MRI and CT scans. Now patients with no time but lots of money can jump the queue for diagnostic 18 Employees imaging. discovered that • Physiotherapy has all but been removed from hospital settings and left in client the hands of privately run clinics where patients pay the bill – either through 19 employment private insurance or out of their own pockets. plans (set a goal, • Deaf and hard of hearing children and seniors are paying a high price for make a work having audiological services removed from OHIP. Audiology clinics have either closed their doors or are now charging user fees.20 plan) that took them one hour • Ontario’s long term care facilities are now the most privatized in Canada. and 30 minutes Basic accommodation costs are amongst the highest but Ontarians in long- term care facilities receive extremely low levels of service compared to to produce, are other jurisdictions.21 now being Through Cancer Care Ontario, the Ministry of Health and Long Term Care contracted out • has established and funded the first private for-profit company to run an by the Ontario after-hours cancer treatment centre since the inception of public Medicare.22 Disability Support for private health care is an ideological position. So it should come as Support no surprise that mental health care is being forced to follow the same path. Program at Support services (or as the Royal Ottawa Health Care Group calls them “hotel $400 apiece. services”) such as housekeeping, laundry, meal preparation, groundskeeping, maintenance, driving and security have been privatized. At the Providence Continuing Care Centre, formerly the Kingston Psychiatric 18 Hamilton Spectator, MRI Hospital, there was an in-house laundry service for both residential patients and scanning, for-profit health outpatients. The laundry had a two-day turnaround, including mending. The care and two tier medicine, service was closed and contracted out to a regional laundry service where Dr. Gordon Guyatt, September 6, 2002. employees earn $6.00 less an hour than they did at the hospital. The turnaround 19 Ontario Physiotherapy now takes eight days and the quality of the laundry is poor. Patients have Association, Private developed skin problems and most have been advised to do their own laundry. Clinics in Public Hospitals: A Discussion Paper, In another example of mindless contracting-out, employees discovered that February 2000 client employment plans (set a goal, make a work plan) that took them one hour 20 The Canadian Hearing and 30 minutes to produce, are now being contracted out by the Ontario Society, OHIP Delists Disability Support Program (ODSP) at a rate of $400 apiece. Audiology Services, November 21, 2001 And if the services themselves aren’t privatized, then their management is being 21 Ontario Health Coalition, contracted out to private companies with the predictable results of cutting costs. A Ownership Matters, May food service employee at the Royal Ottawa Hospital (ROH) said corporate 27, 2002 22 Cancer Care Ontario, management of hospital food has meant the budget for patient meals has been Annual Report, 2000-2001 cut in half. 16 “Everything now is boxed or freeze dried, the quality is way down.” The company contracted to handle the non-medical services at the ROH recently won a business award for getting the ROH food budget down to $4.03 per patient per day. The Centre for Addiction and Mental Health in Toronto contracted out its food Anyone who service to a company that brought in thermalized, ready-to-heat meals. works in a “Pre-mixed and pre-packaged,” describes a member of the housekeeping staff. psychiatric “The quality was so poor, people left it on their plates and everyday I was facility can tell throwing out 500 lbs of food.” you about the The company’s response to the waste? It cut the meal portions for clients in importance of half. Under the current system, says the housekeeping employee, clients can the relationship end up with “eggs for breakfast, an omelette for lunch and quiche for dinner.” between the Support services have always been undervalued and thus, the most vulnerable front line to privatization. But anyone who works in a psychiatric facility can tell you service workers about the importance of the relationship between the front line service workers and people with mental illness. Patients know, count on and respect the and people with contribution made by cleaners, cooks, laundry workers, drivers, gardeners, mental illness. security personnel and maintenance workers. These workers do nothing less than create and maintain a healthy, safe and nurturing environment. There is a second way in which services are being privatized. Programs that were previously operated by the Provincial Psychiatric Hospitals have been closed and transferred to private agencies. One example is the crisis response capacity at Lakehead Psychiatric Hospital in Thunder Bay. Both the emergency department and the telephone crisis line used to operate 24 hours a day, seven days a week and were staffed by registered nurses. The telephone line had a 1-800 number serving all of the 807 area code. The Crisis Intervention Team at the Hospital was also a psychiatric emergency room, coordinating care for a catchment area from the Manitoba border to White River, Ontario. The telephone line has recently been transferred to the local Canadian Mental Health Association, which operates 24 hours a day but the Urgent Care Mobile Service only operates 12 hours a day. The local emergency department only has psychiatric nurses available until 11:30 p.m. As one registered nurse asked: “Does this sound like improved service to you?” Under restructuring at the Centre for Addiction and Mental Health (CAMH) in Toronto, vocational rehabilitation programs now have to be “business affirmative” and turn a profit. So the small coffee machine service, operated by clients at the Queen St. site has been contracted out to the Ontario Council of Alternative Business, (OCAB), which will necessarily hire higher-functioning clients for the work. A small catering operation, run by a few women clients, was also working well. “They did a little catering and they liked it and felt useful,” says one CAMH staffer. “Well, happy or not, they’ve been told: now, it’s about making a buck.” 17 A vocational counsellor who assists with the catering operation puts it this way: “I’m trained as a social worker, not a business person, so I’m not sorry that OCAB is getting more involved. But the truth is, when you move vocational opportunities into the community, you’re moving them into a business environment. And that’s a risky operation, subject to all the ups and downs of the marketplace.” Seniors with Perhaps the most consistent trend towards privatization has been in the care of mental illness psychogeriatric patients. In short, seniors with mental illness are being moved are being moved out of psychogeriatric wards in psychiatric hospitals into for-profit nursing out of homes where care and standards are minimal. psychogeriatric The situation in Kingston is a perfect example. A for-profit nursing home is wards in being expanded to house psychogeriatric patients. This move will cause the psychiatric closure of 75 beds at Providence Continuing Care Centre, the former Kingston hospitals into Psychiatric Hospital. for-profit What’s the difference where psychogeriatric patients live? Well, the Providence nursing homes Continuing Care Centre, and all the other provincial psychiatric and divested where care and psychiatric hospitals, have professional clinicians delivering services and standards are programs to psychogeriatric patients. minimal. In contrast, the standards at nursing homes can be a lot lower. In 1990, the NDP government enacted regulations to ensure that residents be provided with 2.25 hours of nursing care a day. Residents who were “confined to bed or incontinent” were be bathed daily.23 In June 1996, the new Conservative government repealed the requirement for nursing care entirely. And in the summer of 2002, amended the requirement for daily baths. In its place, the new regulation merely requires that “nursing staff shall ensure that proper and sufficient care of each resident’s body is provided daily to safeguard the resident’s health and to maintain personal hygiene.”24 Generally speaking, nursing homes are ill-equipped to deal with psychiatric cases. “Nursing homes are taking psychogeriatric patients and providing staff with a three-week course on violence and dementia,” says a registered nurse at the Penatanguishene Mental Health Centre. “We spend a lot of our time educating the staff in nursing and group homes on how to deal with the mentally ill. But it’s not something you can learn over night. The best we can do is train generic healthcare employees who are working with some of the most difficult and intransigent people with mental disabilities.” 5. Programs are closing with no replacement in the community

23 Ontario Regulation 832 Shutting down Provincial Psychiatric Hospitals is still a work in progress. It of The Revised will take years to conclude. But the impact on important programs for people Regulations of Ontario with mental illness is already being felt across Ontario. 1990. 24 Ontario Regulation 237/ The vocational rehabilitation unit at the Brockville Psychiatric Hospital, now 02, Section 56, subsections part of the Royal Ottawa Health Care Group, is slated for closure. In fact, it was (8) and (9). supposed to be closed before the summer of 2002. The unit has been so 18 downsized over the years that the patients remaining in the program are ones for whom it would be virtually impossible to find work. So, once the program is terminated, how will they occupy their days? How will they find something meaningful to do? So far, front line workers and community supporters have managed to delay the closure. But it’s only a matter of time. The same is true of the dual diagnosis program at Brockville. It’s future is just as uncertain and its patients doubly vulnerable. Patients characterized as dual diagnosis have both a developmental disability and a mental illness. They generally tend to fall through the cracks – often excluded from the mental There are no health system, and within the developmental system their mental health needs suitable homes are seldom addressed. They “pose special problems to service providers. In in eastern many cases the dually diagnosed place heavy demands on the service Ontario for the providers’ resources. [And] there is a general lack of expertise and resources to dually adequately provide for these individuals’ needs.” 25 diagnosed. Are there currently community agencies capable of meeting those needs in the Brockville area? No. According to OPSEU front line workers, there are no suitable homes in eastern Ontario for the dually diagnosed. One staffer recalled cancellation of the day treatment centre for elderly dementia patients who were awaiting long-term placement. “My mother had Alzheimer’s and people loved the program and it worked for her. It was a wonderful program and a great respite for families. It was shut down lock, stock and barrel with nothing to replace it.” Any day programs that are left are “overwhelmed with waiting lists” say staff. At the Whitby Mental Health Centre, the “Care Program,” based on a rehabilitation model, involved 30 to 50 patients per day in a drop-in setting. It was pre-vocational and patients made crafts to raise money. Assertiveness training, recreation, medication awareness and cooking skills were part of the program. “It was a place to work and relax,” said one staffer, “for low functioning patients in the hospital and in the community. Now it’s gone.” Gone too is Centralized Services, which provided woodworking, occupational therapy and vocational skills like horticulture or ceramics. The Geriatrics Day Program has been eliminated. A popular summer camp project, that involved young people on a three to four day outing, was cancelled this year because there were no funds to staff it. “Back in 1974-75 we had a three-week camp, then it went to a few days and now there’s nothing,” noted a social worker at the Whitby Mental Health Centre. “These are people who never went to camp. They got to go on hikes. They cooked outdoors. It was great. And they rose to the occasion for it.” In northeastern Ontario, the mental health out-patient clinic at the North Bay Psychiatric Hospital treats over 1,200 outpatients. The clinic is simply too full 25 Grand River District and unable to accept any more referrals. There are no community resources Health Council, capable of taking up the slack. Haldimand Norfolk Dual Diagnosis Service Plan, April 2000 19 The neuro-psychiatric unit has been closed at the Whitby Mental Health Centre, This is a department for patients with acquired brain injury. There is a real need for appropriate programs but no community agency available to offer them. The Penetanguishene Mental Health Centre operates the Georgianwood Addictions Program, a residential treatment facility, open during the week. The Ministry of Health has issued a direction to find an alternative to the residential component although a day program may not be in the best interests of the patients. Vocational counsellors at the Centre for Addiction and Mental Health in Toronto are now focussing on getting their clients ready to take on a job. The work is being supplied by the Ontario Council of Alternative Businesses or through partnerships with community agencies. That means the employment opportunities for their clients are more dependent than ever on the vagaries of the marketplace and on funding for community support. These days, everyone is struggling. Front line workers from all across the province talk about the cancellation of dental programs once the Provincial Psychiatric Hospitals were divested to general hospitals. Consumers used to be able to expect to receive dental care as part of the medical care that was offered to them. Now only minimal dental care, if any, is provided because of the cost. General hospitals just can’t fit it into their overextended budgets. OPSEU front line staff report that the standard now is: “Don’t fix it. Yank it.” The lack of a 6. There is a lack of decent, affordable housing for safe, clean, people with mental illness affordable place to live can lead, OPSEU front line staff across the province talk about one issue above all the inexorably, to a rest when it comes to services for the mentally ill: the lamentable state of decline in housing. Almost no other issue is more important. The lack of a safe, clean, physical and affordable place to live can lead, inexorably, to a decline in physical and mental health and a return to the hospital. mental health and a return to Front line staff talked about the alarming number of people with mental illness living on the streets or finding shelter in hotel rooms and jail cells. Staff talked the hospital. of tenants sleeping in ‘rooms’ under stairwells. Or being forced, because they have no money, to live in unregulated rooming houses or flophouses. Group homes run for profit may have a dozen people crammed into a three- bedroom bungalow, with cots in the furnace room. Clients regularly receive two pieces of bread for breakfast and and are told to “toast it yourself” or are given a bowl of cereal with water. In Kingston, front line workers talk about what they found during the ice storm. “We had two forensic patients at a home that housed 13 people. Since we hadn’t heard from them, we investigated and arrived to find them all sitting in the dining room with a candle, no heat or electricity.” The United Nations defines housing as a basic human right. It is a right that includes shelter, security of tenure, personal safety, accessibility to employment, education and health care, and provision of minimum space to 20 avoid overcrowding.26 It is, and we agree wholeheartedly with this, “a social determinant of health and the cornerstone of community mental health care, providing the foundation from which people may recover from their illness and live successful lives as citizens.”27 Perhaps that’s why 16 District Health Councils across Ontario were asked to conduct local research on the housing situation for persons with serious mental illness. The DHCs consulted landlords involved in Non-Profit Municipal Housing, Local Housing Corporations, Residential Housing including Homes for Special Care (HSC) and Domiciliary Hostels (DH), and Emergency Hostels/ and Shelters. In addition, consumers and families were consulted through the Their first process of focus groups facilitated by various mental health providers and priority was for District Health Council staff. more money and Without exception, no matter the location of the District Health Council, the lower rents. In themes around housing for people with mental illness or disabilities remained the words of one the same: consumer, “just • Their first priority was for more money and lower rents. In the words of one give me consumer, “just give me affordable housing…” On a regular basis, affordable consumers are forced to choose between paying their rent and feeding housing ” themselves. • Rising costs of rent have also forced people with mental illness to turn to subsidized housing for assistance. However, there are wait times of at least two years for most social housing including supportive housing. • Although there has been an increase in the number of supported units, there is still a crisis in the number of spaces available and no evidence to suggest that the crisis in supportive housing will be solved soon. • There needs to be a continuum of housing options that meet the specific and changing needs of people with a mental illness. That currently does not exist at a scale to provide adequate housing or housing supports to the number of people who need them • There is a concomitant need for a range of community supports such as occupational therapy, emotional counselling, homecare services, recreation, life skills, vocational rehabilitation and affordable transportation. The lack of mental health supports makes it difficult for consumers to keep or 26 United Nations maintain their housing Commission on Human Settlements (Habitat), There is one supportive housing program that worked well to address some of Istanbul Declaration of the these gaps. Approved Homes in Thunder Bay are privately owned and second United Nations operated. But residents maintain their status as inpatients at Lakehead Conference on Human Psychiatric Hospital (LPH). That means residents are still attached to a unit. Settlements (Habitat II), June 1996 as quoted in They have access to the unit social worker, have an attending psychiatrist, are Hamilton District Health guaranteed a bed at the hospital should they experience a relapse and generally Council, Housing and stay in the home until they are ready to move into a more independent setting. Support Requirements for Persons with Serious The Approved Homes are staffed by the Home operator and although the Mental Illness, October training is pretty minimal, the Home must accept all types of behaviour. Like 2001 most supportive housing, the Homes are funded at a rate of $40 per day. The 27 Hamilton District Health difference is that the cost is approved and assumed by the LPH. This means that Council, op. cit. p.8 21 residents can keep, spend or save their Ontario Disability Support Program payments. They are not left impoverished by the need to pay their rent out of their monthly benefit. Sadly, the Conservative government is ending the Approved Homes program. Instead, supportive housing will operate on a cost-recovery basis. Homes for Special Care will collect the $40 per day directly from the resident, leaving the consumer with a paltry sum for personal use. There is no limit on the number of beds allowed in a Home for Special Care. This opens the door to an institutional-like setting instead of the supportive, nurturing and family-like environment which Approved Homes offered. One final note on Homes for Special Care: the per diem rate has been increased but the budget for funding There is no agencies has not. That means fewer beds will be available for consumers out in regulated the community. community care The fact is that downloading of services for the mentally ill has been done and no without any extension of hospital standards into community facilities. There is requirement for no regulated community care and no requirement for a license, so that anyone a license, so that can take the mentally ill into their home and get paid for it. anyone can take “There should be standards that carry over into the community, including the the mentally ill Fire Code and adequate space around beds, like in hospitals,” said one OPSEU into their home front line worker. “Each client should have a family doctor and a dentist. A nurse should give medication and professionals should do the testing and and get paid for rehabilitation. There are no regulations to cover any of that.” it. 7. Income from the Ontario Disability Support Program and Ontario Works is too low Typically, people with a serious mental illness qualify for the Ontario Disability Support Program (ODSP). Or they receive a benefit from Ontario Works (OW) as their main source of income. ODSP provides an average individual with $930 a month, including a $414 maximum shelter allowance. OW provides an average individual with $520 a month, including a $325 maximum shelter allowance. Moreover, clients who have been in the workforce and have saved some money in a GIC or RRSP must use up their savings before they can collect benefits. If they’re lucky enough to be on ODSP, people with mental illness can usually find a one bedroom apartment for $500 to $550 a month. That means these consumers are spending almost two-thirds of their income on rent. Let’s put that into perspective. Canada Mortgage and Housing Corporation considers 30 per cent of annual income to be an affordable level for rent. Of course, if you are on Ontario Works, and you receive only $520 a month, then you’ll probably have to settle for a room in an unregulated flophouse. When people spend that much of their total income on housing, it means they have very little available each month for food, clothing and basic necessities. On a regular basis, people with mental illness are forced to choose between

22 paying their rent and eating. In recent years, consumers have had no choice but to rely increasingly on food bank usage in order to meet their basic needs. One of their basic needs is medication. And here’s where people with serious mental illness fall into a classic Catch-22. Ake Blomqvist, a professor of economics at the University of Western Ontario outlined the dilemma in a column for the Globe and Mail28. Patients with a mental illness need drugs to stay out of hospital and lead productive lives. But only hospital inpatients have full coverage for the cost of drugs. You lose the full coverage when you leave the hospital. For outpatients, a co-payment of $2 per prescription is required. So, if you’re on weekly medication of three different drugs, that would require a co-payment of $24 a month. It may not seem like a lot, but it is a very significant amount for people with only minimal disposable income. “After the Ontario Drug Benefit Plan introduced co-payments in 1996, use of anti-psychotic drugs decreased by 9 per cent. Ensuring that patients in the community take appropriate medication regularly is one We no longer of the greatest challenges for caregivers. The last thing they need is a monetary disincentive for their clients to follow recommended carry a caseload. treatment.”29 That means OPSEU represents the front line staff at the Ontario Disability Support Program clients with (ODSP). Here’s what one of them said: mental health disorders, who “We see so many desperate cases nowadays that we tell clients to call their MPPs and complain directly. Our customer service has been really have a devastated since the ODSP program took effect. We no longer carry a hard time caseload. That means clients with mental health disorders, who really trusting anyone, have a hard time trusting anyone, end up having to talk to a new ODSP end up having to representative each time. They don’t cope well with this situation. talk to a new “They now shop to see who gives them the better answer, and often ODSP become violent and distressed coping with our new way of business. representative Our counter clerks are incredibly stressed because they feel they are not each time. able to help the clients at all. We no longer will help with other government forms like Old Age Security or housing. We end up They don’t cope sending people to another counter. The public, and especially people well with this with mental illness, find that very frustrating.” situation.

