Community Mapping – Operational Review

ACKNOWLEDGEMENTS

Kahui Tautoko Consulting Ltd (KTCL) wishes to thank the management and staff of the participating First Nations communities including Chiefs and Council, Health Directors and their teams and the members of the First Nations community focus groups; tribal council members and other First Nations participants such as the National First Nations Health Technicians Network (NFNHTN) and members of the Non-Insured Health Benefit (NIHB) Navigators Network.

We also thank and acknowledge the key stakeholders from provincial and territorial health services, private counsellors and practitioners; and Health Canada nursing personnel who participated.

We acknowledge and appreciate the leadership, support and advice of the Assembly of First Nations (AFN), the First Nations and Inuit Health Branch (FNIHB) and members of the NIHB Joint Review Steering Committee (JRSC) who are undertaking this review.

TABLE OF CONTENTS ACKNOWLEDGEMENTS ...... 2 TABLE OF CONTENTS ...... 3 GLOSSARY ...... 4 EXECUTIVE SUMMARY ...... 5 INTRODUCTION ...... 19

OVERVIEW...... 19 DEFINING SHORT TERM CRISIS INTERVENTION MENTAL HEALTH COUNSELLING...... 19 SHORT-TERM MENTAL HEALTH CRISIS INTERVENTION IN A FIRST NATIONS CONTEXT ...... 21 THE NATIONAL NON-INSURED HEALTH BENEFITS (NIHB) REVIEW ...... 21 NIHB SHORT TERM CRISIS INTERVENTION MENTAL HEALTH COUNSELLING (STCIMHC) BENEFIT ...... 22 THE INDIAN RESIDENTIAL SCHOOL: RESOLUTION HEALTH SUPPORT PROGRAM (IRS: RHSP) ...... 22 PROVINCIAL / TERRITORIAL SERVICES ...... 23 THE FIRST NATIONS MENTAL WELLNESS CONTINUUM FRAMEWORK ...... 23 METHODOLOGY ...... 25

REVIEW OBJECTIVES ...... 25 REVIEW OUTPUT ...... 25 REVIEW METHODS ...... 25 LIMITATIONS OF THE REVIEW ...... 34 ANALYSIS OF FINDINGS ...... 36

HOW ACCESS TO THE STCIMHC IS EXPECTED TO WORK ...... 36 KNOWLEDGE OF – AND ACCESS TO - THE STCIMHC BENEFIT ...... 38 CURRENT CRISIS INTERVENTION SERVICES AND MODELS ...... 41 CONCLUSIONS ...... 45 RECOMMENDATIONS ...... 55 APPENDICES...... 59

SITE REPORTS ...... 59 NOVA SCOTIA / NEWFOUNDLAND REGION: WAYCOBAH FIRST NATION ...... 60 NEW BRUNSWICK / PRINCE EDWARD ISLAND REGION: OROMOCTO FIRST NATION ...... 70 SASKATCHEWAN REGION: PIAPOT FIRST NATION ...... 80 ONTARIO REGION: OJIBWAYS OF GARDEN RIVER FIRST NATION ...... 89 ALBERTA REGION: STONEY BEARSPAW FIRST NATION ...... 101 QUEBEC REGION: CONSEIL DES ATIKAMEKW DE WEMOTACI FIRST NATION ...... 111 NORTHWEST TERRITORY: LUTSEL K’E DENE BAND ...... 128 MANITOBA REGION – PAUINGASSI FIRST NATION ...... 139 YUKON TERRITORY: VUNTUT GWITCHIN FIRST NATION ...... 152