Since 1995, the cost of living has increased by more than 9.5 per cent, yet people relying on ODSP have not had an increase in their benefits since the Conservatives became government. NDP MPP Tony Martin has introduced Bill 118, the Ontario Disability Support Program Amendment Act (Fairness in Disability Income Support Payments), 2001. It would ensure ODSP payments rise as the cost of living rises. With the 28 passage of this Bill, ODSP recipients would receive an annual cost of living Ake Blomqvist, Stop Punishing the Sick, Globe adjustment every April 1 to stop them from slipping further into poverty. Tony and Mail, December 19, Martin has tried without success to get this Bill passed into law. 2001 29 ibid 23 8. The mentally ill are in our jails when they belong in our psychiatric hospitals According to statistics from Ontario’s Ministry of Public Safety and Security, 10.6 per cent of male admissions and 19 per cent of female admissions in our jails have previously identified psychiatric conditions. To OPSEU correctional officers and front line psychiatric workers, those statistics come as no surprise. There are many different routes to jail for people with mental illness. Sometimes, it’s the only way to get psychiatric treatment. Front line staff call it the ‘gold card of access.’ Staff at the North Bay Psychiatric Hospital site say: “You can wait forever to get some help, even if you’re in crisis. Or you can throw a punch, have someone call the police and get some help right away.” This has certainly been the experience in Windsor for families of people suffering from schizophrenia:30 Families of people suffering from schizophrenia dispute the claim by local hospital officials that psychiatric care is available 24 hours a day. “They may have someone on call, but you never get to see him,” said Frank Sheehan, who has had to take his son to the emergency room on many occasions. Sheehan says he’s often had to resort to asking a Chris Davies has justice of the peace to sign a Form 1 stating his son is a danger to also been himself and others in order to see a psychiatrist in ER. arrested Likewise for Richard McLeod, who said he experience difficulties when numerous times, he tried to have his son seen by a hospital psychiatrist. “The police took usually for him in three times and he was sent home,” said McLeod. “Finally, we minor offences. had a witness say he was suicidal and threatened to cut someone’s throat, then we got a form 1 signed by a JP, got him back to hospital and His anti-social was seen by a psychiatrist.” behaviour is But getting in trouble with the law is no guarantee of access. Take the case of getting worse, Christopher Davies:31 but there is still Chris Davies has schizophrenia and suffers from paranoia. He was no hospital bed arrested in his apartment after an altercation with a new tenant. After for him, even being charged with trespass and public mischief, as well as breach of with a court undertaking for a previous charge, Chris appeared in court and was order. ordered to undergo a 30-day psychiatric assessment. He waited at the Ottawa-Carleton Detention Centre for a bed for more than 30 days. His mother held a protest in front of the Royal Ottawa Hospital in order to bring the city’s attention to this serious and ongoing problem. 30 Veronique Mandel, ER Ms. Davies says her son has been seeking help for years and has been psych care defended, blasted, The Windsor Star, forced to seek emergency psychiatric help. He has also been arrested April 12, 2002 numerous times, usually for minor offences. His anti-social behaviour is 31 Ron Corbett, Mother’s getting worse, but there is still no hospital bed for him, even with a protest courageous, Royal court order. Ottawa Hospital CEO says, The Ottawa Citizen, June Said Dr. John Bradford, head of forensic psychiatry at the ROH, “We 8, 2002 have 12 beds at the ROH which are meant for court-ordered psychiatric 24 assessment. There are at least 10 to 12 people waiting to get into one of these beds at any given time. We do our best to expedite treatment, but the system is overloaded.” “Such situations are all too common,” said ROH CEO George Langill, “The demand for psychiatric services in Ottawa far outstrips the supply. People with a serious mental illness should not be criminalized, yet this is what is happening.” When psychiatric hospital beds close, some patients have a lot of trouble taking responsibility for their own medication and accessing mental health services. They start to act out, get into petty crime or drugs, and soon the police are People with called in. They often end up languishing in the corrections system. borderline personality A staff member from Regional Mental Health Care, London, formerly the London Psychiatric Hospital, reported that one patient had been in solitary disorders, who confinement in the Windsor jail, for two and a half months for repeatedly have poor coping pulling a fire alarm. skills, end up in “He’s refusing medication and is sick. He has a skilled and committed lawyer the corrections working on his case, but he needs a forensic assessment to be deemed system, though incompetent and there is no bed available to get him that assessment.” they could be Other mentally ill patients end up in jail because of housing problems and lack effectively of resources in the community. For example, there is no halfway housing in treated with Penetanguishene or Huronia and the men’s shelter in Midland has closed. group therapy People with borderline personality disorders, who have poor coping skills, end and behaviour up in the corrections system, say OPSEU front line workers, though they could management. be effectively treated with group therapy and behaviour management. “The number of mentally ill in correctional institutions has been escalating over the last six or seven years,” said one probation officer in Penetanguishene. “The down-sizing of psychiatric hospitals means the mentally ill are being criminalized. They are bounced between penal institutions and community corrections.” Halfway houses use to be the place to go for a lot of mentally ill clients. They had staff who provided support on mental health issues as well as criminal issues. Those halfway houses have all been closed. In the Northwest, there is a deep concern, among front line mental health workers and correctional officers, that more of the mentally ill are trapped in the corrections systems. “We’re seeing the criminalization of mental health,” said a Thunder Bay social worker, “There aren’t the resources to help people in the hospitals or the community, so they end up in jail.” It is estimated that 25 per cent of the inmates of local correctional facilities have a diagnosed mental illness and a possible 40 per cent have undiagnosed mental illnesses. Early in 2002, an inquest was held into the death of Michael Douglas Henderson, a 51-year-old man jailed for breach of parole on a narcotics charge. At the time of his admission to the provincial jail in Windsor, he 25 was routinely assessed and deemed not to be suicidal. On the fifth day of his incarceration, he was found hanging by a torn bed sheet from the bars of his cell. Suicide notes dated the previous day were discovered in the cell.32 OPSEU Correctional officers share the concerns of staff in psychiatric hospitals. They don’t have the training for working with the mentally ill, neither do they believe that mentally ill inmates belong in Ontario’s correctional centres. At present there are no mandatory suicide programs and evidence at the inquest indicated a variety of experience and training amongst correctional and nursing staff. As a result, the coroners’ jury in this case recommended that a “suicide awareness program be implemented for all penal institutions in Ontario. Correctional and medical staff must have mandatory attendance on a yearly basis.”33 9. The attempt to combine addictions and mental health is wrong headed and counterproductive It shouldn’t come as a surprise. Mergers have been the order of the day for this Conservative government. There has been the amalgamation of school boards, of municipalities, of libraries, of fire departments, of hospitals. And now, there is the merger of institutions that have traditionally been involved in mental health and addictions. Combining Front line workers recognize that there are a lot of patients with concurrent mental health mental health and substance abuse problems. They recognize that there needs to and addictions be some interaction between the addictions and mental health systems. may spell the But what’s happened, say staff, is an ascendancy of the philosophy that end to the addictions are just another mental health problem. holistic, non- “If that were the case, then everyone who smokes could be considered mentally medical ill,” said one social worker. approach that Combining mental health and addictions may spell the end to the holistic, non- has been medical approach that has been developed for addictions treatment. developed for “There is something unique about substance abuse problems that needs specific addictions treatment and our fear is that substance abuse problems are being wiped off the treatment. map,” said a staffer from the Centre for Addictions and Mental Health (CAMH) in Toronto. “We find ourselves in danger of losing a very large body of knowledge, expertise, research and specific treatments that were helping the people of Ontario.” “We used to have addiction services for older adults. Now that’s been absorbed 32 Verdict of a Coroners’ by geriatric psychiatry. We were once a leader in youth treatment with a whole Jury, on the inquest into continuum of services. Over the years it’s been whittled down and is now the death of Michael subsumed in a small out-patient service. The Addictions Research Foundation Douglas Henderson, provided materials to service providers, from corrections officers to doctors, to January/February 2002. use as tools to deal with addictions. There is a lot less of that now.” 33 Ibid 26 We had a huge service where we responded to calls from the public or we’d go out to speak in the community,” recalls a registered practical nurse. We’ve pulled back on that.” A vocational counsellor says: “I work in specialized services where we serve primarily schizophrenia and continuing care with vocational services and programs. But now we get people whose primary diagnosis is addiction. I’ve worked in mental health for 22 years and my expertise just isn’t there.” “At the time of The end result of integrating the addictions and mental health disciplines is that “our client system is gone,” concluded a social worker. “We continue to reduce the merger, they the resources that our clients can access for both addictions and mental health.” talked about a seamless Instead, front line staff claim that a business focus drives all aspects of CAMH’s work, turning research into a grant-driven operation and applying continuum of “business affirmative” models to vocational rehabilitation. care. It was an Staff cuts and unfilled positions mean that employees are handling triple the assurance that number of clients, slashing one-hour appointments to 20 minutes. at every site, every level of “At the time of the merger, they talked about a seamless continuum of care,” said a counsellor. “It was an assurance that at every site, every level of need need would be would be met. Well, the seams are bursting and some have split.” met. Well, the 10. Recruitment and retention of staff has never seams are been more difficult bursting and some have split.” The turmoil of restructuring, divestment, bed closures and program cuts has taken its toll on the staff at former and current provincial psychiatric hospitals. Across the board, staff say morale has never been lower. Mental health workers say caseloads are too high resulting in staff burnout and turnover. Occupational therapists, psychologists, psychiatrists and social workers are all leaving because of uncertainty about what the future holds. Staff say there is a lack of respect for hard-working and trained professionals from management and provincial officials. “We’ve had three occupational therapists in three years at our workplace,” says one social worker, “We work with difficult clientele. Staff won’t stay if they aren’t treated well.” At the Royal Ottawa Hospital, the number of job postings is a reflection of the high rate of turnover. In a recent arbitration, the statistics were put squarely in front of the arbitrator. “There were 70 job postings in 1999. That increased by 69 per cent to 118 job postings in the following year and another 35 per cent in 2001. Only a fraction of the positions are filled by the date required. The lack of staff really takes its toll on the rest of the workforce.” The fact that the Conservative government will not pay wages comparable to the same classifications in other hospitals is an additional headache for OPSEU front line workers. “The wages here are terrible”, said one worker from Thunder Bay. “They’re not competitive with other hospitals or even the private sector. Last week, 27 unionized cashiers at a local supermarket got a wage increase that brought them up to $18.00 an hour. Here at Lakehead Psychiatric Hospital, we have occupational therapists who have five years of post-secondary education and they make $18.50 an hour to start.” With the shortage of nurses across Ontario, it’s also proving very difficult to hire and retain registered nurses and registered practical nurses. Their wages are still not in line with their counterparts who work in General Hospitals. “People need some assurance that they can make a life in their work,” said a registered nurse from Providence Continuing Care Centre, formerly the “We’ve endured Kingston Psychiatric Hospital. “With the ever-changing restructuring, and all a restructuring the anxiety and uncertainty that it evokes, it adds up to no visible commitment from the Employer.” that’s been going on for some time At Whitby Mental Health Centre, staff are leaving like never before. The now. Regardless combination of a lengthy strike, uncompetitive wages and the government’s tardiness in paying the increase from the contract has made staff consider any of funding, of other job, anywhere. budget cuts, “The government is a horrific employer right now,” said one Whitby social programming worker. “They have no interest in managing people or paying them properly.” changes or our pay package, the In London, it’s the overtime that tells the tale. Management at St. Joseph’s Health Care, London, has had little luck in attracting and retaining professional staff has always staff. Every single day, in every program, two or three people have to work shown flexibility overtime to maintain proper staffing levels. in adapting to “Can you imagine how expensive that is?” said one London employee. change quickly, Registered nurses still earn $8 to $9 less than their counterparts in other with the care of hospitals and registered practical nurses earn $3 to $5 below other rates. the patients “This Employer’s attitude is just terrible. They act like a heartless corporation driving them.” instead of a nurturing health organization. In two years, we’ve had 300 “We’re only still grievances filed.” here because we Hospitals are having difficulty hiring and retain psychiatrists. St. Joseph’s like the work we Health Care in London has dealt with the shortage of psychiatrists by hooking do.” up to a provincially funded tele-conferencing program. A patient sits in front of a TV camera linked up to a psychiatrist in another city. “These patients are delusional or paranoid, for heaven’s sake,” said one nurse. “The psychiatrist doesn’t even know where to look. It’s supposed to be cost- effective. It may be a solution to the lack of psychiatrists, but it’s no good for the patient.” Mental health staff tend to be concerned and caring, explained a PACT team member from North Bay, who works with the mentally ill in the community. “We’ve endured a restructuring that’s been going on for some time now. Regardless of funding, of budget cuts, programming changes or our pay package, the staff has always shown flexibility in adapting to change quickly, with the care of the patients driving them.” Added another: “We’re only still here because we like the work we do.” 28 Chapter 1: The Health Services Restructuring Commission

In March 1996, the Health Services Restructuring Commission (HSRC) was established by the Ontario Conservative government to undertake “the process of hospital restructuring and to advise the government on other changes needed to improve the accessibility, quality and cost-effectiveness of the health and health care services provided to the people of Ontario.”34 Six years later, most Ontarians would give the HSRC a failing grade. In fact, for most Ontarians, so-called hospital reforms have left their communities without needed services, replaced their neighbourhood hospitals with faceless megacorporations and forced patients to endure unconscionable waits for treatment. Most Ontarians would give the But hospital restructuring was not the only mandate of the HSRC. In April Health Services 1998, the Commission issued Change and Transition, its planning guidelines and implementation strategies for a whole range of other health care services.35 Restructuring Commission a In a refreshingly frank admission, the HSRC begins the document by expressing its underlying rationale: failing grade. “The concern that hospital restructuring might result in the reduction of hospital services without the concurrent enhancement of other alternative and appropriate health services was the primary catalyst for the development of this report.” The report goes on to outline some of the policy areas which need to be addressed as part of the health system reform agenda – areas such as the allocation of resources, the development of common assessment tools, the adoption of an appropriate funding mechanism and the need for transitional funding – all areas, we note, that have not been resolved to this very day. 34 A Message from the Chair, Looking Back, The Planning and Reinvestment Guidelines for Mental Health outlined in Looking Forward – A Change and Transition recognize that there is a great deal of regional variation Legacy Report, HSRC, in the use of mental health beds. And just as significantly, that there is a March 2000 tremendous variation across the province in community supports used by 35 Change and Transition, consumers – supports such as case management, crisis response, supportive Planning Guidelines and Implementation Strategies housing, outpatient services, social rehabilitation, vocational, educational and for Home Care, Long recreational programs, consumer/survivor initiatives, and employment Term Care, Mental Health, opportunities. Rehabilitation, and Sub- Acute Care. HSRC. April 1998 29 But it was not a good time to raise the need for an increase in and a more equitable distribution of mental health community supports. Since their election in 1995, the Conservatives had been cutting programs, slashing the civil service, waging war on the public sector and proclaiming their ideology of less government. It is within this context that the HSRC heard about other severe gaps in the mental heath field: • There was simply not enough money to fund the current mental health It was not a system and certainly not enough to meet future demands. good time to • There was very little information about what kind and level of community raise the need services were needed to help consumers live independently in the for an increase community. in and a more • Notwithstanding that lack of information, there was an obvious and equitable desperate need for transitional funding to establish a critical mass of distribution of community resources prior to closing acute or longer-term psychiatric beds. mental health • There seemed to be no recognition of different needs based on age or sex or community socio-economic status or culture or region. supports. • There was a serious lack of beds and services for forensic, psychogeriatric, dual diagnosis and concurrent disorders clients. In the eyes of the HSRC, many of these needs and gaps could be dealt with most effectively by Mental Health Agencies, “transitional structures responsible for the planning, co-ordination and funding of mental health services in a number of regions.”36 This concept of a central entity, which would help manage the transition from institutional to community care, was consistent with recommendations made by the Health Systems Research Group at the Clarke Institute of Psychiatry.37 In addition to the creation of some form of a Mental Health Agency, the HSRC reiterated its planned bed targets but recommended that these targets be applied ONLY when and if:38 • psychiatric beds divested from provincial hospitals were fully resourced in terms of appropriate funding to cover staffing and services/programs • investments were made in the community prior to bed closures • there was enough flexibility to re-examine benchmarks to reflect changes in population, demands on the system, and results of evaluations • there was enough flexibility to adjust mental health beds in accordance with 36 Ibid, p.57 local needs 37 Health Services Research Group of the • local health planning be respected and communities be allowed to develop Clarke Institute of plans to meet their own particular demands Psychiatry, Best Practices in Mental Health Reform: Where did all these research studies and calculations and planning and Discussion Paper, recommendations go? Exactly nowhere. In fact, so frustrated was the HSRC November 1997. with the government’s response that less than a year later, the Commission 38 Change and Transition, issued another planning document for the restructuring of mental health p.59 services in Ontario. 30 Advice to the Minister of Health on Building A Community Mental Health System in Ontario39 was the Commission’s second attempt to kick-start mental health reform. Once again, the document begins with a frank admission. According to the HSRC, “The slow progress in implementing the restructuring of provincial psychiatric hospitals (PPHs) in Ontario has been identified as a key barrier prohibiting progress of hospitals, as well as broader health system reform.”40 Why is progress in mental health reform so slow? The HSRC puts it this way: “There are concerns that the problems resulting from the deinstitutionalization of individuals with mental illnesses/disorders in the early 1970s will be repeated. In addition, there is a need to ensure that monies saved from bed reductions are actually redirected to the development of essential community programs.”41 Well that, at least, is right on the mark. Ontario already had an experience with the deinstitutionalization of people with mental illness. The experience was more of an experiment and the experiment was a failure. The Liberal government at the time, despite a booming economy, chose not to invest in the necessary community supports. And hundreds of people with mental illness ended up as re-admissions to the psychiatric hospitals or on the streets. This time, mirroring earlier concerns, the HSRC urged restructuring be based Ontario already 42 on the following assumptions: had an • The proposed hospital bed targets are achievable once the appropriate experience with community services and supports are in place to reduce reliance on the institutional care (especially PPHs) and dramatically reduce the need for deinstitutional- hospital-based treatment services. ization of people • Up front transitional funding must be made available for the development with mental of community mental health services to support downsizing of regional PPH facilities. This investment would be in addition to the current Ministry illness. The of Health expenditures on mental health. experience was more of an • Primary and secondary services should be decentralized to ensure accessibility. Only the specialized tertiary services should be consolidated experiment and in a ‘regional’ centre to ensure a ‘critical mass’ of patients and providers. the experiment was a failure. • Provincial policies/guidelines are essential to ensure a level of consistency among the various regions, sharing of best practices, and the availability of a comprehensive range of mental health services in all regions of the province. 39 Health Services These assumptions are well meaning but surely naïve when it comes to issues Restructuring Commission, Advice to the Minister of of funding. This is the same Conservative government that cut welfare by 21 Health on Building a per cent in its first year in office. That placed unprecedented barriers in front of Community Mental Health people eligible for Ontario Disability Support Programs. That refused to raise System in Ontario, the minimum wage. That repealed rent controls. That cancelled the construction February 26, 1999 40 of 17,000 social housing units. That took hundreds of millions of dollars out of ibid, p1 41 ibid, p3. hospital budgets. That caused the layoffs of thousands of nurses. That starved 42 Ibid, p. 2 Community Care Access Centres. 31 This is the same Conservative government that has downloaded as much of its It is alarming regulatory and funding responsibility as possible – in transportation, in public that the transit, in housing, in the environment, in employment, in health and safety, in municipal infrastructure. And its unrelenting press to effect ‘efficiencies’ in Commission health care has meant that the cost and care which hospitals once provided are never faced up to now being downloaded onto consumers and financially strapped community the government’s providers. record with any All of this must have been obvious to the Health Services Restructuring honesty or Commission. And it is alarming that the Commission never faced up to the realism. government’s record with any honesty or realism. But the problems with the HSRC go deeper. In an interesting article by Glouberman and Zimmerman, Complicated and Complex Systems: What Would Successful Reform of Medicare Look Like?43 the authors examine why many traditional attempts to change the health care system have failed. They argue that most of these approaches suffer from a narrow understanding of the nature and role of health care systems and, as a result, the potential consequences of interventions are never properly considered. The authors contend that many health care experts describe complex problems as merely complicated ones which can then be solved by a better formula, or better coordination, or better expertise, or better practices. To use the authors’ analogy – it’s as if they’re in the business of sending a rocket to the moon when they’re really in the business of raising a child. Sending a rocket to the moon is a complicated endeavour but once you’ve figured out the right series of coordinated steps, you can follow those steps to do it right over and over again. But you can’t raise a child successfully by resorting to a formula, or by relying on what used to work best, or by treating one child the same as the other. None of these kinds of magic bullets work in complex situations and nowhere has that been more evident than in the interventions by the Health Services Restructuring Commission. For example, the HSRC methodically followed a step-by-step recipe for change:44 Step 1: Determine net expenses Step 2: Calculate program and related transfers 43 Sholom Glouberman, Step 3: Calculate clinical efficiency savings PhD. And Brenda Zimmerman, PhD., Step 4: Determine support service efficiencies Complicated and Complex Step 5: Re-allocate other expenses Systems: What Would Step 6: Calculate site closure savings Successful Reform of Step 7: Determine administrative efficiencies Medicare Look Like? Step 8: Add back selected expenses February 4, 2002 (draft only) Step 9: Establish the cost of the reconfigured system 44 HSRC, GTA/905 Health Here’s what the authors of Complicated and Complex Systems thought of that Services Restructuring type of planning45: Report, Appendix I, 1997 45 Complicated and “The methodology of the Health Services Restructuring Commission in Complex Systems, op. cit., Ontario (HSRC 1997) offers an excellent example of how planning is p. 14 viewed as a complicated problem … The methodology, though 32 complicated, must ignore significant features of health care systems such as the cultural role of a hospital. One can also see a clear linear flow from one step to the next. Each step is an event, either data gathering or a decision … The implicit assumption is that feedback loops will be at most a minor irritation, but if one sticks to the plan, the process will unfold as envisioned.” Well, nothing unfolded as envisioned. The HSRC faithfully applied its methodology and determined that hospitals – for example, the Montfort in Ottawa, or Women’s College and the Wellesley in Toronto – could be closed with little effect on the patients which they served. They didn’t understand the By closing these complex relationships that these hospitals (and dozens of others in Ontario) had general with their neighbourhoods and their communities of interest. By closing these hospitals, the general hospitals, the HSRC undermined the security and comfort of whole HSRC communities – of women, of francophones, of gays, of inner city poor. And provoked expensive political and legal battles all across Ontario. undermined the security and Here’s another example: hospital emergency departments. The HSRC, as part of its ‘efficiency’ mandate, recommended closing some emergency rooms in comfort of urban and non-urban hospitals. They had determined that there was a surplus in whole emergency room beds and, as a result, the effect on the health care system communities – would be minimal. They couldn’t have been more wrong. Pretty soon, there of women, of were unprecedented numbers of patients lined up in emergency waiting rooms. francophones, The government was forced to pour more money into ER departments at the of gays, of inner expense of other, less urgent services. A vicious cycle was the result46. city poor.

The Vicious Cycle in ERs

Increased pressure on urgent access

Less funding More resources for non-urgent needed for social support urgent services

Money must come from other services

The truth is that if you push patients out the door and severely underfund community care and cut back on social services and cut funding to health care agencies and stop building affordable housing and ignore workplace health and safety – then the money poured into emergency rooms won’t have much effect on the number of people whose health is at risk and whose only recourse is to 46 Ibid, p.13 33 walk into an emergency department. And why those connections weren’t obvious to the HSRC is a mystery to many Ontarians. Even the HSRC’s much-touted cost savings proved an illusion. The HSRC reasoned that the closure and merger of general hospitals would save hundreds of millions of dollars on operational expenses. But the HSRC never took into account (not even in their short-term calculations) the huge costs associated with closures and mergers – the hundreds of millions of dollars that had to be spent on severance packages, buyouts, capital costs, legal battles, labour ‘harmonization’. We note that no one is talking about cost savings in health care anymore. Patients with mental illness, Again, Complicated and Complex Systems sums up the situation neatly. And although the authors are talking about changes made across Canada, their caregivers, analysis describes perfectly the damage done by the Conservative government families, mental and the HSRC in the province of Ontario: health workers “Because many parts of our health care system interact, large-scale, are now subject complicated interventions can destabilize the entire system with chaotic to the same kind results. In Canada, the health care system has undergone constant of large-scale economic and structural changes for the last 10 years. At the end of this interventions period, everyone is unhappy AND costs are no better contained. that have Complicated repairs have not worked and they have destabilized the destabilized system. They have weakened relationships, and Canadians – both providers and recipients of health care – have lost faith that the general health espoused principles or values of the Canada Health Act will be adhered care. As to.”47 predicted, chaos All of this is terribly relevant to our mental health system. Patients with mental is the result, illness, caregivers, families, mental health workers are now subject to the same dissatisfaction kind of large-scale, complicated interventions – both structural and economic – and tragedy the that have destabilized the provision of general health care in the past. And, as legacy. predicted, chaos is the result, dissatisfaction and tragedy the legacy. The HSRC has finished its term but its mental health proxies – the government- appointed Mental Health Implementation Task Forces – live on.

47 Ibid, p. 30 34 Chapter 2: Mental Health Implementation Task 6orces

We now know (from the document Advice to the Minister of Health on Building A Community Mental Health System), that the HSRC viewed the very existence of Provincial Psychiatric Hospitals as impediments to the restructuring of the health care system province-wide. The Commission’s frustration with the Ministry permeates the document and the result is a strongly worded series of strategies and recommendations for divesting The HSRC Provincial Psychiatric Hospitals (PPHs) to other community organizations, including public hospitals.48 viewed the very existence of Essential to the plan was the idea of creating a local leadership which could restore confidence in the process of reform and get things moving. And so, the Provincial HSRC urged the Minister to establish nine Mental Health Implementation Task Psychiatric Forces (MHITF), whose proposed regions of responsibility would correspond Hospitals as to the catchment areas of existing Provincial Psychiatric Hospitals. impediments to On March 12, 1999, the Minister of Health formally accepted the advice of the the HSRC regarding the establishment of Mental Health Implementation Task restructuring of Forces. Their roles and responsibilities were outlined in the terms of the health care 49 reference. In summary, the MHITFs were to: system province- • develop a regional mental health service system wide. • enhance current community service capacity • restructure the Provincial Psychiatric Hospital system. The savings related to inpatient restructuring will be retained by the Ministry, for reallocation throughout the province to support mental health reform 48 HSRC, Advice to the Minister of Health, op.cit. • develop a continuum of services and supports for the severely Feb 26, 1999, p. 3 mentally ill. These services must be in place before PPH restructuring 49 Ministry of Health, takes place. Mental Health Implementation Task So anxious was the HSRC to get these Task Forces off the ground that it Force, Terms of actually recommended to the government, in an astonishing display of Reference. 1999 micromanagement, the composition of each Task Force.50 In the end, the 50 HSRC, Advice to the MHITF Terms of Reference outlined an expanded core membership which Minister of Health, op.cit. included representatives from:51 Feb 26, 1999, p. 8 51 Ministry of Health, • Provincial Psychiatric (1) and other hospitals (2) Mental Health • Consumers (2) and Family members (2) Implementation Task Force, Terms of • Community agencies (2) and CCAC (1) Reference. 1999s 35 • Community Physician/Psychiatrist (1) • District Health Council(s): number will depend on the DHCs in the region • Local/Regional Business (1) and Education (1) • Ministry of Health and MCSS (ex-officio) (2) This is a long list with, predictably, room for a business representative. Yet nowhere in the personnel of these Task Forces does there seem to be room for even one front line mental health worker. For even one OPSEU member. For even one elected OPSEU local President. Notwithstanding the fact that Political thousands of OPSEU members work with consumers and clients every hour of the day. It is nothing short of contemptuous of the contribution that OPSEU appointments members make and the experience, knowledge, understanding and real have only meant expertise they have. that everything Of course, Conservatives are also well represented. The co-chairs of the has been Provincial Forum of the Mental Health Implementation Task Forces are none shrouded in other than Michael Wilson and Peter Birnie – two well known Conservative collegial secrecy. party members and friends of the former Premier, Mike Harris. In fact, according to local OPSEU members, there are an astonishing number of Conservative Party members or supporters on each of the Task Forces. And even though patronage is nothing new to the Conservative government, it really calls into question the integrity of the process and the real value of Task Force recommendations. We could always take the optimistic view that having Conservatives on the Task Forces might make the government more open to their ideas. But so far, the political appointments have only meant that everything has been shrouded in collegial secrecy. Every single member appointed to the MHITF, and to its committees, has to swear an oath of confidentiality – even though this Task Force is supposed to be a consultation, a public debate about public policy, about the needs of people with mental illness and the resources that must be made available to them if they are to live a decent and fulfilling life in the community. Has a continuum of services and supports been developed? Has funding been made available for reinvestment, and specifically for former PPH clients who now must attend general hospitals or community agencies? Has current community service capacity been enhanced? Were services in place before PPH restructuring occurred? All these questions flow from the Task Force mandate but it’s not clear where to find any of the answers, never mind what the answers are. Nor is it clear where, when and by whom decisions are being made. Some documents are now public though mainly through the auspices of the District Health Councils. And even that source is uneven in its quantity and quality. So the question has to be asked: Why are Task Force reports, studies, assessments and proposals so difficult to obtain? Why isn’t it all routinely posted on the internet? The Ministry of Health MHITF web pages are virtually devoid of any substance, focusing mostly on the biographies of the MHITF Chairs. Where is the openness of this process? Why should it be so difficult for Ontarians to get information and comment on the direction of mental health 36 reform? Using the vernacular of the government itself: Isn’t our taxpayer money paying for these Task Forces? In any case, much of the material made public by the Task Forces seems focused on governance and system issues as if the institutional needs of ‘system reform’ were of overarching concern. Entire papers deal with the concept of a ‘Lead Agency,’ of building a ‘district and regional system,’ of delineating ‘system components,’ of highlighting ‘system-level strengths,’52 of establishing a ‘systems navigator,’ of creating a new ‘consolidated agency.’53 It’s not as if these things aren’t important. But you can get the impression that the Task Forces have spent far more time and energy developing constructs around building a ‘system’ than they have in making sure that consumers have what they need to integrate successfully into the community. Perhaps if the Task Forces had had fewer management people and ‘experts,’ and more front line The framework workers on their committees, the focus would have been different and, we say, more appropriate. is flawed, the goals are Finally, the whole process seems to us completely disorganized. Although bureaucratic some Task Forces have been around for a couple of years, others were established much more recently. But the timelines seem to be the same for all. and ambiguous, And even though the Task Force mandate includes advising the government on the time allowed the divestment of Provincial Psychiatric Hospitals to public hospitals for the work is (essentially the transfer of governance, funding and autonomy), many of the rushed and the PPHs were divested long before the Task Forces had been established. process is not Here’s another example. MHITFs have a responsibility to make sure that inclusive. people with serious mental illness have the community supports they need when they are discharged from the Provincial Psychiatric Hospital. That’s why Comprehensive Assessment Projects (patient assessments internal to the Psychiatric Hospitals) and Comprehensive Community Assessment Projects (service assessments done with the assistance of community agencies) are so important. But according to our information, some Task Forces have no intention of doing the community assessments because they are so rushed for time. Similarly, some Task Forces have held public consultations; others say they have more important things to do. In Toronto, a newly formed coalition of consumers, ex-consumers and front line mental health workers spoke out about the process. This was their 52 Northeast Mental Health evaluation: Implementation Task Force, Northeast Mental “The framework is flawed, the goals are bureaucratic and ambiguous, Health System and the the time allowed for the work is rushed and the process is not Lead Agency Concept. inclusive.”54 February 2001 53 Champlain District That sounds about right. But enough about process. It’s time to talk about some Mental Health of the substantive issues that have been raised. Implementation Task Force, Foundations for Reform, 2001 54 Concerned About Reforming Mental Health Accessibility (CARMHA) as quoted in EYE, January 3, 2002. p. 3 37 Chapter 3: 6unding