GLOSSARY

AANDC Aboriginal Affairs and North Development Canada ADI Aboriginal Diabetes Initiative AFN Assembly of First Nations AHAC Aboriginal Health Access Centre AHP Aboriginal Health Program AHS Alberta Health Services BF Brighter Futures BHC Building Healthy Communities CBT Cognitive Behavior Therapy CEP Common Experience Payments CISM Critical Incident Stress Management [debriefing] CPNP Canada Prenatal Nutrition Program CSSSPNQL Commission de la santé et des Services Sociaux des Premières Nations du Quèbec et du Labrador CSU Crisis Stabilization Unit CYFN Council of Yukon First Nations EMS Emergency Management Services FASD Fetal Alcohol Stress Disorder FNIHB First Nations and Inuit Health Branch (Health Canada) FSIN Federation of Saskatchewan Indian Nations GNWT Government of the Northwest Territories HHN Horizon Health Network IAP Independent Assessment Process IERHA Interlake-Eastern Regional Health Authority IRS: RHSP Indian Residential School: Resolution Health Support Program (FNIHB Program) JRSC Joint Review Steering Committee KTCL Kahui Tautoko Consulting Limited LHIN Local Health Integration Network MCFD Ministry of Child and Family Development (or similar) MHMCT Mental Health Mobile Crisis Team NASYPS National Aboriginal Youth Suicide Prevention Strategy NFNHTN National First Nations Health Technician Network NGO Non-Government Organization NNADAP National Native Alcohol and Drug Addiction Program (FNIHB Program) NIHB Non-Insured Health Benefits NHS Native Health Service NSHA Nova Scotia Health Authority NPTP Northern Patient Transportation Program OTN Ontario Telemedicine Network PACT Program for Assertive Community Treatment PIP Prevention, Intervention, Postvention [suicide framework] RCMP Royal Canadian Mounted Police RHA Regional Health Authority STAR Success through Advocacy and Role modeling STCIMHC Short term crisis intervention mental health counselling (benefit) STHA Stanton Territorial Health Authority TRC Trust and Reconciliation Commission WHG Whitehorse General Hospital YHSS Yukon department of Health and Social Services YHSSA Yellowknife Health and Social Services Authority

EXECUTIVE SUMMARY

Scope

The Non-Insured Health Benefits (NIHB) Joint Review Steering Committee (JRSC) made up of Assembly of First Nations (AFN) appointees and First Nations and Inuit Health Branch (FNIHB) representatives has agreed on three pillars for their Joint Review Inquiry: 1. Process: Review of all components of NIHB policies, guidelines, etc;

2. Access: Analysis of access to include but not be limited to, access to services, information, choice, cultural appropriateness of the service. This will also be looked at through the Social Determinants of Health lens. It will include a survey of clients of NIHB with specific questions to obtain client input on their experience in accessing NIHB and the barriers they faced. Access flow charts will be developed to demonstrate the accessibility of services as compared to non-First Nations accessing the provincial system;

3. Cost: Cost analysis includes both prospective and retrospective costs, expenditures within the unique context of the population served including social and economic conditions.

The JRSC agreed to review all six benefits of the NIHB program including medical transportation, vision, dental, pharmacy, medical supplies and equipment and short-term crisis intervention mental health counselling (STCIMHC). The Committee began the national review by examining STCIMHC in 2015, the first of six benefits to be reviewed. The review findings outlined in this report relate specifically to implementing Pillar 2 above in regard to the STCIMHC benefit, and do not include work related to Pillars 1 and 3 as it relates to STCIMHC.

The review was required to determine what services exist region by region and determine the steps that are required to access the benefit as experienced by First Nations. This resulting report with regional information that includes identification of strengths/weaknesses in the benefit as it currently exists; potential policy and programming innovations; recommendations to improve the benefit from First Nations and service providers’ perspectives; recommendations from best practices from similar programs; and recommendations to positively transform the STCIMHC benefit.

Defining Short Term Crisis Intervention Mental Health Counselling (STCIMHC)

One definition of crisis intervention refers to the ‘methods used to offer immediate, short-term help to individuals who experience an event that produces emotional, mental, physical, and behavioral distress or problems’1. A crisis can refer to any situation in which the individual perceives a sudden loss of his or her ability to use effective problem-solving and coping skills. Crisis intervention aims to reduce the intensity of an individual's various reactions to a crisis; help individuals return to their level of functioning before the crisis; and help individuals to become better equipped to cope with future difficulties or crises. Crisis intervention counselling helps the individual to recover from the crisis and to prevent serious long-term problems from developing. Crisis intervention is not sufficient for individuals with long-standing mental health problems. In such cases, individuals need a variety of therapeutic and other interventions to learn to cope with their mental illness and in extreme cases longer term residential mental health care may be needed.

1 Aguilera, Donna C. Crisis Intervention: Theory and Methodology. 8th ed. New York: Mosby, 1998. Dattilio, Frank M. and Arthur Freeman, eds. Cognitive-Behavioral Strategies in Crisis Intervention. New York: Guilford, 1994. 5

NIHB Short Term Crisis Intervention Mental Health Counselling (STCIMHC) Benefit According to the Health Canada Guide to Mental Health Counselling (2015) NIHB’s STCIMHC benefit is intended to fund “immediate psychological and emotional care to individuals in significant distress ion order to stabilize their condition, minimize potential trauma from an acute life event and, as appropriate transition them to other mental health supports”. A crisis may include:  Distress manifested by symptoms of physical, cognitive, emotional or behavioral disturbance;  Inability to care for self and without individual, family, and / or community support and resources to deal with the issue; and/or  Nature of the circumstances requires the individual to resolve the issue urgently. Further the STCIMHC is offered in a way that:  Recognizes STCIMHC benefit is a component of a mental wellness continuum that includes other FNIHB community-based and provincial / territorial mental health programming and services; and  Supports culturally competent mental health counselling. To help First Nations to access short-term counselling support for mental health crises, the STCIMHC benefit2 includes reimbursement for the initial assessment (maximum 2 hour session); development of a treatment plan; therapy sessions and fees and associated travel costs for the professional mental health therapist. Each FNIHB regional office maintains a list of enrolled counsellors / service providers to deliver the service under the STCIMHC benefit. The NIHB Program covers STCIMHC on a temporary basis when no other services are available – so this is regarded as a ‘last-resort’ benefit. The benefit is not intended to resolve continuing or difficult issues, but to provide a temporary resource until other services (provincial programs, social programs) can be accessed. In fact the 2015 Guide explicitly states that a client must access other health coverage and services before accessing this benefit.

Methodology

This review primarily took a qualitative approach using a small sample of First Nations communities across the country – only one per region in nine regions excluding British Columbia. This included a mix of urban, rural and remote First Nations communities. This is only one part of the broader review of the STCIMHC benefit however and provides a grassroots First Nations voice to the process. The process involved site visits to each of the randomly selected communities to interview health leaders and mental health staff working in the communities. In several cases this included clinical therapists and counsellors working in the community either as employees of the First Nation or as employees of local health authorities or as private practitioners. In addition a community focus group was held in six of the nine communities. Mental health leaders and staff from local provincial or territorial health authorities were also included as participants. In total, 68 people participated in the review from the nine First Nation communities including three members from the associated tribal council. All nine First Nation Health Directors and a total of 14 mental health staff participated in the review. In total, 34 people were interviewed from the provincial and territorial systems with the majority coming from the regional health authority and/or territorial government. In five regions, Kahui Tautoko Consulting Ltd (KTCL) took the opportunity to interview five Health Canada nurses who were based within the community at FNIHB nursing stations. To supplement perspectives from counsellors gathered at community visits, KTCL also sent key questions to 20 counsellors from Health Canada’s list of enrolled counsellors in five regions and offered phone interviews however only one responded. Data collected from these interviews and focus groups were analyzed against the review objectives and recommendations developed to inform the transformation of the STCIMHC benefit. Conclusions and

2 Health Canada: www.hs-sc.gc.ca NIHB Program Definitions 6

recommendations are structured around the key transformation areas identified in KTCL’s Statement of Work and align with the criteria and policies of the STCIMHC as outlined in Health Canada’s Guide to Mental Health Counselling (2015) referred to as ‘the guide’ in this report.