To hear the Conservative government tell it, they’ve been pouring money into community mental health since 1995. Barely a press release is issued without including a lengthy backgrounder outlining government ‘investments,’ ‘mental health initiatives’ and ‘funding announcements’ for community programs We think the across the province. HSRC Of course, every media release repeats the government’s commitment to consistently provide adequate funding for community mental health services before underestimate restructuring begins. the level and “We are committed to ensuring that the appropriate mental health duration of care services are in place for all Ontarians,” said Health Minister Witmer … required by “Our government has already taken important first steps to enhance our severely community-based mental health services … The initiatives announced today will further strengthen our mental health system to ensure that mentally ill adequate community and general hospital services are in place before people living in any restructuring is made to our provincial psychiatric hospitals.”55 today’s Ontario. This commitment echoed the recommendations made by the Health Services Restructuring Commission’s Change and Transition56 in April 1998 and by Conservative MPP Dan Newman in his June 1998 report 2000 and Beyond.

55 Ministry of Health, “All groups expressed the view that funding is critical to implementing News Release, mental health reform. I hear during my consultations that transitional “Government Takes Steps funding was necessary during implementation of reform. More specific, To Enhance Access To funding for community supports and services is vital, and must be Mental Health Services.” 57 June 3, 1998 ensured.” 56 Change and Transition, Several months later in early 1999, the HSRC expressed the same concerns.58 op.cit. p. 59 But this time, the Commission attached an estimate of the money required for 57 Dan Newman, MPP, Parliamentary Assistant to transitional funding and the costs of core community services. At this point, the Minister of Health, we’re not going to take issue with the specific assumptions, estimates and 2000 and Beyond: statistical manipulations of the HSRC. Suffice to say that we think they Strengthening Ontario’s consistently underestimate the level and duration of care required by severely Mental Health System. A mentally ill people living in today’s Ontario. Report on the Consultative Review of Mental Health Perhaps if there were any affordable housing, a decent level of social assistance, Reform in the Province of a much higher minimum wage, no user fees attached to recreation programs, Ontario. June 1998. p. 8 58 Advice to the Minister, sufficient funding for mental health agencies, accessible emergency rooms, op.cit. p.3. neighbourhood hospitals, willing and trained family practitioners, subsidies for 38 public transit, available transportation, properly staffed long term care facilities, and properly funded CCACs – perhaps if all these things existed, then the HSRC assumptions and estimations would have validity. But don’t take our word for it. This is what the OHA thought about the HSRC’s cost assumptions: 59 “Successful implementation of the shift to more community-based care has been elusive because of the complexity of mental illness and the need to ensure adequacy of both health and social services such as housing and employment … The hospital sector and the medical The Commission profession have both expressed concerns that the cost of delivering figures are more community-based care and integrating it with hospital-based care instructive for people with a chronic condition who may have episodes of acute because they are illness has been underestimated by the provincial government.” the first public Nevertheless, the Commission figures are instructive because they are the first benchmark public benchmark against which Conservative community mental health against which expenditures can be measured. Conservative The HSRC proposed reducing the number of beds in Provincial Psychiatric community Hospitals from 2,900 to 1,767 longer-term mental health beds. By their own calculation, the current (1999) cost of a PPH bed is approximately $100,000 per mental health year and if “all savings from the PPHs [are] reinvested in community mental expenditures health services,”60 that should result in a savings and reinvestment of over $100 can be million dollars. measured. Nevertheless, the HSRC calculated that a total transitional reinvestment of between $63 and $87 million dollars would be needed.61 That same amount – between $63 and $87 million – is also estimated to be the cost of community care per year. In any case, we note that neither estimate includes any capital costs associated with the construction of supportive housing.62 By December 1999, the Harris government was under attack for its health and 59 Mike Moralis in hospital cutbacks. Suddenly, every press release gave a running total of Hospital Perspectives, Challenges still remain in government ‘reinvestment’ in mental health care programs. mental health reform in “We will continue to make planned reinvestments in community mental Hospital Perspectives, health services to build a reformed and responsive mental health OHA, Volume 8, Issue 1, Spring 2000. p. 2 system,” Witmer said. “Including today’s announcement, our 60 ibid. p.6 government has reinvested more than $150 million since 1995 to 61 Advice to the Minister, provide the best possible access to high quality mental health care for op. cit. Appendix 2. p.5 the people of this province.”63 62 ibid. p.6 63 Government of Ontario, By June 2000, the government was claiming that it had invested more than Press Release, Ontario $263 million “to create a modern mental health care system that meets the provides $19.5 M to needs of people in our communities”64 and by June 2001 that amount had enhance mental health care, December 15, 1999. jumped to $375 million. 64 Government of Ontario, And there it stuck. By mid 2002, the Conservative government appears to have Press Release, Ontario decided to allocate its mental health dollars to hospital construction. With the Invests $46.3 million to expand community mental exception of some additional funding for addictions and eating disorders, we health services and could find no announcements related to community mental health. children’s mental health beds. June 22, 2000. 39 That means a full seven years into its term, the Conservative government has spent an average of $55 million dollars a year for community mental health programs, including any funding towards capital costs for supportive housing. This is less than the minimum funding recommended by the HSRC for transitional and core community mental health services – a minimum which, we The say, consistently underestimates the true level of funding required in an environment where important public services have been sorely diminished. government’s annual budget These figures come from the government’s own public announcements. It is papers, public unlikely that they understate the case. accounts data But it’s all very difficult to verify because the government’s annual budget and financial papers, public accounts data and financial statements for mental health funding are virtually impenetrable. In the mid-90s, mental health funding was protected statements for under Ministry of Health policy. And although the overall funding envelope mental health was always too low, at least mental health workers and administrators and funding are managers knew where the money came from and how it was being allocated. virtually That is no longer the case. impenetrable. What has been called the ‘tier one’ divestment of Provincial Psychiatric Hospitals to general hospitals, specialized hospitals and continuing care corporations has meant the dispersion of dedicated funds into global budgets. Moreover, ‘tier two’ contemplates the further divestment of mental health services and bed allocations to smaller hospitals and agencies in other communities. This makes it almost impossible to ‘follow the money’. For some hospital administrators, that’s not an issue. Integration of mental health into general hospitals is a worthy end in itself. In the OHA publication, Hospital Perspectives, David MacKinnon, OHA President and CEO says: “We agree with the government that services for mental health should be integrated and normalized within the health care system, not kept in isolation.”65 His views are echoed by Cliff Nordal, CEO of St. Joseph’s Health Care, London: “By incorporating mental health into the public hospital system, 65 David MacKinnon, hospitals can be good advocates for patients with mental illness, help quoted in Hospital Perspectives, Divestment enhance the understanding of mental health services and reintegrate of Ontario’s Public these services fully into the community.”66 Psychiatric Hospitals key to mental health in Who can argue with advocacy and normalization – although we’d be surprised Hospital Perspectives, if these high-powered CEOs weren’t enthusiastic about the prospect of OHA, Volume 8, Issue 1, expanding their hospital empires with the transfer of PPH beds, money, Spring 2000. p. 1 programs and staff. But there’s more to caring for people with mental illness 66 ibid. p.2 than worthy ends. 67 Ministry of Health, (Draft) Making It Happen: The consumers who show up in emergency rooms of general hospitals have a Operational Framework for serious mental illness and/or are experiencing acute recurrence of their illness. the Delivery of Mental Health Services and According to Making It Happen: The Operational Framework, the Ministry of Supports. Mental Health Health’s framework for the delivery of mental health services, these are the core System Management services that should be available at the designated general hospitals:67 Division. February, 1999 40 • Emergency Services, including crisis response services on a 24-hour/7-day- a-week basis including the availability of a psychiatrist for assessment and 24-hour backup for the crisis teams by the emergency room • Intensive Services, especially Short Term In-Patient Assessment/Holding Beds providing crisis access to a bed for up to 72 hours, including assessment services and preferably located in or near the emergency department or psychiatric unit • Assessment, Stabilization and Short-Term Inpatient Treatment to confine, closely observe and treat people whose behaviour is disruptive or difficult to manage and secure beds for patients who are experiencing period of acute disturbance But by the end of 2002, general hospitals are still not up to the task. OPSEU members talk about consumers in crisis who can’t get the help they need in hospital emergency rooms because there is no psychiatrist available. Who spend hours being guarded by security personnel as if they were criminals. Who feel stigmatized and isolated because the nursing staff don’t have the experience or compassion or time to help them out. Who get taken to jail by impatient police officers who can’t wait forever in the emergency department. Who get medicated and discharged out onto the street because there are no available beds. It’s not just the money that gets lost when psychiatric beds are transferred to general hospitals. We can’t deny that the Conservative gtovernment is spending money on mental health, although it’s only a fraction of the overall health budget. And we know that the government is spending money on community mental health although it’s only a fraction of the overall mental health budget. But surely we shouldn’t It’s not just the have to fight our way through layers of confusion and concealment to get an money that gets accurate picture of the current financial state in mental health. Surely, it’s our lost when right to assess whether the Tories have been following through on their psychiatric beds commitment to reinvestment in the mental health care system. are transferred We have reason to worry. to general In her paper Health Spending in Ontario: Bleeding our Hospitals68, Sheila hospitals. Block convincingly puts to rest persistent Conservative myths about the ‘out- of-control’ cost of publicly-funded health care. The document is worth reading for all the points it makes. But for our purposes, the following points stand out: • When you control for both population growth and inflation, real spending on healthcare per person increased only $50 per year over the last seven years. • Moreover, health care spending as a proportion of the province’s GDP has 68 Sheila Block, Health moved over a very narrow range, between 5.3 and 6.3 per cent of GDP Spending in Ontario: since 1993. This shows that provincial health spending is not taking up an Bleeding our Hospitals, Technical Paper #4, The increasing share of the province’s resources. Ontario AlteRegistered • Ministry transfers to hospitals show dramatic swings in funding from one Nurse (RN)ative Budget. year to the next. These abrupt shifts reflect a number of ill-conceived and Canadian Centre for unsuccessful policy experiments. Some of the costs associated with these Policy AlteRegistered swings in funding include layoffs and rehires, closures and re-opening of Nurse (RN)atives, May 2002. beds. 41 • Since 1997-98, the province has spent vast sums of money on the costs associated with restructuring. This includes spending money on severance costs, benefit costs for terminated employees, consulting and auditing costs, As front line renovation costs. mental health • Fully 51 per cent of the increase in hospital spending between 1997-98 and 2000-01 is accounted for by costs associated with restructuring. workers, we know that These conclusions are deeply instructive. We can’t help suspecting that if the consumers are same analysis were applied to mental health funding, the same results would obtain. After all, we’ve been part of the great restructuring movement. And it’s not on their not over yet. radar screen. Most of the Provincial Psychiatric Hospitals have been divested in time- It’s time to get consuming exercises that seemed more like hostile takeovers. Our union has back to the had to engage in representation votes and expensive negotiations around the priorities that ‘harmonization’ of contracts. We can’t begin to imagine how much has been matter. spent on consultants. The to-ing and fro-ing around lead agencies or mental health authorities or networks and alliances would probably fund several community mental health programs. Huge amounts of money have been injected into renovations and brand-new construction when it was never obvious that bricks and mortar were the problem. In the name of ‘efficiencies’ and cost-savings, we’ve had to shut down programs or curtail their length so that waiting lists are worse than ever. This isn’t client focused. The Health Services Restructuring Commission and the Mental Health Implementation Task Forces have made sure of that, notwithstanding the pious platitudes they feel compelled to utter from time to time. As front line mental health workers, we know that consumers are not on their radar screen. It’s time to get back to the priorities that matter.

42 Chapter 4: A Home, a Government 6riend, a Job policies that aim to contribute to 69 The 1974 Lalonde Report, A New Perspective on the Health of Canadians health have to marked a turning point in Canadian health policy. It introduced, for the first time to Canada, the idea that health was a complex concept that went beyond include medical care and traditional public health measures. In other words, there were everything from major contributors to, or determinants of, health. housing policy, This expanded notion of health resulted in the emergence of health promotion to accessibility as an instrument of government policy in Canada70. The early versions to education, to concentrated on ‘healthy behaviours.’ Simply put, people could (and should) employment assume more responsibility for their own health by changing their lifestyle. Out conditions. of this came publicly funded anti-smoking and anti-drinking campaigns, the need for exercise, seatbelt use and healthier diets – all of which endure to this very day. But the focus on lifestyle quickly gave way to a deeper appreciation for the importance of socio-economic factors. 69 Marc Lalonde. A New Perspective on the Health 71 In a relatively recent document , Nickoloff suggested that there are at least 12 of Canadians: A Working critical determinants of health. These include income and social status, social Document. Supply and support networks, education, employment and working practices, healthy child Services Canada. Ottawa, development, biology and genetic endowment, health services, gender and 1974 70 Much of this material culture. Her conclusion is pretty straightforward: if government policy has comes from Sholom health improvement as its goal, then it must better balance its expenditures. Glouberman, PhD. Why is this relevant? Because this Conservative government has spent a great Towards a New Perspective on Health and deal of time and money trying to ‘fix’ mental health by looking at health issues, Health Policy. A Synthesis creating health targets, measuring health outcomes, changing health Document of the Health interventions. But that’s not going to be enough. You need to improve social Network, Canadian Policy and economic conditions to improve the health of the population. That’s what Research Networks. the research shows, overwhelmingly. Government policies that aim to January 2001. 71 Nickoloff and Health contribute to health have to include everything from housing policy, to Canada, Towards a accessibility to education, to employment conditions. Common Understanding: Clarifying the Core That’s essentially what people with mental illness told us themselves, albeit in Concepts of Population a simpler fashion. Health, Ottawa, 1996 72 A home, a friend, a job. Grand River District Health Council, a home, a In its annual review of mental health programs, the District Health Council of friend, a job: A Functional Grand River asked people with mental illness and their families about mental Review of the Community 72 Mental Health Programs in health services. This is what they had to say: the Grand River District. February 2002 43 “If the goal is quality of life then basic needs have to be met: food, shelter, clothing and having enough money to live on. The opportunity to make friends and spend time together.”73 Sure, they talked about health needs that had to be met. The need for psychiatrists, family doctors, trained psychiatric workers. The need for day programs, better access to tertiary beds and better discharge planning. But all of that came second to social and economic needs. Supportive, affordable housing, improved transportation, better public education, and meaningful daily activities. 6or the severely The Conservative government’s record on all these areas is simply dismal. And mentally ill, in economic good times, simply inexcusable. good housing Housing can make the difference For the severely mentally ill, good housing can make the difference between between living living successfully in the community or needing to be hospitalized. Affordable housing can make the difference between being housed or being homeless. successfully in the community That’s what OPSEU mental health workers have been saying for the last or needing to be decade. As the housing market shrinks, they’ve had to spend increasingly more time trying to locate safe, clean and affordable homes. hospitalized. But rent controls no longer exist and affordable apartments are almost impossible to find. If you add to that the stigma of mental illness and the inability of paying first and last months’ rent, it is very difficult for consumers to find and keep a home. “The result has been an increasing number of homeless people with mental illness, families and friends ‘stretched and distressed to the limit,’ large numbers of people with mental illness languishing in jail and many others living in substandard housing or receiving their care in poorly-funded group home settings.”74 The HSRC realized the seriousness of the situation and in Change and Transition, (1998)75 it recommended: “As access to safe and affordable housing is essential to maintaining clients in the community, the role of the ‘domhostel’ program and other support programs funded by the Ministry of Community and Social 73 Ibid, p. 20 74 Canadian Association Services and other government ministries should be reviewed. This for Mental Health. A Call review should be initiated by the Ministry of Health as part of the For Action, 2000 overall reform of the mental health system.” 75 Health Services Restructuring In 1999, the Mayor of Toronto’s Homelessness Action Task Force issued its Commission, Change and report Taking Responsibility for Homelessness76 (more commonly known as Transition, op.cit. p. 60 The Golden Report.) This 294-page opus has become the definitive word on 76 Report of the Mayor’s homelessness, shelters and social housing and, as such, deserves considerable Homelessness Action Task mention. Although it speaks to the situation in Toronto (and the statistics are Force, Taking Responsibility for naturally different elsewhere in the province), the nature of the problem could Homelessness, Golden, easily be applied to any part of Ontario: Currie, Greaves, Latimer. January 1999 • The number of homeless people is on the rise 44 • More people are living on the streets and using shelters • The pressure on food banks and other emergency services is constantly increasing • There are close to 3,000 evictions a month in Ontario and rising • The waiting list for social and supportive housing continues to get longer The Conservative government has painted a picture of shelters filled with single, male alcoholics, sexually promiscuous runaways and consumers. Presumably, all these people ‘have chosen’ to live rough. But The Golden Report and Pathways into Homelessness, a project conducted by the Centre for Addiction and Mental Health,77 outlined the real dimensions of the problem:78 Between 30 and 35 per cent of • The fastest-growing groups of hostel users are youth under 18 and families with children. Families accounted for 46 per cent of the people homeless people using hostels in Toronto in 1996. – 75 per cent of homeless single • Between 30 and 35 per cent of homeless people suffer from mental illness. The estimates are higher for some population groups; for women – suffer example, 75 per cent of homeless single women suffer from mental from mental illness. illness. • More than 100,000 people are on the waiting list for social housing in Toronto • Poverty is getting worse among the applicants for social housing; more than one third of the people on the waiting list have incomes of less than $800 a month. The Task Force identified major barriers that have prevented effective solutions:

• Dramatically increasing poverty • Decreasing supply of low-cost rental housing. • A bias towards emergency shelters • Inadequate community programs and supports for people with 77 serious mental illness and addiction problems George Tolomiczenko, MPH, PhD and Paula In order to alleviate the problem – in Toronto alone – the Task Force Goering, RN, PhD, recommended the addition of at least 5,000 supported housing units, a supply “Pathways into of at least 2,000 new affordable rental apartments, strict controls on existing Homelessness: Broadening the affordable housing so that none is lost, and a percentage of hostel budgets Perspective” in Psychiatry allocated to purchase support services. Rounds, Department of Psychiatry, University of The Conservative government refused to participate in the Golden Task Force Toronto, Health Systems and, ever contemptuous of opposing views, set up their own Provincial Task Research Unit, Clarke Force on Homelessness, comprised solely of Tory MPPs and chaired by Jack Division, CAMH. Carroll, the Conservative MPP for Chatham-Kent. November/December 1998. The Report79 is predictably self-serving, laying the blame and responsibility for 78 ibid. p. iv ff. homelessness on the homeless themselves, on municipalities and on the federal 79 Report of the Provincial government. In contrast, the provincial government is congratulated on its level Task Force on of funding and innovative policy initiatives. Homelessness. Carroll, Gilchrist, Brown and Newman, October 1998 45 The Conservative Task Force recommendations place the burden of relieving homelessness squarely on the shoulders of the municipalities, the school system, Childrens’ Aid Societies, hospitals and correctional facilities. The only new provincial responsibility recommended by the Task Force is to fund domiciliary hostels, a preliminary recommendation that the government On a regular accepted and announced in June 1998. basis, consumers A year later in November 2000, the Conservative government announced are forced to funding of $67.6 million for 2,600 immediate and long term housing units. The choose between funding included $29.7 million in operating grants to non-profit agencies to paying their rent lease housing units and provide support services, as well as $37.9 million in capital grants to purchase units.80 A month later, the government announced $26 and feeding million to increase funding for homeless shelters and other initiatives including themselves. programs for people with special needs related to mental health. The Government announced 2,600 units of supportive housing across the province when at least 5,000 units are needed in Toronto alone. By anyone’s standards, it didn’t begin to meet the needs of people with mental illness. Moreover, supportive housing advocates have complained bitterly that the leasing of housing units is nothing but a boondoggle for private landlords, most of whom charge market rents and get guaranteed payments for substandard accommodation. If the Conservative government were serious about relieving the housing crisis for people with severe mental illness, it need go no further than its own housing studies. Sixteen District Health Councils across Ontario were asked to conduct local research on the housing situation for persons with serious mental illness. The DHCs consulted landlords involved in Non-Profit Municipal Housing, Local Housing Corporations, Residential Housing including Homes for Special Care (HSC) and Domiciliary Hostels (DH), and Emergency Hostels/and Shelters. In addition, consumers and families were consulted through the process of focus groups facilitated by various mental health providers and District Health Council staff. Without exception, no matter where the Council81, the themes around housing for people with mental illness or disabilities remained the same: 80 Government of Ontario, Press Release, Ontario • Rising costs of rent have forced people with mental illness to turn to provides $72 million to subsidized housing for assistance. However, there are wait times of at least help house and support two years for most social housing including supportive housing. people suffering from mental illness. November • Although there has been an increase in the number of supported units, there 22, 2000. is still a crisis in the number of spaces available and no evidence to suggest 81 Summarized from that the crisis in supportive housing will be solved soon. housing studies conducted by the Champlain DHC • There needs to be a continuum of housing options that meet the specific and 2001, Simcoe York DHC changing needs of people with a mental illness. That currently does not 2001, Grand River DHC exist at a scale to provide adequate housing or housing supports to the 2000, Halton DHC 2001, number of people who need them Hamilton DHC 2001, Niagara Region DHC • There is a concomitant need for a range of community supports such as 2002, Peel DHC 2001, occupational therapy, emotional counselling, homecare services, recreation, Southeastern Ontario DHC 2001, Toronto DHC 2001. life skills, vocational rehabilitation and affordable transportation. The lack 46 of mental health supports makes it difficult for consumers to keep or maintain their housing But the first priority – no matter who or where – is for more money and lower rents. In the words of one consumer, “just give me affordable housing…” On a regular basis, consumers are forced to choose between paying their rent and feeding themselves. That says it all. Community mental health supports and services are fine, as far as they go. But they’re not the whole picture. The whole picture (and these consumers paint it so well) has to include the determinants of health. That’s why housing isn’t a side issue. It’s a mental health issue, a recovery issue, an independence issue, a daily living issue. And it’s long past time for the Conservative government to get the message. Employment

On July 25, 2001 Cam Jackson, Ontario Minister of Citizenship with responsibility for disability issues flew to Ottawa to hand out some cheques. In that cheerful, jargon-filled language that government press releases always have, Jackson said: “Building partnerships with community organizations … will help The rate of remove barriers to employment and recognize the contributions persons unemployment with disabilities make to their communities and to this province. for people with Seeking shared solutions that are locally-driven will assist in preventing serious mental the creation of new barriers and allow the disabled community to achieve full citizenship.”82 illness ranges from 75 per Cam Jackson presented grants of $5,000 each to four different organizations that work with consumers – $5,000 to remove barriers to employment, cent to 89 per recognize individual contributions, and allow the disabled community to cent. achieve full citizenship. Now that’s an example of doing more with less. And it illuminates, so clearly, the cheap hypocrisy that we’ve come to expect from the Conservative government when the ideas of employment access and equity are anywhere on the horizon. Does the Minister know (or care) that the rate of unemployment for people with serious mental illness ranges from 75 to 89 per cent?83 And that despite this alarming statistic, his Ministry spends only $200,000 annually on 40 employment support programs and businesses across Ontario?84 We’re sure 82 Government of Ontario, every one of them waits breathlessly for that $5,000 handshake. Press Release, Improving access the goal for Is all this consistent with the Conservative government’s own policy document government grants July 25, Making It Work?85 Making It Work is supposed to be the jobs part of 2001. 83 Government of Ontario, community mental health. It is a program policy framework meant to ensure Making It Work, Policy 86 that employment supports are: Framework for More accessible to consumers across the province employment supports for • people with serious mental • Focused on placing people directly in competitive employment with illness. 1999. p. 1 84 ibid. p. 2 support and training on the job as required 85 86 ibid. p. 2 47 • Fully integrated with other mental health rehabilitation services and supports

• Developing strong linkages with local employers Success of the programs will be measured by:87

• The number of employer contacts made • The number and types of jobs created (full-time, part-time, casual, Structural contract, etc.) reform, • The number of people who actively participate in a program and/or business institutional • The number of people who successfully complete a program governance and • The number of people who are employed as a result of their systemic re- participation in a program or business organization • The number of hours/days/weeks worked have bumped off • The total duration of the job the agenda any All well and good but it’s now nearly four years later. Has there been any real progress? Any success? Any update? Has anyone ever referred to this document considerations or used it since its release? To OPSEU members on the front lines, it is just one that affect the more indication that issues of structural reform, institutional governance and systemic re-organization have bumped off the agenda any real considerations lives of people that affect the lives of people with mental illness. with mental illness. Income It’s not as if jobs aren’t needed. Consumers are desperately poor. The Ontario Disability Support Program (ODSP) is the primary pension for people with disabilities. But the median monthly income for someone receiving ODSP is $914 and, in Toronto, his or her median monthly rent is $450. That means, in Toronto, a person on ODSP has an after-rent-income of $464 per month or $116 a week.88 Believe it or not, people on ODSP are the lucky ones. In the past six years, the provincial government redefined the eligibility criteria for ODSP so as to exclude thousands of people who would otherwise have been able to access the benefits. Not that disability payments are so rich. But they are better than the other forms of social assistance available to people with disabilities. If you’re not getting ODSP, you could be getting Canada Pension, Old Age Security, the Guaranteed Income Supplement or Unemployment Insurance. But the median monthly income of a person in that situation is only $608 and their median monthly rent in Toronto is $425. That leaves $183 per month or $45.75 a week. Ontario Works, the provincial government’s program for social assistance provides the lowest rates of all. In 1995, the Conservative government cut social assistance by 21.6per cent and then froze it at that reduced level. Six 87 ibid. p. 4s 88 Daily Bread Food Bank, years later, the real value of those cuts is 30 per cent. What that means is that in Disabled Benefits, 2001. 2002, if you’re single and eligible for benefits, the maximum you can receive is p. 2 $6,240 per year or $520 per month.89 89 Ibid. p. 3 48 Even if some people with serious mental illness manage to find a job, it’s often paid at minimum wage. The minimum wage in Ontario is $6.85 an hour, a rate that hasn’t changed since 1995. So if you work 40 hours a week, 52 weeks a year, you can look forward to grossing $1,187 a month before taxes. Is going hungry once a week Premier Ernie Eves spends $10,000 a month on clothes and haircuts. But a part of the person with a serious mental illness has to learn to live on 5 to 10 per cent of that a month and pay for rent, food, clothing, personal care items, heat, recovery process electricity, telephone. That’s the poverty gap in technicolour. for people with It’s no wonder that the number of people using food banks in Greater Toronto serious mental has risen astronomically.90 illness? “In 1995, 24 per cent of people using food banks in Greater Toronto had a disability. Over the past six years this number has jumped dramatically to 42 per cent in 2001; 78 per cent of this increase occurring since 1998. When people can not access adequate sources of income, they must turn to food banks for food: since 1995 more and more disabled people at food banks can not access disability benefits provided by the federal and provincial governments. Six years ago, 62.5 per cent of disabled food bank users received disability benefits. By 2001, only 41.6 per cent were receiving benefits. Indeed, survey data reveal that food bank users with disabilities who are not receiving benefits account for over 80 per cent of the increase in the disabled population at food banks. Again, most of this increase has occurred since 1998. So, perhaps the Conservative government can tell us. Is going hungry once a week part of the recovery process for people with serious mental illness? Is having to share a bachelor apartment with three other people the Tory definition of supportive housing? Is not being able to afford public transit the employment supports Making It Work had in mind? And won’t closing PPH beds just make it all worse by putting more consumers into an environment that cannot (and will not) sustain them?

90 Ibid. p. 1 49 Chapter 5: Bed Numbers

On June 3, 1998, Richard Patten, the MPP for Ottawa Centre, asked then Minister of Health Elizabeth Witmer the following question – one of those friendly set-ups that Conservative Members get to ask their Ministerial colleagues: “My question is to the Minister of Health. Minister, you said in your announcement [this morning], ‘The initiatives announced today will further strengthen our mental health system to ensure that adequate community and general hospital services are in place before any restructuring is made to our provincial psychiatric hospitals. We will Even though also be taking additional steps in the months ahead.’ Minister, will you there are long call for a moratorium on any further closures of psychiatric beds in waiting lists and psychiatric hospitals or in general hospitals?” plenty of space, The Honourable Elizabeth Witmer (Minister of Health) replied: Provincial “Yes, this morning I did indeed make an announcement regarding Psychiatric mental health reform … We have committed today to ensure that the Hospitals and appropriate community services and support are going to be there for the receiving those in the community. As you know, we have already placed a hospitals (post moratorium on the closure of psychiatric beds. That moratorium was divestment) imposed by my predecessor, the Honourable Jim Wilson. Until such time as we have the services and the programs that we feel are going to refuse to admit respond to the needs of the individuals in the psychiatric hospitals, there any new or long will be no further closure of those beds.” absent patients. Well, like everything else that’s faintly decent from the Conservative government, this is a promise only half kept, if kept at all. OPSEU members can confirm that beds haven’t been closed in the Provincial Psychiatric Hospitals. But they haven’t been kept open either. Even though there are long waiting lists and plenty of space, Provincial Psychiatric Hospitals (PPHs) and the general hospitals that took over the six former PPHs, refuse to admit any new or long-absent patients. 91 Frank Etherington, Tell that to Beth Skinn whose 20-year old daughter, Teresa, killed herself at her “More resources needed apartment soon after she was twice taken to the Grand River Hospital crisis for mental health clinic by her parents and police. Despite the fact that she was suicidal, Skinn problems”, The 91 Kitchener-Waterloo was not admitted to the Hospital. Record, January 14, 2002 50 Tell that to the family of Barbara Skultety, 49, who killed herself after spending four days in the emergency department at Collingwood Hospital waiting for a bed at Peneganguishene.92 The coroner’s Tell that to the families of Wayne Cutler, 31, Cory Wibberley, 20, and David jury was so Lumgair, 32, all of whom committed suicide while patients at the Grand River upset by the hospital. Inquest jurors heard that Cutler hanged himself the day he was absence of a scheduled to be discharged. They were told Wibberley was in the psychiatric psychiatric ward for 10 days before he killed himself and Lumgair hanged himself in the acute-care unit 93 emergency department while waiting to see a doctor. The coroner’s jury was at Grand River, so upset by the absence of a psychiatric acute-care unit at Grand River, that they recommended a study be done to determine whether the Kitchener- that they Waterloo region needed a Provincial Psychiatric Hospital.94 recommended a The psychiatric hospitals say they can’t keep the beds open because they study to haven’t got the necessary nursing or psychiatric staff. That may or may not be determine so. But the fact remains that people with a serious mental illness, and their whether the families, and mental health workers, all relied on Elizabeth Witmer’s word – Kitchener- that PPH bed complements would remain intact under the promised Waterloo region moratorium until community supports and programs were available ‘to respond needed a to the needs of the individuals in the psychiatric hospitals.’ Well, as far as anyone knows, the moratorium hasn’t been lifted. And as far as everyone Provincial knows, the community services and programs are still not in place. Psychiatric Hospital. So, what’s really going on? Here’s one possible explanation. The Health Services Restructuring Commission proposed closing 1,133 PPH beds by 2003. That would be a reduction of 39 per cent. 95 In the words of the Commission: 92 Roberta Avery, “Jury “The bed targets are intended to serve as a catalyst for shifting the calls for funding for delivery of care to the community and, in so doing, bring about new mental-health facilities: approaches for supporting individuals who have relied primarily on Woman killed herself while waiting for bed in hospital services for treatment and ongoing care. Therefore, Penetanguishene” in The achievement of the bed targets should not be seen as an end point, but Collingwood Connection, rather as a strategy for achieving the overall goal of PPH divestment May 8, 2002 within the context of broader health system reform.” 93 Frances Barrick, “54 steps urged to prevent Are we the only ones who think this quote turns consumers into political suicides. Victims’ families pawns, used by the HSRC to force action on mental health reform? That one like jury proposals; hospital way or another, PPH beds are going to be reduced whether or not the general says it can’t afford them” hospitals or community services are ready? Of course, it’s all so much easier in The Kitchener-Waterloo when you talk about beds and not about people. Because if you talked about Record, February 16, 2002 94 ibid people, then you might have to remember the suicides of Teresa Skinn and 95 Advice to the Minister Barbara Skultety and worry about all the other consumers in crisis who no of Health on Building A longer have a safe place to go to get the professional care they desperately Community Mental need. Health System in Ontario, 1999, op.cit. p. 5 OPSEU members pointed out the difficulties in the HSRC methodology in a 96 OPSEU Locals 111 and systematic and thorough way:96 144, Submission to the HSRC Regarding London “It is our view that the direction [to close London Psychiatric Hospital and St. Thomas and St. Thomas Psychiatric Hospital] is based on an extremely flawed Psychiatric Hospitals, process. 1997 51 The HSRC did not visit the facilities, nor permit oral presentations from our members – the mental health care providers who care for the clients of LPH and STPH. We believe the HSRC’s data and analysis regarding current and future mental health care needs in the Southwest is inaccurate, incomplete and There has been misleading. a decline in the We will present new data to the HSRC that shows the emergency quality of care departments and psychiatric wards of general hospitals are referring received by all many of their patients to our facilities. We are clearly the best equipped consumers and to care for these vulnerable clients and the Schedule 1 agencies know it. nowhere is this The HSRC report does not reflect the full range of services LPH and more evident STPH provide, nor the magnitude of the mental health care needs they respond to. For example, the two facilities serve a combined outpatient than in those population of close to 3,000. who need care and treatment We are flabbergasted that the HSRC chose to ignore the District Health Councils of Southwestern Ontario’s recommendation for one the most. psychiatric hospital to serve the region prior to any decentralization of services.” Sadly, it took the suicides of three men at Grand River Hospital for a coroner’s jury to come to the same conclusion, five years later. Somehow, these bed counts and planned bed targets reflect the worst attributes of the Health Services Restructuring Commission’s methodology. No doubt there is a remarkable sophistication to the statistical models. But, at the same time, there is a mechanistic and linear flavour to it all that seems to ignore the human dimension in all its complexity. There is no appreciation for the nature of the work, the requirement for professional, committed and compassionate relationships, the range of patient pathology and behaviours, the fact that treatment and support needs cannot be easily predicted or planned. There is no consideration given to the existing socio-economic conditions, the impact of current political ideology, the influence of geography, the needs of local communities. In short, there seems little understanding that health and health care is a complex, interactive system, not reducible to simple, or even complicated formulae. We say, from our vantage point as front line workers, that the results have been disastrous. There has been a decline in the quality of care received by all consumers and nowhere is this more evident than in those who need care and treatment the most.

52 6orensic clients consume a disproportionate share of services Chapter 6: The Seriously in the mental health, developmental, Mentally Ill policing, courts and corrections As recently as 15 years ago, Canadians were among the most satisfied people in the world with how they received health care, but by the late 1980s, this began systems. to change97. There were growing fears about the rising costs of health care and the sustainability of the existing health care system. More and more, governments were attracted to the idea of tax cuts and balanced budgets. Within this context, who gets first call on limited resources? In the area of mental health, that question was answered fairly early on98: people with serious mental illness or disability were identified as the priority for mental 97 Michael Decter, Smug health services. No More, Paper presented at the King’s Fund In the document, Making It Happen99, three dimensions are used to identify International Seminar, individuals with serious mental illness100: disability, anticipated duration, and Banff, Alberta 1994. diagnosis. Once those definitions have been established, the next exercise 98 Provincial Community looked at the three levels of need, namely first-line, intensive and specialized.101 Mental Health Committee, Building Community Making It Happen is replete with lists and definitions and classifications and Support for People: A tables. And generally speaking, those kinds of exercises tend make your eyes Plan for Mental Health in Ontario, 1988 glaze over. But, in this case, they serve a useful purpose. Making It Happen 99 Ministry of Health, carefully delineates the services considered essential for the treatment and care Making It Happen: of the seriously mentally ill. Implementation Plan for Mental Health Reform, So, is it happening? Are the most seriously mentally ill getting the services they 1999 need? The forensics population, a group universally identified as needing 100 , Making It Happen: specialized services, is a good test case to evaluate services.102 Implementation Plan for Mental Health Reform, 6orensic patients op. cit. p. 11 101 ibid. p. 17 Forensics is commonly defined as the overlap between law and medicine. When 102 see above it’s applied to the area of mental health, it refers to adults with a mental illness 103 Government of or developmental disability who are involved in the criminal justice system103. Ontario, Human Services and Justice Coordination “All too often, forensic clients appear before the courts charged with Project, A Provincial offences of a minor nature, more a result of the individual’s mental Strategy to Coordinate Human Services and illness than a conscious act. For these individuals the criminal justice Criminal Justice Systems system is an inappropriate forum for dealing with their mental illness.” in Ontario, 1998. p. i. 104 104 Grand River District Health Council, Diversion Although the number of forensic clients is comparatively small, they consume a Program Plan for the disproportionate share of services in the mental health, developmental, policing, Severely Mentally Ill, courts and corrections systems. So, from a therapeutic and cost-benefit point of 1999 53 view, what these consumers really need are clinical interventions likely to reduce any future participation in crime. This kind of thinking led to the creation of Court Diversion Programs. As their name suggests, these programs provide an alternative to the criminal justice Court Diversion system for the seriously mentally ill who commit minor offences. The diversion program is therefore a pretrial action by the Crown to transfer an accused, who Programs has committed a minor offence and who is known to be mentally ill, out of the provide an criminal justice system and into the mental health system for treatment and alternative to management105. the criminal The diversion process consists of:106 justice system • A referral for potential diversion for the seriously • An assessment to determine if mental health was the underlying cause mentally ill who for committing the offence commit minor • Establishing a liaison with the Crown Prosecutor’s office offences. • Court deferral of prosecution until an acceptable diversion plan has been developed • A diversion plan, usually for six months; if successful, the charges are dropped. • Follow-up by the diversion worker with the client In almost all cases, diversion is a voluntary exercise on the part of the accused and the agencies. During the six-month diversion period, a case manager is expected to connect the client with community supports to prevent a reoccurrence. If the client is high-risk, then agencies are encouraged to involve the police, the Crown and other professionals who can help make the diversion a success. It’s legitimate to ask: divert to where? After a few false starts, the Ministry of Health and the Ministry of the Attorney General chose community mental health agencies to run the court diversion projects. These agencies traditionally provide case management, psychosocial counselling, social welfare services, therapeutic recreational and rehabilitation activities.

107 105 Ministry of the Solicitor After some time, three models of court diversion evolved : General, Mental Disorder • In the Court Based Case Worker model, a mental health worker is Project, Linkages of Community Mental Health assigned to, and attends the courthouse on a daily basis. He or she works Agencies and Hospitals with duty counsel, Crown and defence in determining who is mentally with Provincial Courts ill and should be diverted. The person then works with the community undated mental health agencies in arranging admission to their programs. In 106 Central South Mental addition to diversion, the court caseworker also deals with convicted Health Implementation Task Force, Forensic Sub- individuals on probation, suspended sentence and on bail. Committee, Diversion, • In the Agency Based Court Response Worker model, the mental health Interim Report, August 2001 worker attends court at the request of the Crown. The accused is 107 Ministry of the Solicitor assessed at the court, and if appropriate, diverted. If that particular General, Mental Disorder agency isn’t suitable, then the court response worker provides the court Project, Pretrial Diversion with names of other more appropriate agencies. of Mentally Disordered Accused, p. 4, undated 54 • In the Telephone Assessment and Diversion model, the Crown calls the mental health agency and they agree to admit the accused or do an onsite assessment. Now, by all accounts, whatever model is used, the court diversion projects work terrifically well. They help unclog the courts, the correctional centres, the jails and the detention centres. They save money in court hours and jail costs. Court diversion They keep consumers out of the corrections system where their mental health projects work often deteriorates because of victimization and isolation. They connect terrifically consumers with the services they need in the community. And they build a well... collaborative relationship between the courts, the police, the Crowns, the Defence bar, and probation and parole officers. So why are they So why are these diversion projects so underfunded, so understaffed and the so underfunded, court diversion workers so overworked? If ever a case could be made for so understaffed? prevention, assessment, treatment and rehabilitation all in one, this is it. Yet, everything seems to conspire to frustrate the efforts of these mental health workers. There isn’t a program in the province that has enough staff to handle the caseload and not a region of the province that isn’t demanding more diversion programs:108 “Participants raised concerns surrounding services for the forensic population, including lengthy detention of individuals in correctional settings, accessibility of hospital beds when required, and the need for enhanced court diversion services. Our government was told that the immediate enhancement of court diversion services was needed and that our government should explore options such as the establishment of a consolidated mental disorder court.” District Health Councils are leading the way in demanding an expansion of existing projects. This is what the Simcoe York District Health Council had to say:109 “At this time the Newmarket Provincial Court only has a “bare frame” organizational framework … The total number of staff working in the Bail Program and the Mental Health Court Program is only two. The two in-custody duty counsel are assigned to the court each day. They are frequently so busy that they struggle to provide basic legal representation to the accused, let alone develop a suitable community release plan for the mentally ill offender. Many of clients at this stage do not have a case manager. The typical waiting period for a case manager is between a few months to a couple of years in York Region. The Mental Health Court Support Program does not currently have the resources to provide service to all clients in need of a case management service as a pre-requisite to a pre-trial 108 Dan Newman, MPP, release. The Program will explore the possibility of clients getting 2000 and Beyond, op.cit. immediate access to case management when release from custody is p. 9 109 Simcoe York District contingent on this service. Health Council, Final There is another aspect of forensics, quite separate from the court diversion Report, A Plan To Support projects. This has to do with the substantial number of people in detention The Forensic Population InYork Region June 2001 centres who have a psychiatric condition. 55 When Provincial Psychiatric Hospital beds close, some patients have a lot of trouble taking responsibility for their own medication and accessing mental health services. They start to act out, get into petty crime or drugs, and soon the police are called in. They often end up languishing in the corrections system. Other mentally ill patients end up in jail because of housing problems and lack of resources in the community. For example, there is no halfway housing in Penetanguishene or Huronia and the men’s shelter in Midland has closed. People with borderline personality disorders, who have poor coping skills, end One way to jump up in the corrections system, say OSPEU front line workers, though they could the long queue be effectively treated with group therapy and behaviour management. for mental But, sometimes, it’s the only way to get psychiatric treatment. OPSEU health services members call it the ‘gold card of access.’ In other words, one way to jump the in Ontario is to long queue for mental health services in Ontario is to threaten someone, or their threaten property, or yourself. Since there are an insufficient number of beds in someone, or psychiatric facilities, and virtually no acute care capacity in public hospitals, and scarce resources in community mental health agencies – if you want and their property, need treatment, you can always try going to jail. or yourself. In fiscal year 2000/2001, there were 59,783 adult male admissions in Ontario’s jails, correctional centres and detention centres. Of these, 6,345 came in with a mental health flag. That’s 10.6 per cent of all male admissions. In the same year, there were 6,900 female adult admissions of which 1,340 had a mental health flag. That’s over 19 per cent.110 Normally, ‘flagged’ inmates are kept in a psychiatric unit where a psychiatrist or psychologist is on retainer to do assessments and help corrections staff assist appropriately. Experience has shown that without a psychiatric unit, forensic clients are victimized by other inmates. Putting them in isolation merely leads to psychiatric deterioration.111 The Toronto West Detention Centre has provided additional training to the correctional officers who work in the psychiatric unit (the Case Management Unit as its called) so that they can provide more on-site support and help in discharge planning. But it’s not clear whether training of this kind has been offered to any other detention centre in the province. That leaves correctional officers in a terrible bind. Most would probably want more training so as to work more successfully with forensic inmates. On the other hand, many correctional officers feel that a detention centre is no place for someone with a serious mental illness. Well, we know where the Conservative government stands on that issue. 110 Ministry of Correctional In Mike Harris’ and Ernie Eves’ Ontario, correctional institutions are busting Services, Statistical out all over. A government that can’t find even one dollar to build a single unit Services, February 2002 of social housing can pour $500 million into correctional facilities – and 111 ibid. p. 11 112 Government of Ontario, preferably correctional facilities that are privately owned. Press Release, Newly- The chest-thumping mindset is revealing:112 Expanded Maplehurst Facility Heralds New Era Minister of Correctional Services Minister Rob Sampson announced the in Ontario Corrections, opening of Ontario’s newest correctional complex, Maplehurst March 15, 2001 56 Correctional Complex. The $89 million expansion incorporates modern design with advanced maximum-security technology:

• At 1,500 beds, it is the largest correctional facility in Canada It’s difficult to • 21 different types of security systems imagine people • 29,200 square metres of new construction with a serious • 110 football fields could fit on the property (over 41 hectares) mental illness • 300 metres of razor ribbon • 1 million cement blocks and 10,000 cubic metres of concrete doing well, • 1,000 tons of steel getting better, A year later, Sampson was at it again:113 getting the help they need – in a “Unlike our federal counterparts, who believe in treating inmates likes place that guests with special perks… we are using taxpayer dollars responsibly to build state-of-the-art, no-frills jails. Jail should be a punishment, not a boasts more of holiday,” Sampson said. its size than its Frankly, it’s a bit hard to see how inmates with a serious mental illness will get care. along in this kind of atmosphere. Will staff be trained to deal with the 10 to 20 per cent of inmates who are flagged as mentally ill? Will forensic inmates ‘get services tailored to their needs,’ ‘based on best practices’114 in jails the size of a warehouse and in a self-declared atmosphere of punishment? Perhaps Minister Sampson intends to transfer them all to the St. Lawrence Valley Correctional and Treatment Centre, another big box correctional facility. The first phase of the SLVCTC includes a 100-bed secure treatment unit and a 44-bed forensic unit. Phase two includes the construction of a 300-bed correctional treatment unit, a 50-bed remand unit, and a new admissions and discharge area.115 There too, it’s difficult to imagine people with a serious mental illness doing well, getting better, getting the help they need – in a place that boasts more of its size than its care. And whatever happened to the government maxim about ‘getting treatment closer to home’?