Strengths and Weaknesses of current implementation of the STCIMHC Benefit

Community Perspective on Short-Term Crisis Intervention Mental Health Counselling

There were generally three types of events or triggers that initiated the need for short-term mental health crisis counselling that were identified by the First Nations communities: • immediate high impact crises (such as a suicide or attempt in the community, homicide, shooting, accidental / unexpected death; an infant or child death) that affected an individual, the immediate family (e.g. spouse, child, parent, grandparent) and often the broader community; or • a short-term mental health crisis affecting one or more individuals, especially family members, several days, weeks or months after a high impact crisis (such as those described above) during the grieving, healing or bereavement process; or • an environmental catastrophe that impacted the whole community (fire, flood) and traumatized individuals for a short-term period. Community feedback during the review – including feedback from First Nations health centre staff – indicated that effective short-term crisis intervention counselling was most useful when it could respond to any of the above events at an individual, family and / or community-wide level. Additionally the response needed to be immediate and not hampered by administrative delays. As one community member stated “When people reach out for help they need it right away, not 3 days or a week later.” Based on community feedback, KTCL has developed a set of pre-conditions that emerged as consistent themes for ensuring effective STCIMHC services in First Nations communities (that also aligns with the First Nations Mental Wellness Framework):  Regular counselling services already exist in the community (and do not require travelling away to access); and  the existing counsellors have developed trusting relationships with the community, elders, Chief and Council and the First Nations health centre staff, and  the existing counsellors are First Nations / Aboriginal and accepted as culturally competent (ideally from the Nation concerned and speaking the indigenous language where English is not the first language); and  the existing counsellors are strongly linked with or connected to the provincial / territorial services i.e.: o they know the key staff within the provincial/ territorial mental health system including lead psychiatrist and other counselling and mental health crisis response staff; o they understand and participate in the referral and discharge process for community members; o they participate in mental health service planning, training and professional development opportunities with their peers in the system; and o they share care through communications and effective case management); and  the existing counsellors can call on additional crisis support capacity from a tribal council or collective body or provincial / territorial service that they have established relationships with when needed; and  the counsellors and health team (including any FNIHB or Territorial Nursing station staff) have a formal crisis response protocol or arrangement in place with the community’s doctor or nurse practitioner, RCMP , victim services, ambulance or local emergency room; and local social workers; and  there is ability for those involved to make individual short-term mental health crisis counselling; family counselling and community healing ceremonies or events available when desirable for those impacted by any crisis. The success factor that is most challenging for communities to put in place is the availability of First Nations/ Aboriginal counsellors, particularly those who speak the local indigenous language. Much progress has been made

in putting in place other success factors in many communities. In summary, the review found that the more of these pre-conditions that existed, the more seamless and effective the counselling services were for the specific community.

Information and Awareness of the STCIMHC

A key fact about this benefit is that it is only applicable ‘when no other mental health services are provided or available” - so this is considered a ‘last resort’ benefit. Where communities who were part of this review did not know about or access the STCIMHC, one could either assume that they did not need to access it because existing mental health services were available OR that they could have benefitted from the STCIMHC because they did not have existing services, but did not know it was available. Health Canada’s guide (2015) describes how ‘eligible recipients access Short-Term Crisis Intervention Mental Health Counselling’ and states that ‘NIHB clients should first contact their local community organizations (health centre, friendship centre, or primary health care provider) to determine if community mental health programs are available, and if other mental health crisis counselling services are not available, clients may contact their Health Canada regional office for a list of mental health counselling providers close to their community of residence’. The results of this review show that overall NIHB clients were seeking help from their local mental health counselling service and/or health centre – and that where these were not available – they were not aware that the STCIMHC benefit was available for them to access counselling through FNIHB’s enrolled counsellors. The majority of feedback from the communities was that someone in crisis would not be in a state to look up Health Canada’s website to find crisis counselling help and to work through the process outlined in the guide. Targeting the information about accessing the STCIMHC benefit at NIHB recipients in crisis was seen as highly impractical. Furthermore the majority of First Nations health team staff from the participating communities did not know about the STCIMHC benefit either so did not refer clients to access it where they felt they were eligible. The review found that access to and use of the STCIMHC benefit was determined primarily by counsellors who knew of its’ availability and who claimed the benefit for clients who met the criteria. The review team did not learn of any occasion where a community member had directly contacted FNIHB for the names of enrolled counsellors, and accessed the STCIMHC themselves. Another factor related to the lack of awareness was that the crisis counselling sessions are confidential between the counsellor and the client, and the claims are sent by counsellors straight to FNIHB, so there is often no role for the client or the First Nations health team in the process. The First Nations health teams were unaware of how many clients needed short-term crisis intervention mental health counselling in any given year and how many claims were made by a counsellor direct to FNIHB for STCIMHC for community members. Some felt this prevented them from doing constructive planning around mental health services. From a provider perspective, having the STCIMHC available for them to provide additional counselling for clients in crisis appeared to be positive from the interviews that were conducted with counsellors. Where counsellors are enrolled with FNIHB they are aware of the STCIMHC (and IRS: RHSP benefit) that they can claim, and most stated that they did not have difficulty with processing or payment provided they produced the required paperwork. Overall therefore there is very limited knowledge of this benefit by the sample communities. Of 62 First Nation staff and community group members (excluding the NWT where STCIMHC is not available) interviewed at the nine sites, only nine participants (three Health Directors and six staff) were aware of the STCIMHC benefit. Enrolled Counsellors providing short-term crisis intervention mental health counselling