113 Government of Ontario, Press Release, Ontario Builds No-Frills Jails While Ottawa Uses Tax Dollars to Build “Club Feds”, February 25, 2002 114 Ministry of Health and Long Term Care, Making It Happen: Operational Framework for the Delivery of Mental Health Services and Supports, 2001 115 Government of Ontario, Press Release, Public Safety and Security Minister Tours St. Lawrence Valley Correctional and Treatment Centre, April 26, 2002 57 Chapter 7: Integration and Streamlining

It’s probably fair to say that the issues of fragmentation and access underlined mental health reform in Ontario. “Consumers … and their families continue to have trouble getting the Something is services they need. Because services are not well coordinated, missing: where consumers … may be shuffled from one place to another, assessed again is the psychiatric and again, and still not receive appropriate services. At the same time, consumer in all the people who provide mental health services feel frustrated by the 116 this model gaps and lack of coordination in the system …” building? “The mental health system in Ontario is not really a ‘system’. It is a collection of different services, developed at different times and managed in different ways. Although this is gradually changing, there is little coordination among the different services: the provincial psychiatric hospitals, the general and specialty hospitals, the community mental health programs and OHIP-funded services. In fact, these services have been described as the four solitudes of mental 116 Ministry of Health, 117 Putting People First: The health.” Reform of Mental Health Then followed the inevitable catalogue of facilities: 10 provincial psychiatric Services in Ontario, 1993. hospitals, 4 specialty psychiatric hospitals, 65 general hospital psychiatric units, p. 2 117 Putting People First, 370 community mental health programs, 346 Homes for Special Care, 36 op.cit. p. 5 consumer/survivor initiatives. The reader is led inevitably to the conclusion that 118 ibid. p. 5 it’s all too much, too messy, too time-consuming, too confusing.118 119 Ministry of Health, Making It Happen: The move was on to come up with a new model for the delivery of mental Operational Framework health services. The Conservative Government’s Making It Happen: for the Delivery of Mental Operational Framework119 defined some of the characteristics of the ‘reformed Health Services and system’ which speaks to integration: Supports, Reprint May 2001 • centralized information and referral functions 120 Durbin, Rogers, • lead agencies, hospitals, networks, amalgamations Macfarlance, Baranek, • service agreements Centre for Addiction and Mental Health, Health • common assessment tools/protocols Systems Research and Soon, the imprimatur of academia was enlisted. A team from the Centre for Consulting Unit, Strategies for Mental Health System Addiction and Mental Health reviewed and synthesized the research on mental 120 Integration: A Review, health system integration and came up with three possible models for Final Report, August 2001, integration and governance. It’s all good work. And important work. But, you p. 4 can’t help but get the feeling that something is missing: where is the psychiatric 58 consumer in all this model building? Why isn’t the quality of life of the psychiatric consumer at the centre? Sure, it’s difficult to make causal connections between governance models and consumer well being. But even the CAMH research team acknowledges the importance of keeping the consumer pivotal to the exercise:121 “In the long run, integration should improve the consumer and family experience using the system and the achieved outcomes. Although it is not easy to demonstrate, integration activity cannot be rationalized if it Suddenly, after is not connected with improved benefits to the consumer and family.” years of The fact is these models aren’t just academic constructs. They are being dedicated considered by every Mental Health Implementation Task Force in the province as the basis for reorganizing mental health services. service to the community, an For example, the Northeast MHITF is already busy implementing the model of agency’s the consolidated agency, a decision we find extraordinarily puzzling. Although that particular design maintains much stronger control over the allocation of autonomy, resources and the setting of standards, it obviously requires significant and funding, wrenching change. Essentially, it pits agency against agency in a competition services, for only one prize – the right to be the lead agency in the district. Suddenly, programs and after years of dedicated service to the community, an agency’s autonomy, very raison funding, services, programs and very raison d’être are on the line. And, if it d’être are on the loses the competition, it loses everything. Not only is that exercise bound to be extraordinarily difficult, it will require a huge amount of time and effort to line. effect. The proposal from the Champlain Region (Ottawa and Brockville) seems to us even more wrong headed. The MHITF is proposing a regional mental health authority complete with the model’s system navigator and ombudsperson. But in addition, the Task Force is recommending the creation of a new Integrated Community Mental Health Agency. As appealing and necessary as these different elements may seem on paper, they seem to us to have the makings of a whole new bureaucracy, many steps removed from the front line, and competing for money and resources when both are tight. Forgive us, but we’ve seen it all before. Single, monolithic, integrated health care organizations just don’t work. And they cost a lot of money. Hospital restructuring should have proven that by now. Here’s what the CAMH research team found in their review:122 “Adequate resources are needed to support system integration. Resources are required to develop and maintain the system infrastructure, in particular the information system, to support the transition process, and to meet costs related to labour realignments. While cost savings may emerge through reduced administrative costs, system integration is unlikely to result in overall savings.” 121 ibid. p. 42 122 Strategies for Mental If system integration doesn’t save money, it also doesn’t lead directly to a Health System better quality of life for the psychiatric consumer. The CAMH team felt it was Integration: A Review, necessary to make that point.123 Final Report, August 2001 op.cit., p. 5 123 ibid. p. 5 59 “Long term outcomes of system integration are expected to occur in the areas of: system operation (increased accountability and system responsiveness to change) and service use (increased engagement, use of less restrictive services.) There may be improved individual outcomes (e.g. in clinical status, functioning and quality of life) but multiple community and service factors influence outcome. As a result, demonstrating the positive impact of system integration on individual outcomes is highly complex and the research evidence is weakest in this area.” In fact, the more important integration, from the point of view of its impact on patients’ lives, is clinical integration. If the information database is centralized, if there is a centralized intake and referral, if there are common assessment tools, if there is an integrated client record, if the players in the system are aware of and use best practices – then you can establish a cause and effect Whenever between integration and patient outcomes.124 The CAMH team feels so strongly consumers or about this conclusion, that they urge it be given priority in the integration their families process.125 come into With all that in mind, we feel extremely uncomfortable with the second aspect contact with the of integration – the idea of streamlined access. Again, it seems a logical mental health response to the fragmentation of services that consumers and their families system, they often face. But it has the potential of negating an important principle in mental should be health care, namely that there is ‘no wrong door’ for consumers. That whenever certain they will consumers or their families come into contact with the mental health system, they can be certain they will receive timely, appropriate help. receive timely, appropriate The problem is that streamlined access removes consumer choice. This is how the CMHA in Ottawa put it: 126 help. “A singular mental health agency may be rejected by consumers/ survivors based on a number of factors such as past experiences, cultural incompatibility, or suspicions/paranoia. What choice is left to the consumer/survivor then? Moreover, what happens to consumers if they have been barred from this integrated service? These questions help to highlight how limiting a single consolidated mental health agency would be.” Moreover, the whole concept smacks of a ‘mental health’ Community Care Access Centre. CCACs were initially designed to support and maintain frail and vulnerable seniors in their homes. Then the province rushed to close hospitals and empty beds. The role of the CCAC was soon transformed into providing follow-up nursing care to acute-care patients and the whole idea of support services to seniors went out the window. In a rush to privatize, the Conservative 124 ibid. p. 5 government required CCACs to tender for agency services and, naturally, the 125 ibid. p. 43 126 Canadian Mental Health low bid won. Familiar, neighbourhood workers who had coordinated and Association, Ottawa provided care for years were suddenly gone replaced by people poorly paid, less Branch, Submission to the experienced and rushed off their feet. Champlain District Mental Health Implementation The parallels and potential parallels in mental health are too close to ignore. Task Force, Foundations Psychiatric hospitals have been divested and beds emptied. The focus now is for Reform 2001, p. 17 exclusively on the seriously mentally ill and forensic clients. There is nowhere 60 near enough money for the support services and determinants of health which While so many everyone acknowledges are vital for the well being of people with mental are mired in the illness. Mental health agencies are being forced to compete for funding and fallout from employees. Community-based staff are terribly overworked and receive lower restructuring wages than their counterparts in the hospitals. and engrossed It all bears watching and watching closely. And that’s what we intend to do. by arcane Mental health staff tend to be concerned and caring, explained a PACT team arguments member from North Bay. “We’ve endured a restructuring that’s been going on around system for some time now. Regardless of funding, of budget cuts, programming design, OPSEU changes or our pay package, the staff has always shown flexibility in adapting to change quickly, with the care of the patients driving them.” is keeping its eye on what Added another: “We’re only still here because we like the work we do.” really matters – While so many are mired in the fallout from restructuring and engrossed by the well being of arcane arguments around system design, OPSEU is keeping its eye on what the psychiatric really matters – the well being of the psychiatric consumer. consumer

61 Chapter 8: Regional Reports

London and St. Thomas Loss of beds leaves mentally ill in crisis. “All you have to do is walk downtown in London to see mentally ill patients are living on the streets or in hotel rooms out by the airport. At the Men’s Mission 45 to 60 per cent of their clients are mentally ill.” As the former St Thomas and London Psychiatric Hospitals lose almost 300 beds, people with mental illness in southwestern Ontario have trouble accessing services and often end up in the corrections system or a cycle of homelessness. “They are languishing in the community or in jail,” says a registered nurse. Closing “They’re not getting their medication or they’re falling through the cracks…it’s psychiatric beds hard for us even to get people in for a diagnosis.” isn’t working. Closing psychiatric beds isn’t working. “There is a lack of affordable housing for the mentally ill in the community and they are victimized on the street,” says a registered practical nurse. “Yet, there is still a perception that these people are on the street by choice, that they’re just lazy people not buying into the system.” These observations are from the staff of Regional Mental Health Care, London and Regional Mental Health Care, St. Thomas, formerly known as the London and St. Thomas Psychiatric Hospitals. St. Joseph’s Health Care in London took over the two hospitals in January, 2001. Prior to that, the two sites were Provincial Psychiatric Hospitals directly operated by the province. 127 Front-line workers from Regional Mental Health The staff are nurses, case workers, vocational councillors and other mental Care, London and health staff in London, St. Thomas, and Waterloo, Essex and Elgin counties. Regional Mental Health They participated in a union forum about mental health services.127 Care, St. Thomas, members of OPSEU Local Moving the mentally ill back into the community is failing because there are no 152. The two sites are housing supports and the Ontario Disability Support Program (ODSP) is totally under the operation of St. inadequate. Joseph’s Health Care in London. 62 “At least in the hospital, patients got a roof, food and clothing,” says a staffer. “A lot of people didn’t have anyone but the staff and consistency is very important in their lives. It takes years to develop trust.” 6ocus is finance What is key about mental health services in southwestern Ontario, say front line workers, is that cost cutting rather than rehabilitation is driving the mental health system. Employees worry that the province says there is dedicated money going to mental health but there is no way to track that funding, to find out where it’s going. “Clients find their drug plans cut off, they don’t qualify anymore for ODSP, because they can’t get a diagnosis and they can’t get a bed in a hospital to get an appropriate diagnosis.” “It snowballs,” explains a member of a PACT team. The team helps mentally With divestment ill clients adjust to life in the community. it comes down “It’s hard to get on the list for subsidized housing and vocational services are a to doing it on thing of the past. Funding has been cut in these areas but you can’t see anything the cheap. that’s come up in its place.” Employees don’t oppose the concept of deinstitutionalizing the mentally ill, if rehabilitation can be done in the community with patients close to their families. But the government implemented deinstitutionalization in order to save money, suggested one staffer. “With divestment it comes down to doing it on the cheap,” says a 30-year veteran employee. “For instance getting rid of specialized staff in favour of generic workers – the quality of care deteriorates for a clientele that can’t complain and can’t organize to become a political force.” “Politically the hoopla was about de-institutionalizing and upgrading the quality of life, but the small print was about saving money. It’s been cut, cut, cut.” Not enough beds Reducing the beds at the London and St. Thomas sites from 400 to approximately 160, fails to consider people who will always need long term care. The bed reductions break down this way: 50 beds will go to a hospital in Windsor and 50 beds will go to a hospital in Kitchener-Waterloo. An additional 140 will simply be eliminated, leaving 160 beds for the London and St. Thomas sites. Some clients are so ill they don’t want to be “divested” to the community. Yet, clients are urged to return to their home areas, even though that often means, according to one staff person, “putting a square peg in a round hole. We are supposed to make it fit, but it doesn’t work that way.” Some divested clients end up in group homes, where staff aren’t equipped or trained to deal with severe mental illness. 63 “We took the time to deal with the difficult ones, the staff in group homes don’t have the training or the time,” says a nurse. “They have no idea what to do with these patients, or how to recognize the warning signs or the suicide signals.” Staff say the provincial norm of 35 psychiatric beds per 100,000 population isn’t working. There are too many seriously ill patients and not enough services in the community for the others. “According to the master plan, when a person leaves the institution, when they walk out that door, they’re chopped from the service. Unless they’re strangling somebody or slitting their wrists they won’t get back into the service.” Hospitals can’t cope General hospital emergency wards are now responsible for handling the mentally ill in crisis, although the hospitals aren’t equipped to handle out-of- Waiting lists are control patients, the suicidal or the delusional. long and suicide Front line staff report that the hospitals often re-route the mentally ill to rates are up. agencies that may be inappropriate. Or the hospitals medicate the mentally ill and release them back onto the streets, where they often get caught up in the corrections system. One Kitchener hospital kept a difficult patient in lock-up for four days. Waiting lists are long and suicide rates are up. “Family members are at risk and petty crime increases, with increased police calls,” says a case worker, “Police say it has increased their load and they don’t have the training to deal with it.” A staff in forensics reported that one patient has been in a Windsor jail, in solitary confinement, for two and a half months, for repeatedly pulling a fire alarm. “He’s refusing medication and is sick. He has a skilled and committed lawyer working on his case, but he needs a forensic assessment to be deemed incompetent and there is no bed available to get him that assessment. The system is full of road blocks yet the government said they would make access to services better for people.” Cases up, so is confusion A long-time registered practical nurse says change has been more rapid in the last few years that at any time in his career. “Rapid, constant changes have made it more difficult to access services. Yet the requests for community services are up and everybody who is working anywhere in this field is noting phenomenal increases in the statistics of ill people they’re seeing.” Disjointed, overlapping services and organizational confusion is the rule. “To get access to service in the community, there is an access point. The Canadian Mental Health Association now works as a broker for agencies in the community. It’s confusing to know who’s responsible for what, so it’s even harder for a person off the street.” 64 Even though there are beds remaining at the London and St. Thomas sites, it is almost impossible to access them because the administration’s goal is to lower bed use. “There are hundreds of stories of people who can’t access the system,” says a vocational counsellor. 6unding folly Meanwhile, cost cutting takes extreme forms: • Homes for Special Care program case workers must now attest to the therapeutic value of trips home for clients before any money will be spent. Staff must also spend time trying to get families to cover the costs of trips home. • To deal with the shortage of psychiatrists the province is funding teleconferencing, where a patient sits in front of a TV camera linked up to a psychiatrist in another city. “These patients are delusional or paranoid, for heaven’s sake,” says a nurse, “the psychiatrist doesn’t even know where to look. It’s supposed to be cost- effective. It may be a solution to the lack of psychiatrists but it’s no good for They say they’re the patient.” putting more Cambridge is so under-serviced that staff drive from Kitchener-Waterloo every money into the day. Cambridge gets very little help, say staff, and even the Schedule 1 hospital system but let’s in Kitchener won’t accept clients from Cambridge. follow the Funding isn’t consistent over southwestern Ontario, say staff, and there is no money trail and way of knowing why some agencies and programs are funded and some not. see if the client “With multi-year funding there is no way a front line worker, even with benefits. accounting experience, can figure it out,” says a PACT team member. “They say they’re putting more money into the system but let’s follow the money trail and see if the client benefits.” “The Ministry of Health has said over and over that there is a funding envelope for mental health and that it is going to be protected – but there’s no gatekeeper. And the new system of program funding has created turf wars and duplication.” Divesting doesn’t work Divesting psychiatric beds into the community has also meant the government is offering money to nursing homes to create geriatric psychiatric beds. Nursing homes often try to hide the fact that they house mentally ill seniors. Also the homes have no experienced staff to treat the mentally ill. Front line workers despair that other jurisdictions, who tried divesting mental health services the way Ontario is doing, have now recanted. “New Zealand and England did away with specialty programs and people ended up on the street,” explains one social worker, who says Ontario should be learning from the mistakes of other countries, not repeating them. “It doesn’t work and we could be making it so much better for the ones who can’t go back into the community.” 65 Staffing stress Mental health workers say caseloads are high, so is staff burnout and turnover. “This is a specialized field that requires training,” explains one vocational counsellor. “The growth of unregulated care has caused more generic workers, which leads to inefficiencies and danger. These workers lack training in dealing with violence and that puts the clients and the community at risk.” There is a general lack of training within the mental health system, say the employees and Even when that means “second rate service to our clients.” training is “Even when training is offered,” says a nurse, “we can’t leave the floor to take offered, we can’t it.” leave the floor to Staff speak of feeling a lack of dignity and respect from management and take it. provincial officials. “We’ve had three occupational therapists in three years at our workplace,” says a social worker. “We work with difficult clientele, staff won’t stay if they aren’t treated well.” Mental health staff tend to be concerned and caring, explains a PACT team member. “We’ve endured a restructuring that’s been going on for some time now. Regardless of funding, of budget cuts, programming changes or our pay package, the staff has always shown flexibility in adapting to change quickly, with the care of the patients driving them.” Adds another: “We’re only still here because we like the work we do.”

Hamilton and Niagara Lack of resources & coordination cripple service. “We fear mental health will be run by bean counters not the clients’ needs.” Services for the mentally ill are fragmented in the Hamilton and Niagara regions, front line workers suffer burnout and the burden of care is falling onto families. Those are the concerns of social workers employed at Hamilton’s St. Joseph’s Health Care – Mountain Health Site, the Wellington Psychiatric Outreach Program and at the eight amalgamated Niagara hospitals called the Niagara 128 Front-line staff from St. Health System.128 St. Joseph’s Health Care took over the Hamilton Psychiatric Joseph’s Health Care – Mountain Health Site Hospital in November, 2000. Prior to that, it was a Provincial Psychiatric (receiving hospital for the Hospital directly operated by the province. former Hamilton Psychiatric Hospital), Front line workers report lack of resources for outpatient programs, for group members of OPSEU Local homes, recreation and dual diagnosis patients. The regions lack primary care 206 and the Niagara Health centres (health service organizations or community health centres) for initial System, members of assessment and treatment and, as a result, there is little redirection to OPSEU Local 215. appropriate specialists. 66 Cross sectional issues, like housing, create barriers to mental health care in Hamilton and Niagara regions. “There are few supports in the community and housing is a mess,” says a social worker. Says another: “The appalling state of housing in Niagara Falls means places like the Barely Legal Motel downtown become homes for the mentally ill.” Central coordination needed Both regions lack a central access point for the care and treatment of severe mental illness. “There is no way of knowing where services are,” explains a social worker. “Some patients never qualify and they are never referred to a proper service. There is no single patient file so you can be kept on four different waiting lists and end up getting the same service in different agencies.” Local studies have re-iterated the need for coordination of mental health services in the Niagara Region. Some services are lacking. For people with developmental delays, for instance, Hamilton has many more resources than Niagara. Social workers are concerned that with psychiatric bed closures, mental health funding may not be protected. In Hamilton-Niagara it is impossible to ascertain how many mental health beds there will be. There are currently no designated There are now children’s mental health beds for the areas. increased No continuity arrivals of the The restructuring of St. Joseph’s Health Care, resulting from the amalgamation mentally ill at of eight public general hospital sites, has fragmented its role as the only hospital psychiatric emergency facility. There are now increased arrivals of the mentally emergency ill at hospital emergency rooms, which are ill equipped to handle them. rooms, which “Patients can’t get longer term care because there is no continuity of care from are ill equipped Emergency Rooms,” says a social worker. “That leads to an increase in to handle them. hospitalization and an increase in the cost of treatment because patients end up in acute care beds. Or the burden of care shifts to families and if there is no family available, that can lead to homelessness, transience and untreated clients end up in the criminal justice system.” There is no centralized patient history that can be followed, noted one employee, so that a client can sit in emergency for six hours when he may have been seen there six months before. Without client histories there is duplication and inappropriate service that can cause more problems. “Streamlined access and integration of services are needed to improve patient care,” says another social worker. “ But you need to put resources into it or you’ll just get three to six month waiting lists.” Computer poor Lack of resources in the region extends to technology: there are no computers or any common information technology at the Niagara hospitals or at the 67 Wellington Psychiatric Outreach Program. Anecdotal evidence suggests the lack of computers has an impact on patient care. “In children’s mental health, the Ministry of Community and Social Services tried to have a standardized assessment system,” says a social worker. “A lot of money went into it and we all trained for it. But it all came to naught for the simple fact that in the Niagara Health System, we don’t have computers so we couldn’t participate.” If the Human resources have a large impact on the mental health system. The government shortage of psychiatrists is critical. In one city, two psychiatrists are unable to philosophy is retire because there is no one to replace them. Family GPs, occupational therapists and psychiatric nurses experience severe burnout. Social workers are community also quite aware that as government shifts services to the community, social based treatment, workers in community agencies earn $10,000 to $15,000 less than those in they need to get hospitals. people like us, “If the government philosophy is community-based treatment, they need to get who specialize, people like us, who specialize, and give them adequate salaries to work away and give them from institutions.” adequate Contracting-out salaries to work The OPSEU members say the Ontario government should not apply its away from Community Care Access Centre model to mental health care. The CCACs look institutions. at for-profit agencies to provide health services outside institutions. That simply means unskilled, low paid generic workers dealing with the mentally ill, say staff. “You do need sophisticated clinicians like we are,” says a social worker. “Our work for our clients includes organizing housing, peer support, vocational training, pharmacological intervention, to see that they get the right service in a timely way.” There is a sense among the employees that mental health staff aren’t communicated with or respected within the health system. In Niagara, there is definitely a lack of consultation with staff, say employees. Staff were dismayed at not being represented on the region’s Mental Health Implementation Task Force. “Even though as case managers we experience a lack of autonomy and feel that we are being scrutinized to death, in fact there is no one listening to mental health workers.” ACT & CTO need resources Concerns were expressed over the ACT teams currently in place to facilitate integration of the mentally ill into the community. Based on a U.S. model, one social worker called the ACT system “a quick fix answer to problems you run into when you send out services to the community.” Says another social worker: “They didn’t do the logistical legwork required and the ACT teams can be a waste of time and money if they are not managed properly. In our case the criteria are so high you have to be incredibly sick to 68 get the service, the geographic area covered is too broad so that we spent more time in our cars than with the clients.” Also there are no resources in the regions to implement new initiatives like Community Treatment Orders, now mandated when a client is a danger to himself or the community. “The paperwork is unbelievable, then you have to get the patient back into hospital. If he disagrees you have to get a psychiatrist to make a decision on competency. Then you still have to have a network of services on board for treatment, monitoring and supervision.” Advocacy is key Social workers in Hamilton and Niagara worry that cost cutting is currently the only focus in Ontario health care. They cite the firings of managers who went over budget at a local CCAC and McMaster Health Sciences as proof that “mental health will be run by bean counters not the clients’ needs.” And that, they say, could put them in conflict with their professional affiliation and obligations. “Traditionally, a social worker’s duty is to advocate for clients and this new trend could put us in jeopardy.”

Toronto The chaotic merger of four top Canadian mental health and addictions facilities has reduced research expertise and fragmented services to the public. “The people we service are already marginalized, disenfranchised and have a stigma on them. There is no client-centred care, we’re closing programs and putting people on the street.” “We were the jewel. Now no one wants to work here anymore.” World-class research decimated and patients sacrificed to bogus ‘efficiencies.’

The chaotic merger of four top Canadian mental health and addictions facilities We were the has reduced research expertise and fragmented services to the public. jewel. Now no “We’re losing something,” warn front line staff at Toronto’s Centre for one wants to 129 Addictions and Mental Health. The Centre was created four years ago by the work here amalgamation of the Clarke Institute of Psychiatry, the Queen Street Mental Health Centre, the Donwood Institute and the Addiction Research Foundation. anymore. The Queen Street Mental Health Centre was a Provincial Psychiatric Hospital directly operated by the provincial government prior to the amalgamation in 1998. 129 Staff outlined their concerns at a union forum. Front-line workers and members of OPSEU Local 500 69 For in-patient and outpatient clients, the merger has meant lost beds, fewer programs and long waiting lists. The renowned Donwood Institute for residential addictions treatment is slated for closure. And the quality of research at the facilities has been affected by staff turnover, poor morale and the absorption of addictions research into mental health services. “World class scientists in addictions have gone elsewhere,” says one staffer. “The leading Canadian role in treating addictions as a separate discipline is lost.” Addictions absorbed Integrating addictions into mental health services has been an enormous learning curve for researchers and a new challenge for staff who deal with clients. Front line workers recognize that there are a lot of patients with concurrent mental health and substance abuse problems and that there needs to There is be some interaction between the addictions and mental health systems. something But what’s happened, say staff, is an ascendancy of the philosophy that unique about addictions are just another mental health problem. They fear an end to the substance abuse holistic, non-medical approach that has been developed for addictions problems that treatment. needs specific “There is something unique about substance abuse problems that needs specific treatment and treatment and our fear is that substance abuse problems are being wiped off the map,” says a staffer, who came to CAMH from the Addictions Research our fear is that Foundation (ARF). “We find ourselves in danger of losing a very large body of substance abuse knowledge, expertise, research and specific treatments that were helping the problems are people of Ontario. being wiped off “We used to have addiction services for older adults; now that’s been absorbed the map. by Geriatric Psychiatry. We were once a leader in youth treatment with a whole continuum of services; over the years it’s been whittled down and is now subsumed in a small outpatient service. The ARF provided materials to service providers, from corrections officers to doctors, to use as tools to deal with addictions; there is a lot less of that now.” “And we had a huge service where we responded to calls from the public or we’d go out to speak in the community,” recalls a registered practical nurse. “We’ve pulled back on that.” Model is gone The Addictions Research Foundation was based on a model that permeated the organization. “The model was research that informs clinical practice that informs the publication of resources that can be disseminated widely,” says a researcher. “That model, that the ARF did so well, has in fact influenced the way we do business at the Centre, but the content around addictions has been lost.” If you cut the research component, the whole model collapses, notes another employee.

70 “And this is clinical research that was very recognized when we merged, it gave us World Health Organization status. Now it’s gone,” she continues. “It’s all about dollars, with the pharmaceutical companies funding more and more of the research.” The end result of integrating the addictions and mental health disciplines is that “our client system is gone”, concludes a social worker. “We continue to reduce the resources that our clients can access for both addictions and mental health.” A vocational counsellor relates: “I work in specialized services where we serve primarily schizophrenia and continuing care with vocational services and programs. But now we get people whose primary diagnosis is addiction. I’ve worked in mental health for 22 years and my expertise just isn’t there.” Key researchers Reduced research in addictions and mental The quality and the nature of research in general has changed since the merger. health have left One researcher put it this way: “Key researchers in addictions and mental health have left and been replaced with people not as capable to lead or mentor and been or nurture good quality research – but they’re good grant getters.” replaced with Research is driven by fiscal concerns, say staff, and the strategic direction of people not as the Centre’s research department is to get away from any core funding, so that capable to lead 80 per cent of research is grant-driven. or mentor or “Which really eliminates any kind of vision possibilities for the kinds of nurture good research we’d been noted for,” explains a researcher. “We just react to funders quality research like Eli Lily [the drug company].” – but they’re A subject that does get funding these days at the Centre for Addictions and good grant Mental Health is gambling, since a portion of provincial revenues from getters. gambling must go to research. “So people who previously did other kinds of addictions research are now shifting their focus because that’s where the money is.” Patient Care For the in-patients and the outpatients of the four facilities, the merger has meant a loss of service, say staff. “Whatever may have been wrong with this place, there were some measures in place that allowed people to receive treatment no matter what,” recalls a registered practical nurse from the Queen Street site. “Now that doesn’t happen. The reality is you could go without services.” One social worker has helped develop community-based rather than institution- based services for youth… “more store front, on the ground, street level services.” But, that is not enough, she says. “The street services doesn’t mean we need to get out of the service we provided, because what we were able to do was treat the most seriously dependent. We had the professional services to do that. Now there will only be one such facility for Ontario, in Thunder Bay.”

71 Staff cuts and unfilled positions mean that employees are handling triple the number of clients, slashing one-hour appointments to 20 minutes. “At the time of the merger, they talked about a seamless continuum of care,” says a counsellor.“It was an assurance that at every site, every level of need would be met. Well, the seams are bursting and some have split.” Patients evicted Discharging clients is done with no follow-up. “You have to have faith that when the person gets out there, you might have had time to call a VON or put together a loose plan, that they’ll do it on their There have been own,” says one staffer. “So when they’re at their most vulnerable, when they’re seven client leaving the hospital, there’s no service for our clients.” deaths since the “Also, we don’t have enough beds in Toronto for people who are unstable with merger, three of substance abuse problems,” says a social worker, “they are on waiting lists, in them suicides by detox or shelters.” people waiting There have been seven client deaths since the merger, three of them suicides by for treatment. people waiting for treatment. “That is a higher rate than usual and now we’re at 98 per cent capacity all the time,” reports a registered practical nurse. Treatment is down for most outpatients and there are waiting lists for the 10 hospital and community outpatient services in the Toronto region, says a registered practical nurse. The waiting lists are eight to nine months long for an outpatient program. “The people we service are already marginalized, disenfranchised and have a stigma on them. There is no client-centred care, we’re closing programs and putting people on the street. That is not a seamless continuum of care.” One nurse relates the story of a client who died recently in a boarding home nearby. “They found him after two days. He’d had a heart attack at 35. He’d been much better since being on medication for his mental health, but the meds made him obese and his medical condition deteriorated…and there was no linkage to him, no monitoring of his diet, no nutritional assessments.” Program cuts One programming loss for clients has been the community centre inside the Queen Street site, including a mall that was “a real meeting place for clients.” It is being dismantled. “Our clients have complained about how they used to be able to play hockey here or do activities. Now they’re at home, watching TV.” There was also a spa for clients: “a huge value to the patients, with candles and a massage.” It was closed down immediately after the merger. Staff say the Centre is more intent on cost-savings, consumed with concerns about liability in case of client accidents and making money. The swimming pool and gyms at the Centre are now rented out to the public.

72 “There has been a depletion of services in terms of activities in the evening and weekends. It’s just not there anymore. And this was a safe place for some of our clients – they aren’t accepted in the community because they talk to themselves or lash out – this was so much better than the street.” The Queen Street site has also lost its popular house on Toronto’s Centre There is a sense Island, a haven for clients who could go on a weekly basis, using the house as a among base for barbecues and bicycling. The house was given up after the merger. employees at the Staff are concerned that clients now have to qualify to get service at the Centre. Queen Street Since the institution needs certain profiles for its research purposes, some site of a people aren’t accessing services because they don’t fit the profile. There is a concerted effort sense among employees at the Queen Street site of a concerted effort to get rid to get rid of of their long-time high maintenance clients in favour of more “fundable” their long-time clients. high “Now our high-maintenance clients are sent to private nursing homes and our maintenance staff is sent in to teach the staff how to look after them.” clients in favour No safeguards of more Nor are there standards or protection for the clients in private nursing or “fundable” boarding homes. The Centre’s staff speak of a large number of non-approved clients. boarding homes with no clinical staff, “where the kitchen help handles the client’s medication.” “The over-crowding is terrible,” says a counsellor. “You have a schizophrenic sharing a room with an ex-con who is a cocaine addict. We’ve seen rooms built under stairwells, with just a bed in them, for $595 a month. We force people into these kinds of conditions every day to get them into the community because the philosophy is ‘that’s where they should be’.” The Centre’s staff say that all their links are now with community agencies because the Centre doesn’t have its own resources to do the work that was going on prior to the merger. It’s the fragmentation rather than the outright closure of programs that hurts clients, they say. “It’s a re-alignment and re-distribution of programs. They’re split and sent to other parts of the community. Programs that were run out of the Centre, are now run out of the community somewhere else. They may not be accessible to our clients, people for whom change is particularly difficult.” Another staff concern is that Ontario disability pensions are way too low for their clients to live on. There is real pressure in the re-structured system to get the mentally ill “earning a buck.” “But even when they can get a small job with pay, they have to report all of their income to ODSP, which could cut them off. Our clients get so nervous about losing their pensions, they won’t go to work. It’s a sick system.” The merger of four distinct Ontario institutions has been chaotic and ad hoc, say staff. A business focus drives all aspects of the Centre for Addictions and Mental Health’s work, say employees –turning research into a grant-driven operation and applying “business affirmative” models to vocational rehabilitation. 73 There are fewer activities for clients on site because the Centre worries about liability in case of accidents. Staff work with injuries that go unreported because the Centre wants to get its Workers Compensation Rebate. And security at the Addictions Research Foundation site was contracted out. Clients are often treated like vagrants by ARF security guards. “The Queen Street mall area isn’t quite that bad. But this place used to bustle and was full of patients,” says a staffer. “Now the security guards are told by management to move the patients out, like they’d be better off on the street.” If social workers or counsellors want to enhance their programs, “You have to go before a group of people, including the corporate real estate person and the head of finance. You have to have a business plan prepared and pitch your case.” Selling is also now a feature of the publications unit. The facilities used to be mandated to distribute publications freely to health care providers and the public. “Now we have to sell them,” noted one dismayed employee. Affirmative business Under restructuring, vocational rehabilitation programs have to be “business affirmative” and turn a profit. So the small coffee machine service, operated by clients at the Queen Street site has been contracted-out to the Ontario Council of Alternative Business, which will necessarily hire higher-functioning clients for the work. A small catering operation, run by a few women clients, was also working well. “They did a little catering and they liked it and felt useful. Well, happy or not, they’ve been told: now, it’s about making a buck.” A vocational counsellor who assists with the catering operation puts it this way: “I’m trained as a social worker, not a business person, so I’m not sorry that OCAB is getting more involved. But the truth is, when you move vocational Clients can end opportunities into the community, you’re moving them into a business environment. And that’s a risky operation, subject to all the ups and downs of up with “eggs for the marketplace. These days, everyone is suffering.” breakfast, an The Centre for Addiction and Mental Health contracted out its food service to a omelette for company that brought in thermalized ready-to-heat meals. lunch and quiche for dinner. “Pre-mixed and pre-packaged,” is how the meals are described by a member of the housekeeping staff. “The quality was so poor, people left it on their plates and everyday I was throwing out 500 lbs of food.” What was the company’s response to the waste? It cut the meal portions for clients in half. Under the current system, says the housekeeping employee, clients can end up with “eggs for breakfast, an omelette for lunch and quiche for dinner.” Nine dieticians in four facilities were cut to two in the merger, leaving the Queen Street and Clarke sites with no dieticians. At the time of the merger, consultants looked at dietary services and recommended six full-time positions because of the scope and magnitude of the job. 74 “Right now, we can’t do proper assessments in the geriatric unit, where there’s real risk of choking. We can’t do teaching about diabetes because there isn’t enough staff. Some dieticians left the Centre because they were violating their Some dieticians standards of practice.” left the Centre The Centre seems to believe “it can get by minimally on everything,” says one because they staffer. The finance department was cut in half upon the merger and the financial system was contracted out to a U.S. firm. The company’s system were violating didn’t calculate GST or PST, so for months the staff couldn’t pay bills to client their standards landlords, vendors or suppliers. of practice. Morale sinks The turnover rate of staff is 18 per cent at the Centre for Addictions and Mental Health. Morale is poor. “We have three new graduates here,” explains a researcher. “They won’t stay. There are no resources. They can’t work with clients. The Centre wants staff with master’s degrees, but they will only pay you $19.97 to start.” Adds a registered practical nurse: “There is no recognition of staff here. The Centre for Addictions and Mental Health has a World Health Organization designation, but they treat the employees like garbage.” The attempt to cut costs, including leaving positions unfilled, means that staff have increased responsibilities and are unable to meet their obligations. “People are being asked to do things that are a violation of their standards of practice.” “We were the jewel,” laments a staffer. “Now no one wants to come work here anymore.” Employees suffer from information over-load, yet they say: “there is no way to have a sense of all that’s going on.” They want more meetings and a more structured administration that communicates with staff. No efficiency Top-heavy management comes in for bitter criticism. Says one social worker: “We had to merge four totally different facilities and cultures. Four years later we have tried but there has been no effort at the management level, no incentives to integrate, nothing. The management works on bottom lines and public perception.” The whole idea behind re-structuring “was always efficiency,” suggests one staffer. “Well, how efficient has it been to have fragmentation, duplication, trial and error in finance and down-sizing and then having to up-size again?” The Centre cut staff in the merger, say staff, and then had to re-hire. “In almost all of the re-organized programs that we’ve gone through, the number of staff that were let go, they hired them back, plus more.” What’s more galling is that at the time of the merger, the Centre for Addictions and Mental Health brought in KPMG consultants to look at the operation as a whole, at a cost of $1.5 million. The study, which recommended downsizing

75 and streamlining management, was never used. Employees say the number of managers they report to has doubled in the last four years. The huge gaps in hiring have led to inconsistencies of care for clients, say the staff. But for mental health workers themselves, the high turnover crushes any One program sense of continuity. had five different “One program had five different managers in five years and each manager had a different agenda and so brought a different change to the program that affected managers in five the clients every single time.” years and each manager had a different agenda Whitby and so brought a Whitby Mental Health Centre: A hopeful haven different change to the program Mental health services in Whitby rate high, but cuts to established that affected the programs and a rise in complex forensic cases darken the scene. clients every Social workers and nursing staff at the Whitby Mental Health Centre say its 130 single time. programs are conscientious and make sense. “We have people coming in and using our facility as much as possible and we encourage it,” says one social worker at a union forum. The Whitby Mental Health Centre has gone through rigorous developments of its own. It’s one of four Provincial Psychiatric Hospital directly operated by the province. There are no plans for it to be divested to a general hospital. “People here don’t balk at change,” says one staff person. “The model for psychiatric service changed here sooner than in other hospitals and we were moving into the community earlier. People here have a broad concept of service.” Up-to-date Staff appreciate that the physical plant and organization is client-focussed. There are programs for adolescents, a dual-diagnosis unit and a growing forensic unit (for patients who’ve come in contact with the courts and corrections systems) with well-defined policies. “There has been recognition of the urban-rural split and the different ethnic components of our placements and how to integrate that into our practice,” reports one psychologist. “A lot of people are here because they like the work they do and the specialty that they provide.” The Whitby Mental Health Centre was referred to by a registered nurse as “an odd-ball child” in Ontario mental health system – not yet suffering the divestment policy that has resulted in more mentally ill people in the homeless shelters and jails of many Ontario communities. Yet, there have been severe budget cuts at the centre nonetheless. 130 Front-line staff from the Whitby Mental Health “We’ve had benefits that other areas haven’t had,” commented one social Centre, members of worker. “But with the increased proportion of complex forensics patients here, OPSEU Local 331. we don’t have adequate resources for placing them back in the community.” 76 Courts involved All staff attest to the rise in the proportion of forensic patients over the last five years. “Yet there has been no adequate or participatory assessment of what staffing requirements should be,” as one psychologist puts it. “When the forensics program was developed here, the original estimates included adequate occupational therapists and psychologists on medium security,” she explains. “But there’s been no money for these positions.” “So frankly, if you have a medium secure patient, who’s going to be in the system for some years and you don’t have an occupational therapist who can do a full functional assessment of this person’s needs and you don’t have a Lack of psychologist providing individual psychotherapy, there is no treatment.” appropriate Lack of appropriate service means more acting out and violence by patients, service means says one staff person. more acting out “We had a patient, recently, who was acting out in the neuro-psychiatric unit and violence by and caused severe head injuries to another patient. Here was a person with high patients. risk for aggression – but there’d been no psychologist’s consultation, no behavioural program, and now there will be a lawsuit.” Notes a registered practical nurse: “We’ve had situations where teams identified an accident like that waiting to happen. And unfortunately those accidents have happened.” Needs not met Currently there is a long waiting list for mentally ill persons who have been charged with an offence and are waiting for a forensic bed. “In my program we have 25 forensic patients,” recounts a social worker, “We get the services of a forensic psychiatrist once a week. For example, this week we have six Ontario Review Board reports that have to be prepared for next month’s court session. And then we have 10 to be done for November 1. Which means on the one day we have this doctor, he has to work with the team to deal with all the patients and do all the work of the Review Board reports. So, the patients get short-changed.” Because one third of the Whitby Mental Health Centre’s are forensic patients, there is a greater risk of violence and injury to staff and other patients. “These are high-maintenance patients, high paper-work patients,” explains one staffer. “It is complex. One of the challenges in this facility is to make sure we have standardized programs and kinds of care for the management of the forensic population.” When it comes to placing forensic clients in the community, the follow-up is hard work. Lately some courts are ordering patients into the community in spite of a clinical treatment team’s assessment that they aren’t ready. “You have to know what you’re doing, they’re still under a warrant, and they have to be followed.” 77 Left out Staff fear that the growing focus on forensics means the rest of the mentally ill get short-changed. The unit for acute and complex forensic cases at Whitby Psychiatric used to be a ward that served as a group home for low functioning patients. “Services for the mentally ill that we used to help are slowly being sifted out, we’re losing beds for people who aren’t forensics,” comments a social worker. Also, because complex forensic patients require more staff time, employees Because complex worry that non-forensic patients are “losing out.” Staff say it’s a concern forensic patients already voiced by the families of ordinary patients. For instance, there is a large gap in vocational programming for adolescents. require more staff time, “This clinical population is growing and there are families suffering and kids on employees worry the street,” says a social worker. that non- “It’s good that we have gone to care for the severely and persistently mentally forensic patients ill,” says a staffer. “But there are other people who can’t get service anywhere, the hospital is flooded, they’re months on a waiting list and they can’t get are losing out. continuing service.” Doctors in general are also hard to come by in the region. “In Oshawa, you simply can’t get a GP,” says a registered nurse. “I tried to get a doctor for myself. You can’t. And we have patients going out there who need care and treatment and to be linked to a physician.” Cruel cuts Apart from under-funding in forensics, several popular well-established programs for the mentally ill have been cut at the Whitby Mental Health Centre. The “Care Program” involved 30 to 50 patients a day in a drop-in, based on a rehabilitation model. It was pre-vocational and patients made crafts to raise money. Assertiveness training, recreation, medication awareness and cooking skills were part of the program. “It was a place to work and relax for low functioning patients in the hospital and in the community,” says one staffer. Centralized Services, which provided woodworking, occupational therapy and vocational skills like horticulture or ceramics, has also been cut. So has the Geriatrics Day Program. A popular summer camp project, that involved young people on a three to four day outing, was cancelled this year because there were no funds to staff it. “Back in 1974-75 we had a three-week camp, then it went to a few days and now there’s nothing,” notes a social worker. “These are people who never went to camp. They got to go on hikes. They cooked outdoors. It was great, and they rose to the occasion for it.” Poor conditions Staff refer to the strain caused by the limited disability pensions which many clients must live on. 78 “Someone can be living in high supportive housing and be getting $708 a month, but paying $504 in rent. In Homes for Special Care, your room and board can take up all but $112 a month.” Housing has improved in the region over the last few years, but there is less high support housing. The waiting list for supportive housing for forensic patients, who are often hard to place, is over a year long. Meanwhile the patients stay at WPH. Staff point out the need for a diversity of housing to meet the diverse needs and skills of the mentally ill. Transportation costs are a real burden for the mentally ill who are poor, say staff, because of their many medical appointments and the bureaucracy they must deal with. The system is too rigid and complicated. A client’s transportation costs are subsidized if there is an appointment with the doctor, but not if there is an appointment with the social worker. Coordination of services would be a real boost to the mentally ill, suggests one social worker. We have a segment of “We have a segment of society that needs compassionate support. Wouldn’t it be great if there was a central place they could go for a health card, a bus pass, society that English as a second language training. It would be a good preventative measure needs – for people to know that if they’re going to fall apart, there’s one place to go.” compassionate No mentors support. Negative management style and lack of leadership in specific professions are Wouldn’t it be among the staffing concerns raised. great if there “The mentorship that once existed is gone,” says one social worker. “It was was a central very valuable to the quality of care.” place they could go for a health Accountability to a discipline chief has been replaced by a program management system. card, a bus pass, English as a “It’s gone to a voluntary model and many of us are so taxed by direct clinical demand that we can’t respond voluntarily,” says one staff member. Another second language worried that new employees coming in don’t get the proper interactive training. leadership they need. “Lack of accountability is built into the system,” says a social worker, “A lot of things falls through the cracks.” There are no performance appraisals. Review of client files is weak: they aren’t as accurate as they could be and there are gaps in data. “That goes to direct risk management and risk assessment,” notes one staffer. It was suggested program managers might do a good job of keeping the lid on budgets but not of monitoring the clinical success of programs and the consistency and quality of care. Morale suffers Staff say professional and management salaries aren’t competitive and so recruitment to the facility is difficult.