Mental Health Counselling Provider Eligibility According to the Health Canada guide (2015) and website, enrolment of mental health counselling providers for NIHB and IRS: RHSP is managed by the NIHB Program. All mental health counselling providers wishing to serve clients for reimbursement by either of these two programs must first enrol with the NIHB Program. To be enrolled,

mental health counselling providers must be registered with a legislated professional regulatory body and eligible for independent practice in the province/territory in which the service is being provided. In exceptional circumstances, other mental health counselling providers who do not meet these requirements may be accepted subject to the following conditions: there are no other mental health counselling providers enrolled with the NIHB Program in the vicinity and access to services is limited; or where there is an emergency situation such that the health and safety of the client or other persons is at immediate risk. Four of the communities considered that elders, matriarchs, traditional healers and cultural practitioners should also be eligible to be compensated under this benefit for providing crisis intervention counselling as often they are the ‘immediate responders’ called upon in the communities when a crisis occurs, or when someone is in crisis. Participants stated that on many occasions these key community leaders often spent many hours stabilizing an individual and their family to enable the next steps in care and healing to begin, or to prepare someone for travelling out for more intensive care. Often they did so before registered clinical counsellors, RCMP or any other health professionals arrived on the scene. This occurs especially when there are no resident counsellors or RCMP on- reserve. It is believed that non-recognition of these important community responders, healers and counsellors as eligible service providers removes valid choices for clients and does not acknowledge or respect the skills and experience of these recognized First Nations community leaders, and the trust that the community has in them. Many communities would like to see them recognized (perhaps with a form of health centre endorsement) and not treated as ‘exceptional’ providers that need permission to be compensated by the STCIMHC benefit.

Mental Health Counselling Provider Enrolment The Health Canada guide (2015) and website states that ‘mental health counselling providers wishing to deliver services reimbursed by NIHB and/or IRS RHSP must complete and submit a Mental Health Counsellor Provider Agreement form to the Health Canada regional office in the Province/Territory where they practice’. Health Canada reviews the application for approval of eligibility. There were generally three categories of counsellors providing services to the communities: • Those employed or contracted to routinely provide counselling on a semi / permanent basis; and / or • Those who were independent practitioners providing services to communities (and being paid on a contract or claims basis by FNIHB) often on as as-required basis; and / or • Those employed by provincial / territorial authorities who were located in or near the community or made frequent scheduled visits. The review involved a number of counsellors some of whom were enrolled with FNIHB (and who had claimed STCIMHC in the past) and some of whom were not enrolled but who still provided counselling services to the community under another funding or employment arrangement. Counsellors who worked regularly in the community were clearly more trusted by community members and the vast majority of community participants stated that it was much better being able to see a regular counsellor in the community and not have to travel – especially in a crisis where they would be away from family support. Challenges with travel were mentioned by four of the communities. Counsellors who worked regularly in the community were also more likely to have established relationships with the First Nations health centre staff and with RCMP, social workers, nursing station staff and doctors who worked in the community. An additional benefit of a regularly operating counsellor in the community was the opportunity for them to become part of the local health ‘team’ and to benefit from broader relationships that the community has with neighboring First Nations communities and tribal councils / collectives. Counsellors who part of these processes are able to provide additional benefits for community members through being able to access this extra support. Some community participants also supported a mechanism for local health leadership (e.g. Health Director or manager of mental health services) to have a role in deciding which counsellors work with their community members so that they are a good “’fit” with both the First Nations health team as well as the community culture, dynamics and protocols. It was acknowledged this may be impractical where the access to STCIMHC counsellors is