79 “It’s hard to get a physiotherapist here and it’s led to gaps when positions are left unfilled,” says a social worker. “When you can’t hire regular staff within the facility and you’ve got positions left unfilled, it reflects on management. The salaries they pay for managers aren’t competitive and it’s a terrible situation to be caught in.” There has been a significant cut in education positions so training is patchy and Mental health professional development is down. staff say their “In our unit,” reports a registered practical nurse. “Staff are coming in with no esprit de corps training, not even in aggressive behaviours.” comes from Management’s style is authoritarian, said staff, rather than engaging the clients bonding together in a partnership. on a recent “It can undermine the effectiveness of what a program can do.” strike picket line, not from As for morale among mental health staff, they say their esprit de corps comes from bonding together on a recent strike picket line, not from morale building morale building within their institution. within their institution. Penetanguishene Central north under-served in mental health “We are having to make decisions for an ineffective system and we’re putting our own licenses and well-being on the line to do it.” Loss of psychiatric hospital beds, lack of community supports and gaps in rural service are causing turmoil for the mentally ill in central Ontario. “Our clients needs aren’t being met at all,” explains a Penetanguishene nurse. “Some are homeless and there is a back log of the mentally ill in jails and mental hospitals. “They become more acutely ill, the community is at risk and the clients are abused and taken advantage of in the community.” Nurses, social workers, forensic attendants and addictions counsellors from Penetanguishene, Collingwood and Orillia131 spoke out together in a forum about how the current health system impacts on the mentally ill. These front line workers are seeing patients discharged from facilities into a community with no support systems in place. A psychiatric hospital attendant put it this way: “There isn’t enough community follow-up, not enough community resources, not enough staff.” Nothing to replace beds When the Penetanuishene Mental Health Centre cuts beds, there aren’t the 131 Front-line workers from group homes or community agencies to care for patients who have been the Mental Health Centre, discharged. At least the residential facilities provided safe haven for the Penetanguishene and Oak seriously mentally ill, noted one staffer. Ridge Division, OPSEU Locals 329 and 307. 80 With deinstitutionalization, there are big housing problems and huge waiting lists to place clients with the community outreach teams, called ACT teams. These teams are in place to help consumers adjust to life in the community. The teams help consumers get income support, find housing, and check to see if they’re taking their medication. More people are “More people are falling through the cracks than there are people getting proper falling through treatment,” said one attendant at the Oak Ridge Division of the Mental Health the cracks than Centre. “The system is more fragmented than it ever was.” there are people Discharge of the mentally ill from public institutions, like the closure of beds at getting proper Huronia Hospital, involves seniors, who are transferred into nursing homes which aren’t equipped or staffed to deal with psycho-geriatric patients. treatment. Rural wrongs Mentally ill residents of rural Ontario not only suffer from lack of services, say staff, but also the materials, research and “best practices” used for this population are urban based and have nothing to do with rural life. Front line workers have huge geographic areas to cover. One counsellor has 200 clients, each of whom has to be seen once a week, in a catchment area that includes Muskoka, Parry Sound, Midland and Elmvale. “The mentally ill are more socially isolated. They need us to do things for them we wouldn’t normally do, like shopping for groceries, banking. Funding for medication is erratic and the Ontario Disability Support Program is simply inadequate.” Clients in crisis hurt most Front line staff spoke of suicide cases which they attribute to chaotic and inadequate resources. A Collingwood client admitted to hospital emergency was put on a waiting list for service and committed suicide in the meantime. An Orillia client, discharged because of lack of beds, also killed herself. “We have a hard time negotiating this system and we’re immersed in it,” commented one employee. “Our clients have no idea where to go to get the help they need.” Another noted that the issues of housing, public education, continuity and flow of care were all supposed to be addressed in the restructuring of Ontario health care. “None of it has been addressed and there aren’t any resources for it either.” Communities in central Ontario have varying resources for people with mental health problems and staff resources are limited. Orillia, for instance, is completely underserved, say front line workers. Orillia has a population of 30,000. Provincial cuts have been compounded, say staff, by a funding system that is unclear. The funding that used to come through psychiatric hospitals is now fragmented, explained one counsellor. There is no accountability from the community and private agencies that now get provincial money.

81 Bed loss looms Front line staff say the provincial bed count of 33 to 35 psychiatric beds per 100,000 doesn’t take into account the rapid growth in the region. It also doesn’t take into account the over-representation of mentally ill who live in Penetang They created day because of the mental health centre and the Oak Ridge forensics facility. programs to replace the beds, The government wants to cut the Penetanguishene Mental Health Centre from 247 to 204 beds, shrink the Psycho-Social Rehabilitation Program from 36 to but no one can 18 beds and reduce the Bayview Dual Diagnosis Unit from 25 to 16. come to the Employees are frustrated that the bed closures came without discussion, programs regardless of need. because there is no Notes one staffer: “They created day programs to replace the beds, but no one can come to the programs because there is no transportation for them.” transportation Penetang rates high for them. It doesn’t make sense, say staff, to apply the provincial bed norm to Penetanguishene. The city’s population of 20,000 includes 500 seriously mentally ill and 500 other manageable psychiatric clients, a very high rate for a five-mile radius. “Because the hospitals here were the resource for all the surrounding communities, a lot of patients re-located here,” explains a Penetang registered nurse. “Deinstitutionalizing patients into the community has meant discharging clients into local rooming houses with no money for transportation to their medical appointments or programs and no way to return back to their home bases.” Discharged patients are also harder work for the counsellors and outreach workers who must help the clients integrate into the community. “The workload is higher for staff,” said an attendant. “We must find them a place to live and money to live on. And that’s just for a start.” Housing crisis “We have a lot of clients who are basically homeless,” notes an addictions counsellor whose workload is rising. Lack of affordable housing is a “huge” problem for the mentally ill, say staff. “The risk of homelessness is increasing, especially for the young,” said one nurse. “This makes makes things worse for them, because if you don’t have an address, you can’t get any money.” In Collingwood and Penetanguishene, social workers have single mentally ill clients living on $520 welfare a month, with housing costs taking most of it. Clients who use local food banks, which will provide a week’s worth of food every month, must prove their need. “The resources needed just to access housing leaves nothing left for the client’s well-being. So they don’t eat, they don’t have a quality of life whatsoever, because they have to spend all their resources on housing. It just creates more need, more hospitalization and more psychiatric care.” 82 Transportation is also a big issue for the mentally ill, many of whom can’t afford even the public transit costs to get to programs and appointments. “So they’re even more socially isolated, they need us to do things for them we wouldn’t normally do, like shopping for groceries or banking.” The distribution of medications, and the funding of them for poor clients, are also a large part of the workload for staff. Prison cure There aren’t More mentally ill patients are ending up in jail because of housing problems and lack of resources in the community. There is no halfway housing in enough beds to Penetanguishene or Huronia and the men’s shelter in Midland has closed. serve people. So People with borderline personality disorders, who have poor coping skills, end they show up, up in the corrections system, say front line workers, though they could be psychotic, at the effectively treated with group therapy and behaviour management. general Pressure to discharge patients from psychiatric facilities is leaving some clients hospital, where on the street. Often they end up in hospital emergency wards, which aren’t they occupy beds trained or equipped to deal with them. in emergency. “It’s a revolving door,” says one counsellor, “there aren’t enough beds to serve people. So they show up, psychotic, at the general hospital, where they occupy beds in emergency.” Addictions services for the mentally ill are poorly managed and under new pressures from the new super jail in Penetanguishene. Deinstitutionalization of addictions patients doesn’t seem to be working, says one counsellor. And services are more and more fragmented. Elders at risk Seniors who need follow-up, supportive services or counselling are also at risk in the region. Psycho-geriatric patients discharged from Bayview Dual Diagnois Unit can’t get follow-up treatment. Bed closures at Huronia Hospital include geriatric clients now transferring to long-term care facilities. The problem is that nursing homes are ill-equipped to deal with psychiatric cases. “Nursing homes are taking them in and providing staff with a three-week course on violence and dementia, says a registered nurse. “We spend a lot of our time educating the staff in nursing and group homes on how to deal with the mentally ill.” Staff stress Burnout among the clinicians is another factor threatening mental health services in the region. Along with the cuts and increased caseloads, staff say they feel demoralized, under-appreciated and under-valued. There is a shortage of staff and no funding to bring in specialists. Communications are weak and front line staff are never consulted. “There is no help for the helpers,” says one attendant. “So clients face longer waiting lists for any psychiatrist, clinician or counsellor.”

83 An added stress, adds one employee, is trying to function in a system that doesn’t function well. “We are having to make decisions for an ineffective system and we’re putting our own licenses and well-being on the line to do it.”

Kingston No care in rural southeast: Motels and jails house the mentally ill “If you have cancer in this province, they won’t wait until you’re close to death to treat you, but with consumers you have to be a day away If you’re going from the crisis of your life to get treatment.” to move the In southeastern Ontario, the mentally ill often live in isolated motel rooms or seriously trapped in the corrections system, as Kingston’s psychiatric beds are cut mentally ill into without any matching services in the community. the community it That is the picture painted by front line staff from the Providence Continuing should never Care Centre – Mental Health Services, formerly the Kingston Psychiatric have been about Hospital, at a union forum. Correctional Officers from the Quinte Detention Centre, Probation and Parole Officers and staff from the Leeds-Grenville saving money. Counselling and Rehabilitation Services also participated in the forum.132 The choices for “If you’re going to move the seriously mentally ill into the community it should the mentally ill never have been about saving money,” says one social worker. “It should have now range from been about moving to the community. There was never a corresponding re- the street, a allocation of resources to the community.” flophouse or a As Providence Continuing Care Centre – Mental Health Services (PCCC – rooming house MHS) shrinks from 220 to 104 beds, there is currently no access to beds for where the evaluation, treatment or respite. Beds are “frozen” and a person must be landlord treats certified as psychotic before PCCC-MHS can even consider them. you badly “If you have cancer in this province, they won’t wait until you’re close to death to treat you, but with consumers you have to be a day away from the crisis of your life to get treatment.” 132 Front-line staff from Private homes substandard Providence Continuing Care Centre – Mental In closing down beds, the Providence Continuing Care Centre is discharging Health Services, (formerly patients into totally unsatisfactory living conditions say front line staff. the Kingston Psychiatric Hospital), members of “The choices for the mentally ill now range from the street, a flophouse or a OPSEU Local 431; Quinte rooming house where the landlord treats you badly,” says a psychiatric nurse. Detention Centre, members of OPSEU Local 467; Group homes run for profit may have a dozen people crammed into a three- Probation and Parole, bedroom bungalow, with cots in the furnace room. In another group home, members of OPSEU Local clients receive two pieces of bread for breakfast and told to “toast it yourself” or 427; and Leeds Grenville Counselling and a bowl of cereal with water. Rehabilitation Services, members of OPSEU Local 441. 84 Staffers say there are a number of substandard homes “but there’s a reluctance to go after them, so we hope at least the Fire Code will be applied and they’ll be investigated.” “We discharge to Tim Horton’s basically,” says one social worker. “Or to the We discharge to kind of home where, if the client gets sick they’ll lock him up in a motel outside of town for two weeks.” Tim Horton’s basically, or to “During the ice storm, we had two forensic patients at a home that housed 13 the kind of people,” recounts one social worker. “Since we hadn’t heard from them, we investigated and arrived to find them all sitting in the dining room with a home where, if candle, no heat or electricity.” the client gets Things are so bad, say employees, that one of the better facilities, an sick they’ll lock unsuccessful retirement home that was transformed into a home for mentally ill him up in a seniors, has “one nurse at night for 36 people and the cleaning staff hand out motel outside of the medications.” town for two Community living could work weeks. PCCC-MHS employees were instrumental in launching Kingston Friendship Homes, an agency that helped to develop housing in the community for consumers. Soon, it became an independent entity, renamed the Frontenac Community Mental Health Services. From the beginning, the Friendship Homes joined other psychiatric facilities in calling for deinstitutionalization. “We nurtured the idea and fostered it,” says one PCCC employee. “But when the government implemented it, they handed the responsibility off to agencies who don’t have the training or background or resources to effectively provide the best care. For one thing, Frontenac Community Mental Health Services can be very selective about whom they provide services to. They can refuse the more challenging, the difficult, the hard to treat patients.” “These agencies smelled dollars. Now it’s a very competitive field with small agencies wanting to grow. One of the key issues is: when will government take the competition out and sit down and do some methodical and rational planning.” The Mental Health Implementation Task Forces, now set up in nine regions of Ontario, have provided no opportunity for front line or union representation. “If the government were really interested in, or gave priority to, looking after the clients we serve and their families, don’t you think they’d have more than one representative of each on the task forces? Most of the task force members are upper management and academics, with one client representative and one family rep.” No standards Downloading of the mentally ill has been done without any extension of hospital standards into community facilities. There is no regulated community care and no requirement for a license, so that anyone can take the mentally ill into their home and get paid for it. 85 “There should be standards that carry over into the community, including the Fire Code and adequate space around beds (like in hospitals),” says one employee. “Each client should have a family doctor and a dentist. A nurse should give medication and professionals should do the testing and rehabilitation. There are no regulations to cover any of that.” The standards should also be made in Ontario, since the models for moving the mentally ill into the community are from the U.S. and geared to a for-profit health system and not a public one. “It’s like in corrections,” says one parole officer, “The government keeps telling us private jails will be much more efficient and much better service. Well, I suppose if they don’t have the cost of health care and the public builds the institutions so there’s no overhead, why wouldn’t it cost less?” Homeless rates up Because so many of the mentally ill are looking for shelter, they now take up much of the budgets earmarked for the homeless. One nurse explains, “The Homeless Initiative Project money for Kingston, the way it’s divided up, the lowest priority are those who are actually homeless. So homeless funds are now The downsizing used to get people out of the psychiatric hospitals and keep them out.” of psychiatric Prison rates up hospitals means the mentally ill Deinstitutionalization has also meant that some of the mentally ill who are put into the community, and cannot operate in a normal population, get stuck in a are being jail cell with no services at all. criminalized – “The number of mentally ill in correctional institutions has been escalating over bounced between the last six or seven years,” says one probation officer. penal institutions and “The downsizing of psychiatric hospitals means the mentally ill are being criminalized – bounced between penal institutions and community corrections.” community corrections. Halfway houses, which have been closed, were appropriate living for a lot of mentally ill clients because they had staff who provided support on mental health issues as well as criminal issues. “I work in forensic assessment. “We’re supposed to have 30 patients on our ward. Well, we have 35 and how many of those 35 do you think should be there for assessment before the courts? There’s one. Why? Because there’s no where else to put the others.” 6orced out Front line workers also worry about the forced relocation of the mentally ill into the community whether they like it or not. Patients are taken to an Admission/ Discharge/Transfer committee, which determines a relocation “to a flophouse or a hole,” according to one employee. “So it looks like you’re emptying beds even though the client may be back in emergency 24 hours later.” Staff say the discharge committee often forces clients to relocate back to their home region, even if they’ve been in the Kingston area for some time. Front 86 line workers consider this a violation of their clients’ rights. “In physical medicine, just because you’re diagnosed as sick in Kingston, they don’t force you to go back to Ottawa because you were born there.” Youth Gap For young offenders, aged 12 to 18 with mental problems, there is “absolutely nothing” in the way of service, front line staff say. “As much as we’re not doing well for the adults, at least we’re doing something.” One social worker considers it “criminal” that there are clients as young as 17 North of the and 18 in the penal system, confined to “long stay wards” with the severely 401 there’s very mentally ill. little in the way Services to children and adolescents have been cut back. Residential facilities of mental health for the developmentally disabled were closed, so there are no long-term services. residential beds for youth needing more than three weeks of treatment. North of There is a lack of specialized programs for youth. There is pressure on the Highway 7 there system from the lack of residential beds for young adults with developmental is nothing at all. disabilities and acquired brain injury. “There are huge gaps in service for children,” reports another social worker. “We can’t access mental health beds and CAS can’t deal with these clients because of mental health issues. There is no coordination of services so we’re criminalizing young people. If they do end up in a facility, the staff usually aren’t trained for kids that age. Why even medication doesn’t work the same on kids as on adults.” Rural wasteland When it comes to services for the mentally ill in rural areas, there’s a saying among staff: “North of the 401 there’s very little in the way of mental health services. North of Highway 7 there is nothing at all.” The mentally ill being discharged from institutions may want to go back to their homes in Westport or Portland, but all the bulk of resources and services are in the city. It is not enough to send Assertive Community Treatment (ACT) teams from the city. Although they provide 24-hour service to the deinstitutionalized clients, the criteria of patients accepted by the ACT teams is narrow and the geographic areas covered are too wide. “People want a worker close by so they can develop a working relationship with the community and support systems,” says a social worker. Historically, because of the federal corrections facilities in Kingston, there is a migration into the city. “A patient comes once for a three- or six-month stay and ends up staying in the area because the psychological support services are there,” says a long-time local resident. “This has perpetuated an imbalance, so it puts a strain on urban services and when you go to repatriate that person back home it’s difficult because they’ll lose their supports.” 87 No services, no rights The waiting lists in Belleville and Kingston are very long for rural patients awaiting care, and that’s true for shelters, counselling and AIDS services. Also If you’re rural clients constitute a very vulnerable, isolated population who don’t have the ability to advocate for themselves. mentally ill and someone has In fact there is no advocacy system or defence of the rights of the mentally ill, jammed you into as in the prison system, where inmates can take issues to an ombudsman. a motel room for “There is nowhere to go if services are unsatisfactory. In prison the advocate’s two weeks and phone number is prominently displayed. The mentally ill have no resource or outside body to investigate or act on their behalf.” comes to see you every day for five “If you’re mentally ill and someone has jammed you into a motel room for two minutes, your weeks and comes to see you every day for five minutes, your rights are being violated. But you can’t advocate for yourself.” rights are being 6ocus is costs not care violated. But you can’t advocate Front line workers feel that Ontario is following a business model rather than a for yourself. rehabilitation model in mental health. Psycho-geriatric care is falling to the hands of U.S. companies providing low quality, poorly staffed rest homes. “Not only will service to the mentally ill suffer, the institutions will be staffed by aides and high school students.” At Providence Continuing Care Centre, the in-house laundry service had a two- day turnaround. It did mending for patients and outpatients. It was contracted out to a regional laundry service where employees earn less money. The turnaround time for laundry is now eight days and the quality is poor. In another example of mindless contracting-out, PCCC-MHS staff discovered that client employment plans which including setting a goal and making a work plan, and which took them one hour and 30 minutes to produce, are now being contracted out by the Ontario Disability Support Program (ODSP) at a rate of $400 apiece. Staffs are stretched Human resources in mental health are as fragmented as the system itself. Staffing levels are down, staff training is lower and standards of training and care are weak. Staff have no training to deal with new populations of the mentally ill, like people with developmental delays or acquired brain injuries and dual diagnosis patients. Correctional officers are given no training to deal with the large number of mentally ill who fall into the prison system. “Morale is as low as it could possibly go,” says a registered nurse. “It’s been an all-out assault on front line workers. It’s not a cooperative effort to resolve issues and provide the best possible service to clients.” One staffer recounts that her unit had 30 beds and three outpatients in 1996. “Now we have 35 beds, 22 out-patients and we’ve gone up by one staff person. – one nurse to do community support for all those patients.” 88 Staff are being lost by attrition, because of working conditions and because salary levels aren’t competitive with the hospital sector. We take an oath “Some hospitals, for instance, recognize that there’s a nursing shortage and so to provide they’re treating the nurses better. That doesn’t happen in mental health.” quality care to The current system even threatens the professional oaths taken by health care our clients and providers. when you’re “We take an oath to provide quality care to our clients and when you’re working for an working for an organization where that’s not the specific mandate, you can’t organization fulfill the oath and, well, that organization won’t attract the most proficient people, will it?” where that’s not the specific mandate, you Brockville and Ottawa can’t fulfill the Patients are in peril and in Canada’s capital, food oath. banks sustain the mentally ill.

“We know cases of people suffering, even dying. Some of our clients come to appointments hungry.” Patients deinstitutionalized from the Brockville Psychiatric Hospital live in serious danger because necessary life supports aren’t available to them in the community. And poverty levels in eastern Ontario hamper attempts to integrate the less-acute mentally ill into society. These are the major concerns of counsellors, social workers and therapists from Royal Ottawa Hospital and the Brockville Psychiatric Hospital who participated in a union forum133. Brockville Psychiatric Hospital was taken over by Royal Ottawa Health Care Group in October, 2000. Prior to that, it was directly operated by the provincial government. “Most front line workers know cases of patients suffering, and even dying, after being divested from hospital without proper housing or community resources to handle them,” says a BPH social worker. The Brockville area has lost 550 psychiatric beds since the “restructuring” of Ontario health care. “Poor planning and lowered staffing levels mean mentally ill clients are showing up in police custody, on the street or in emergency rooms at local hospitals, where staff aren’t trained to deal with them.” 133 Front-line workers from the Royal Ottawa Poverty is key Hospital, the Royal Hospital Health Care An Ottawa caseworker says: “We are having to rely on food banks more Group (Brockville, heavily for our clients, some of them come to appointments hungry.” formerly Brockville Research shows poverty has a clear impact on mental health, explains a Royal Psychiatric Hospital), and Queensway Carleton Ottawa Health Group (ROH) social worker. Hosptial. They are “Can we get the task forces and the government to recognize that the largest members, respectively, of OPSEU Locals 479, 439 single indicator of child abuse is unemployment? We’ve had 6,000 people and 491. 89 made unemployed in Ottawa-Carleton in September, 2001. Don’t we think that will have an impact on kids very soon?” Vicious circles There are huge obstacles built into the system, say employees. “They want patients to get a job but there is no provision for transport, clothing, food, daycare. If you don’t manage to finish your training course, you go onto welfare, which hasn’t risen since 1995. This makes people crazy. It is mean- spirited and destructive.” Government Another employee notes that there are too many Catch-22s for the mentally ill. should focus on services like “I have a client in despair, living in a home owned by her brother, so she receives only $135 from welfare per month. She is trying to take a course but is housing, income in such a state of agitation over finances because she can’t find a job to get off support, day welfare. And she’s not a priority for public housing, so that is not an option.” programs, school Employees point out that government should focus on services like housing, and home care if income support, day programs, school and home care if it is serious about it is serious integrating the mentally ill. about “Recognizing all the components of mental health – like income, housing and integrating the social involvement would do more to unclog the system than all the re- mentally ill. organization, integration and streamlining that we’re undergoing now,” said one therapist. Decade of deterioration The situation is worse for the mentally ill than it has been for 10 years, says a Queensway-Carleton Hospital staffer, pointing to the street people created by deinstitutionalization and the housing crisis. It is difficult to get accommodation for patients when psychiatric hospital beds are shut down. Families already wait seven years for Ottawa Housing. In Brockville, a city with a large proportion of consumers, finding housing for the mentally ill is really tough. “They’re just put out there and forgotten because the funding isn’t in place to help them,” says one social worker. Brockville staff see more young clients falling through the cracks and getting in trouble with police. “Police are overtaxed by our clients,” said another social worker, “people don’t know whom to call when the mentally ill are disruptive.” Says another BPH staffer: “We’re seeing a wholesale transfer of services and problems, that used to be dealt with here, moved downtown – to the shelters, the streets and the police – without the structures or the experience there to deal with them.” During restructuring, the government has been in denial about the fact that some acute cases simply cannot live in the community, say front line workers. Instead the seriously ill are being divested regardless of their needs. They are currently disrupting hospital emergency rooms and homes for long term care, where seniors with dementia are being placed with other patients. 90 ACT teams need support Assertive Community Treatment teams are operating to help the mentally ill integrate into community living. But in Belleville, the teams get bogged down doing things for patients that aren’t treatment-oriented, like trying to get the patient some income, taking the patient to medical appointments or to the food bank. “That doesn’t help clients get into daily living,” says one staffer. “In Ottawa it Although the took three months to refer a client to ACT. If there were more community severely supports the ACT teams could do their jobs and the clients could move on.” In mentally ill can Brockville the ACT teams are under-resourced, say staff, and the waiting lists be stabilized, are long. front line Although the severely mentally ill can be stabilized, front line workers have no workers have no resources to follow up with clients, so there is no stabilization and even less resources to preventative care. follow up with “The government says it wants to integrate the mentally ill into the clients, so there community,” says one counsellor, “but instead we have fragmented services, is no waiting lists, poor utilization of acute beds and difficult to access specialized services.” stabilization Make the links and even less preventative Front line workers in the Champlain district say there has been a failure in care. Ontario to think systemically; to link mental health to necessary support systems in the community. “There seems to be a failure to recognize that clients usually need a whole range of services. When they don’t get that range, they end up in acute mental health services.” More than one employee commented on the mean-spiritedness of the current system. It is suggested that a perfect illustration is the new policy for Ontario’s Community Care Access Centres, where seniors must accept the first bed available to them, no matter where it is in the region. “That kind of one-size-fits-all approach can lead to deterioration in the mental health of a patient.” The province also applies the urban model to rural residents and that doesn’t work either, noted one counsellor. “Some people need 24-hour support, some people need eight- to 12- hour support, some people need an hour a day and some need to call a counsellor on an emergency basis,” explains a social worker. “There needs to be a range of housing options right up to 24-hour support with nursing assistance, day programs, places where people go to do things, vocational, recreational and learning experiences.” Cuts are the problem The political agenda that underlies health restructuring means cost cutting and centralization, say front line staff. 91 “The process is like re-arranging the deck chairs on the Titanic,” says a vocational counsellor. “You can’t deliver because you’ve sucked so much money out of the system.” “It’s doing everything on the cheap,” says a Brockville staffer. “The underlying thread that ties it all together is privatization. They’re claiming it’s cheaper, but when you have to extract a profit, that profit comes from reducing expenses and reducing service.” Patients suffer “We are placing clients in Homes For Special Care, sometimes run by a guy who isn’t sufficiently trained and has trouble reading the meds dosages,” says a Brockville social worker, in connection with widespread criticism of group homes for profit. A food service employee at the ROH said corporate management of hospital food has meant the budget for patient meals has been cut in half. “Everything now is boxed or freeze dried, the quality is way down.” The company contracted to handle the non-medical services at the ROH recently won a business award for getting the ROH food budget down to $4.03 per patient per day. “What’s left is a government that says it’s deregulating these homes and services for the mentally ill and letting people police themselves, so we have unqualified cheap labour and all the things that led to Walkerton.” Long lists In Ottawa-Carleton, cuts and “reshuffled resources” in mental health have simply increased waiting lists and focused all attention on crisis situations. At the Royal Ottawa, the day program waiting list varies from one to three months. The waiting list to see a psychiatrist in Ottawa is six months. In Brockville there is one psychiatrist for every 400 outpatients. “So our clients get poor service, they don’t get the help they need to get them stable and out into the community,” says a registered nurse. “They just get One therapist sicker.” tells of a client The only way to get help in the mental health system is to have a crisis, who waved a explained front line staff. One therapist tells of a client who waved a machete machete around, around, because he knew it was the only way to get immediate assistance. because he knew “But then the patient is discharged quickly and there is no home care. With no it was the only home care you go into relapse and end up back in the hospital.” way to get When Brockville Psychiatric Hospital was being cut, say staff, it was promised immediate that no unit would be cut without services in place in the community. assistance. “Now the vocational centre, which serves 20 to 25 people, will be cut with no replacement,” explains a counsellor. “The philosophy is everyone should get a job for real wages and that’s fine for the few who can, especially those who haven’t been affected with mental illness all their lives. But there has to be a range of services for those who can’t.” 92 One staffer recalled cancellation of the day treatment centre for elderly dementia patients who were awaiting long-term placement. “My mother had Alzheimer’s and people loved the program and it worked for her. It was a wonderful program and a great respite for families. It was shut down lock, stock and barrel with nothing to replace it.” The walking Any day programs that are left are “overwhelmed with waiting lists” say staff. wounded won’t Only the severe be taken at There are few resources for the prevention of mental illness and people with hospital lesser mental illnesses also have trouble accessing services. emergency. “These days,” says one social worker, “the system is focused totally on the There is a six- seriously mentally ill and not the walking wounded.” month waiting “The walking wounded won’t be taken at hospital emergency, there is a six- list for a month waiting list for a psychiatrist and if they don’t have the money for other psychiatrist and providers, they’re out of luck.” if they don’t Likewise, there are long waiting lists for outpatient programs. have the money “Young people can wait for months to see a youth psychiatrist and we’re for other seeing people go to emergency just to try and speed up their access to providers, outpatient services.” they’re out of Staff over-worked, under-valued luck. Increased workload in the mental health sector is a major concern for employees. And they are frightened at the prospect of under-staffing when the boomer demographics peak. Current micro-management by the Ministry of Health is neither client-focused nor consultative with front line workers. “The top-down model we’re supposed to buy into is a model we haven’t had a role in creating,” says one social worker. “The system now ignores the role modeling and mentorship that are the art of working in mental health. If you don’t have a team, if you don’t make it so your staff stays, then you aren’t providing an excellent system.” Staff report burnout and demoralization. Vacancy rates in Brockville show a chronic problem of under-staffing, say employees there. It is partly due to a chronic sense of uncertainty; partly it’s a way of saving money. For example, no vocational counsellors have been hired in Belleville since the union won a grievance seven years ago. At the ROH there are job postings but they aren’t filled. All this leads to large workloads. “No stable structure, no stability in staffing, no longer term planning,” is how one Brockville staffer sums it up. Sick leave up “Our sick leave statistics aren’t as high as for nurses,” says an Ottawa case worker, “but that’s because mental health staff can’t be sick – there’s no one to step in if you don’t show up. Rather than leave it to your colleagues, you drag yourself around.”

93 When front line staff in Brockville are absent they are not replaced. Employees are being asked to do things, like work alone in risky situations, which produce undue stress on them and their clients. Brockville staff are struck by the lack of transparent planning in the system. There is confusion among staff and clients as to what resources will be available in the future. There is no interplay between management and front line staff when it comes to planning. “Yet the needs are so much more obvious now,” says one social worker. “So is the need for consultation.” They seem to In Brockville, some programs and buildings have closed, some have been left in think labour’s limbo and there is general uncertainty. view will be self- “The government is creating such a stressful environment for everyone working serving, but we in it,” says a registered nurse. “And in an increasingly insecure system, the have genuine patients feel it and so do their families.” concerns for No role for front line people in this system. Employees lament there is no role for front line staff in the mental health implementation task forces currently operating throughout the province. “They seem to think labour’s view will be self-serving, but we have genuine concerns for people in this system.” “Staff strengths are ignored,” says one counsellor. “The wealth of experience from people with a commitment and dedication to the mentally ill is down- played. The Ministry has also stripped down all our discretion, so to give people a little extra or help them out you would have to do something fraudulent.” Front line staff also report insufficient French-language services in eastern Ontario. They also fear the Mental Health Authority’s new Fund-raising and Volunteer Coordinator branch will weaken natural volunteer constituencies and focus on charity to pay for mental health services.

North Bay and Sudbury Neglect and danger for mentally ill in the northeast

“We’re fearful and we don’t see much future for our clients.” Children and seniors are neglected and consumers are trapped on the streets, as services to the mentally ill are restructured in Ontario’s northeast. Social workers, therapists and registered nurses from the North Bay Psychiatric 134 Front-line workers from Hospital and Northeast Mental Health Centre in Sudbury134 tell of suicides and the North Bay Psychiatric clients embroiled in the criminal system because they can’t get treatment. And Hospital, OPSEU Local 636 and Northeast Mental it’s because psychiatric institutions have been closed without proper community Health Centre in Sudbury, supports in place. OPSEU Local 666. 94 The North Bay Psychiatric Hospital is one of four Provincial Psychiatric Hospitals still directly operated by the province. However, the Ministry of Health has plans to divest it to a general hospital. “Our clients are suffering, and dying in some cases,” says a registered nurse. We are forced to “They leave the institutions, have no contacts in the community and no proper work really shelter.” hard to keep Says a social worker: “We are forced to work really hard to keep people in people in substandard living conditions. Instead of rehabilitating them, we do control and substandard surveillance.” living “But it shouldn’t be just about getting people medicated and getting them out. conditions. It’s about ensuring that all the systems are in place and that includes Instead of socialization and inter-personal relations.” rehabilitating No strategy to cuts them, we do In Sudbury, the region’s 72 beds for in-patient acute care services have been cut control and to 39. surveillance. “Community services won’t make up the difference,” says a counsellor. “Everybody knows it but nobody talks about it. So it’s chaos, in that there is no strategic plan. The government hasn’t done its homework, for instance, to say that if we invest here in community services then there will be less demand for acute care in hospital emergency rooms.” “Our patients who have left hospital have substandard living conditions, are pan-handling. There are no GPs in the community, so there is lack of follow-up and they get re-admitted to hospital.” Divestment has begun at the North Bay Psychiatric Hospital with “community services” no longer a part of the facility. The hospital has 307 beds officially but the number has been cut back to 240, because, say staff, the hospital is reducing in-patients in an attempt to pay off its debts. The move has created a crisis with waiting lists. “We, as workers at the psychiatric hospital are like surrogate parents to our clients – I feel that connection to them,” says a front line worker. “They will have to maintain beds because there is no room in the community for some people. They have to be institutionalized.” No housing There is a lack of education and public awareness about moving the mentally ill into the community, say employees, and housing is the major drawback. “I know every slum landlord in town and many of them I wouldn’t want my clients living with,” explains one therapist. “We have a few good landlords now and they’re trying to give us breaks. But this shoving people out of a hospital into the community, with no support, no back-up, no medical or psychiatric coverage…it’s wrong.” An occupational therapist, who works in a small room with 18 clients, says counselling and rehabilitation are becoming things of the past.

95 “Instead of the goal of secure care in the community, pharmacological solutions are the norm.” If services aren’t available for the mentally ill in the community, divestment should stop, says a social worker. “It’s wrong.” “We advocate for these people and there is so much we want to do. There are only eight people on my 10-person ACT team because of budget cuts. It’s frustrating.” Dangerous work One front line worker reports that three patients have disappeared over the last There is a lot of while and a local crown official predicted the next inquest would be over the burnout among death of a client or a worker on an Assertive Community Treatment (ACT) staff on the ACT team. The 10-person teams work with the mentally ill to help them adapt to teams, who are living in the community. highly trained The ACT teams are at the heart of mental health services, providing 24-hour and specialized service to the mentally ill living in the community. professionals. “We’re always there,” says one team member. “Phone calls at 3 a.m. aren’t my They are liable cup of tea, but I’ll answer the pager and call back.” to confront There is a lot of burnout among staff on the ACT teams, who are highly trained danger with and specialized professionals. They are liable to confront danger with violent or violent or psychotic patients. psychotic ‘It’s a high stress job and we’ve had 10 people leave in the last two years,” says patients. one team member. “Now they want to contract in staff without the specialized training and there isn’t enough training time. It’s become a health and safety issue.” ACT is key The teams are the lynchpin in the divestment of consumers from institutions. “We’re the ones who will be looking after the severely mentally ill who’ve been discharged after years of institutionalization,” says another team member, “Yet the ACT teams are not staffed or funded properly.” Increases in workload, since provincial cutbacks, have also included Ministry- imposed workload measuring that employees say doesn’t focus on client needs or the skills of staff. “These days a front line worker spends 5 per cent of the time with the client, 70 per cent on administrative matters and 25 per cent on clerical matters,” says one employee. “We work our buns off with the small amount of money we have to work with. Yet we have to document all the time. It’s all statistic-driven. A social worker explains: “Therapy is out, medication is in and the practice of social work is shifting to discharge planning and negotiating with other government programs for appropriate services because that’s what my clients need. It’s a non-utilization of resources.” Says a psychometrist: “We spend so much time on paper-work, yet there is such a wealth of experience among us, and a commitment and dedication to the 96 mentally ill.” Need for prevention Other employees worry that restructuring has placed all the emphasis on the severely mentally ill with no provisions for geriatric or pediatric services. “There is nothing for seniors, the idea is obviously to get them back to their families or into a nursing home, which as we know have four to five year waiting lists,” says a social worker. “Children’s needs are also ignored and it’s costly if you don’t do prevention and early intervention with children.” Many people fall through the cracks because of cutbacks, said staff in Sudbury. “There are a lot of lost people with psycho-social illnesses. Because we deal This is leading only with the severely mentally ill at the outpatient clinic, the walking wounded to a crisis are not being helped. There is an adult mental health care program being run because the out of the public health unit but it’s going to be closed soon.” holding beds In North Bay, the outpatient clinic used to deal with 700 clients. It has been cut and emergency to 500 and is taking no new clients. Patients in crisis are sent back to their family doctors or hospital emergency rooms or walk-in clinics. wards use low- paid, low-skilled “All this is leading to a crisis because the holding beds and emergency wards security guards use low-paid, low-skilled security guards to oversee the holding beds. This scares the mentally ill patients and the rest of the hospital.” to oversee the holding beds. Employees say restructuring has meant “taking mental health services in Temiskaming and throwing them in with services in North Bay under one This scares the umbrella and one pot of money.” mentally ill “That’s not cohesive, it fragments services, creates distrust and slows down the patients. pace of care.”

Thunder Bay

Shortages and chaos in mental health in the northwest “We see the increased vulnerability of our clients, decreased opportunities for them, weaker access to housing, medical care and jobs.” The mentally ill in northwestern Ontario face confusion and chaos as psychiatric facilities are closed without the resources in place to care for patients in the community. And there is a deep concern among front line mental health and corrections’ staff135, that more of the mentally ill are trapped in the corrections systems.

Staff from the Lakehead Psychiatric Hospital, Thunder Bay Jail, Thunder Bay 135 Front-line staff from Correctional Centre and from Probation and Parole participated in a union Lakehead Psychiatric forum on mental health care. Hospital, Thunder Bay Jail, Thunder Bay “We’re seeing the criminalization of mental health,” says a Thunder Bay social Correctional Centre and worker. “There aren’t the resources to help people in the hospitals or the Probation and Parole. They community, so they end up in jail.” are members, respectively, of OPSEU Locals 720, 737, 708 and 701. 97 It is estimated that 25 per cent of the inmates of local correctional facilities have a diagnosed mental illness and a possible 40 per cent have undiagnosed mental illnesses. “And the correctional officers don’t know how to handle these people when they hear voices or get scared. We’ve seen special needs kids in handcuffs and shackles.” What replaces LPH? A major problem is that the community has lost its one-point entry for the region’s mentally ill at the Lakehead Psychiatric Hospital, (LPH) which has cut beds and is due to close. The Thunder Bay Regional Hospital and the Canadian Mental Health Association are two new points of entry. There is no agency in place “That has created gaps,” explains a registered nurse. “Each facility has different to undertake the criteria, depending on the mental health problem. There are a lot more patients falling through the cracks, the result has been less accessibility.” psychiatric hospital’s role in One social worker puts it another way: “The patients are suffering like hell, they don’t know who is looking after them.” accepting ANYONE with Staff at the LPH say general hospitals aren’t equipped or trained to handle mental mental illness emergencies. And there is no agency in place to undertake the psychiatric hospital’s role in accepting anyone with mental problems. The LPH problems. was the only service that provided help to mentally ill people who were also poor, homeless or without a family doctor. “When clients are discharged from hospital, it’s more confusion and chaos when it comes to accessing community services for them,” explains one staffer. “There are increased complaints from clients about the lack of service.” Bed shortage When the LPH closes its 97 psychiatric beds, staff agree that the provision to have 38 beds opened at St. Joseph’s will “clearly be insufficient.” Thunder Bay has the largest number of brain-injured clients in the province. “This piece cannot be forgotten,” notes one counsellor. “Many of these people were born mentally challenged. They run into trouble in group homes. Where will they go when the LPH closes?” There should be a moratorium on bed closures, suggests a registered practical nurse, and services should be in place before the LPH is closed. Employees are concerned that groups who have applied to establish community programs plan to use generic workers instead of professional, experienced staff. “How will unregulated health professionals affect our clients?” Inadequate housing for the mentally ill is a key issue, with patients discharged from LPH or prison ending up at Shelter House. “That’s your community-based service,” notes one employee sadly.

98 Shelter House in Thunder Bay is, in fact, the only emergency housing for the mentally ill of the community. At a local drop-in for the homeless, it is estimated 80 per cent of the clients have a history of psychiatric care. Lesser needs not met There is a It is not just services to the seriously mentally ill that are being fragmented, particular lack explain the staff, but the general public is also affected. of services for “Take yourself,” says a social worker. “If you have a crisis in your life, you young people may need help. You’re stressed out, but you won’t find answers because you’re with special referred to one person and then to another. By then you may be seriously ill, needs or just because you couldn’t make one phone call to understanding people who behavioural had the resources available to help you.” problems and One front line worker notes that there is a particular lack of services for young youth with people with special needs or behavioural problems and youth with developmental handicaps. developmental handicaps. Staff say that the provincial government claims the goal is an integrated, non- fragmented seamless service. “It’s the very opposite of that today,” says an occupational counsellor. “People are so confused right now.” Bad idea, poor design Employees question why Ontario is undertaking deinstitutionalization of the mentally ill since U.S. and English jurisdictions who have tried it, warn against it. “I’ve taken case management,” says one social worker. “Believe me, the U.S. model is more costly.” One rehabilitation counsellor worries that the province intends to design a mental health system for poor people, “and so it will be a poor service.” “You don’t get a lot of people with power and money trying to access services at the LPH – it’s the poor, the down-trodden, people who’ve been denied disability pensions, they don’t have a voice to speak out about quality of service.” Another staffer counters that wealthy patients are admitted to the LPH. “The problem is that the system isn’t designed for poor people, people who don’t have a family to lobby for them, people who end up on the street or in jail when they aren’t given the help they need.” Crisis patients Employees are worried that suicides among their clients have risen during the current cuts. Also, crisis intervention is the rule. There is no prevention work being done. Staff feel that the government focus on “recovery” has meant there is no funding or support left for the hard-to-treat and the non-recovering. A big question for many providers is: where will the elderly who are acutely mentally ill be served in the new system? The long-term care needs of seniors 99 who have dementia is a real problem, say staff, who have noticed more operators of long term care homes looking to dump patients who get tough to handle. Staff report that there is no longer quick access to service for clients in crisis who aren’t sick enough for the hospital, but may need medication. Those patients can’t access anything immediately. “But trust me, wait long enough and they will need the hospital,” says one employee. There has been chaos, say staff, because the 24-hour emergency service at the LPH was cut to eight hours, put back up to 16 hours and is now closed on weekends. Bureaucracy is Staff shortages bigger, there is a Another key question is how to pay, recruit and maintain psychiatrists in lack of Thunder Bay “when we can’t even keep the ones we have.” leadership, There is a strong sense among front line employees that the mental health communication system in Ontario has shifted focus away from “hard-working, experienced staff and vision. who have a commitment to help the mentally ill.” They say bureaucracy is bigger, there is a lack of leadership, communication and vision. Morale is plummeting and it’s difficult to recruit staff. “So we have inconsistency of service and absolutely terrible staff morale,” says one Correctional Officer. The impact of the chronic shortage of doctors in the north can’t be underestimated, say staff. The desperate need for psychiatrists means that at least 70 people are on the waiting list for urgent care. And as it stands, the existing psychiatrists don’t have adequate services and resources to tap into for their clients. One front line worker speaks of “a mental health system so costly and weighed down by the requirement for psychiatrists.” “Maybe it’s time to focus on costs in a different way. A focus that sees the real value of psychologists and psychometrics and social workers. You can have several of them for the cost of one psychiatrist.”

100 Chapter 9: Recommendations

1. The province must stop closing beds in the current and former Provincial Psychiatric Hospitals (PPHs) as there is an urgent and demonstrable need for those beds. 2. The province must order an increase in the number of acute mental health beds in Ontario’s hospitals in order to eliminate waiting lists and prevent the practice of prematurely discharging patients from hospitals. 3. The province must order an increase in forensic beds in psychiatric hospitals to alleviate the wide-spread problem of the mentally ill being in our jails and correctional centres and eliminate waiting lists at hospitals. 4. The province must legislate and enforce standards of quality and care wherever services to the mentally ill are provided, including but not limited to housing, and establish an accountable provincial body to enforce the standards. 5. All general hospital emergency rooms must have skilled and qualified psychiatric staff on hand 24 hours a day, seven days a week. 6. The province must ensure that every psychiatric consumer has the right to publicly-funded and publicly-delivered mental health services. Support services in hospitals, such as laundry, dietary, housekeeping, security and maintenance are an integral part of publicly-funded health care and should not be contracted out. 7. The province must increase the income support that individuals receive from the Ontario Disability Support Program in order to more adequately and humanely meet the needs of the mentally ill.

101 8. The province must develop and implement publicly-funded and publicly-operated community supports for the mentally ill, including supportive housing for consumers who are discharged from hospitals. 9. The province must develop and implement social and vocational rehabilitation programming to meet the needs of the mentally ill and integrate it into the continuous care model. 10. The province must not allow the closure of beds, programs and services in the former and current Provincial Psychiatric Hospitals until their equivalent is available in the community. 11. Community agencies must not have the right to refuse consumers. 12. The province must study the impacts of the integration of addiction and mental health services at the Centre for Addiction and Mental Health in Toronto before undertaking any further integration of addiction and mental health services.

102 Appendix 1

The divestment of the Provincial Psychiatric Hospitals

• London and St. Thomas Psychiatric Hospitals were divested to St. Joseph’s Health Care, London, Feb., 2001. • Hamilton Pyschiatric Hospital was divested to St. Joseph’s Health Care, Hamilton, Nov., 2000. • Queen Street Mental Health Centre was merged with the Clarke Institute of Psychiatry, the Addiction Research Foundation and the Donwood Institute to become the Centre for Addiction and Mental Health in 1998. • Kingston Psychiatric Hospital was divested to Providence Continuing Care Centre, March, 2001. • Brockville Psychiatric Hospital was divested to the Royal Ottawa Health Care Group, Oct., 2000. • The four remaining Provincial Psychiatric Hospitals are: Whitby Mental Health Centre, North Bay Psychiatric Hospital, Lakehead Psychiatric Hospital and Mental Health Centre Penetanguishene and Oak Ridge Division.

103 Appendix 2

OPSEU’s record of publications on Mental Health

Ontario’s Mental Health Care Breakdown, 1979. Madness: An Indictment of the Mental Health Care System in Ontario, 1981 Ontario Mental Health and Heseltine, A recipe for restraint: A discussion paper on mental health, June 1983 Ontario Health Care Directions: Sounding the Alarm 1983 We are all guilty: a report based on a public hearing sponsored by the Ontario Public Service Employees Union at North Bay to study the needs of consumers, March 1985 Highlights from the Hucker Report on Oak Ridge Mental Health Centre: An analysis of the report by OPSEU, 1986 Mental Health Care in Crisis: Ontario’s psychiatric nursing shortage, October 1989 Care For Those Who Need It – Principles of a Comprehensive Mental Health Care System 1991 Community Reintegration: Putting the System in Perspective 1993 Mental Health Reform in Ontario: Developing Our Vision 1993 Submission to the Health Services Restructuring Commission regarding the proposed amalgamation of the Clarke Institute of Psychiatry and the Queen’s Street Mental Health Centre, submitted by OPSEU Local 531, November, 1996. Submission to the Health Services Restructuring Commission, Submission by Local 720, Lakehead Psychiatric Hospital, 1996. Analysis and Arguments for Keeping Brockville Psychiatric Hospital Open: Submission to the Health Services Restructuring Commission, March 1997 Submission to the Hon. Jim Wilson , Minister of Health, regarding London and St Thomas Psychiatric Hospital, Submitted by OPSEU Locals 111 and 114, April 1997. Submission to the Health Services Restructuring Commission regarding the Hamilton Psychiatric Hospital, Submission by OPSEU Local 203, January, 19, 1998. Submission to the Health Services Restructuring Commission from OPSEU Local 431, Kingston Psychiatric Hospital, October, 1997 Follow up submission to the Health Services Restructuring Commission from OPSEU Local 431, Kingston Psychiatric Hospital, December, 1997 Mental Health Reform: A Kingston Perspective, Submission from OPSEU Local 431, Kingston Psychiatric Hospital, February, 1998. OPSEU Responds to Contracting out at the Centre for Addiction and Mental Health, Submitted by OPSEU Locals 531, 5104 and 541, September 10, 1998. Submission to the Health Services Restructuring Commission Regarding the North Bay Psychiatric Hospital, Submitted by OPSEU Local 636, November, 1998.

104 Appendix 3

Participants in OPSEU’s workshops on mental health

OPSEU staff from the following workplaces participated in the workshops: • Regional Mental Health Care, St. Thomas (formerly St. Thomas Psychiatric Hospital) • Regional Mental Health Care, London (formerly London Psychiatric Hospital) • St. Joseph’s Health Care – Mountain Health Services (formerly Hamilton Psychiatric Hospital) • Niagara Health System (the amalgamation of eight Niagara Region hospitals) • Mental Health Centre, Penetanguishene and Oak Ridge Division • Centre for Addiction and Mental Health – Toronto • Whitby Mental Health Centre • Providence Continuing Care Centre (formerly Kingston Psychiatric Hospital) • Leeds-Grenville Rehabilitation and Counselling Services • Quinte Detention Centre • Probation and Parole – Kingston • Royal Ottawa Health Care Group – Ottawa • Queensway-Carleton Hospital – Ottawa • The Royal Hospital Health Care Group – Brockville (formerly Brockville Psychiatric Hospital) • North Bay Psychiatric Hospital • Northeast Mental Health Centre – Sudbury • Lakehead Psychiatric Hospital • Thunder Bay Jail • Thunder Bay Correctional Centre • Probation and Parole – Thunder Bay

105 Published by the Ontario Public Service Employees Union 100 Lesmill Road, Toronto, Ontario M2B 3P8 www.opseu.org 106