between the client and FNIHB, but there may be room for a First Nations panel or committee to review applicants seeking enrolment with FNIHB to assess their cultural competency.

Communicating Availability of Enrolled Providers The Health Canada guide (2015) states that Health Canada will communicate any updates to this Guide or related policies and benefits, to clients, providers and stakeholders in a timely manner. During the course of the review it became evident that the vast majority of First Nations community health centres (as key stakeholders) were not aware of whom the enrolled providers were in their region or that FNIHB maintained a schedule of enrolled providers3. Only one region visited (Manitoba) had an arrangement whereby the local health authority received the latest schedule of enrolled service providers on a routine basis from FNIHB for circulation to their mental health team, while the others did not receive it or had not seen it at all. Provider Roles and Responsibilities The Health Canada guide (2015) and website state that among other things enrolled providers making STCIMHC claims must: Complete a client assessment and discuss the recommended counselling and sessions schedule with the client; Complete a treatment plan to be kept on the client's file. As part of the treatment plan, develop an aftercare plan that links the individual to community based mental health services or culturally appropriate services during and/or after the counselling. The guide also states that the STCIMHC is offered in a way that: Recognizes STCIMHC benefit is a component of a mental wellness continuum that includes other FNIHB community-based and provincial / territorial mental health programming and services….”

In order to meet the requirement to develop treatment plans, aftercare plans and to link clients to community-based mental health services it was considered by community members as well as health staff, and provincial health services staff, that to achieve this, the counsellors needed to have an established relationship with provincial mental health service. This included crisis mental health services and any Aboriginal health services located within the provincial / territorial system. It was also considered that any new counsellors should be required to complete an orientation with the provincial / territorial mental health services so that the person could build links with those services to provide more integrated care for clients. A strong relationship with provincial / territorial mental health and emergency services was seen as critical to effective treatment planning; case management; referral and discharge and client outcomes (and is one of the identified success factors previously mentioned for effective STCIMHC services). Many regions have well developed successful collaborations that have demonstrated strong relationships and excellent coordination within communities between health (including First Nations community-employed staff as well as contracted counsellors and psychologists), RCMP, doctors / nurse practitioners, FNIHB nurses and social services to respond to crises. Some have gone as far as developing a formal protocol including rapid communication mechanisms while others are in the process of developing these. Successful regions have also extended those local response mechanisms to the provincial services so that emergency rooms, psychiatric units and Aboriginal advocacy services can respond appropriately if someone needs to be transported out of community. An excellent example was provided in one region (Nova Scotia) where the counsellor is treated as part of the provincial mental health service; has easy access to training, staff and clinical supervision; has shared case management and open communications; and has high levels of collegial support from their peers within the provincial system. In other regions the continuum is not as effective. Three regions were concerned that the large number of private practitioners (counsellors) enrolled with FNIHB were not connecting with either the local health team or the provincial services. In fact some provincial / territorial health services did not know who the enrolled counsellors were and how to access the list of enrolled counsellors. This meant there was little shared case management or information sharing to support access to other services. Nevertheless it was noted that communication and

3 During the course of the review this was raised and the AFN and FNIHB arranged for all regions to provide their latest schedules of enrolled providers and circulated it to the communities. 10

collaboration with provincial partners continues to strengthen as health authorities continue to build capacity to establish lasting relationships with First Nations communities. It is clear that services work best for clients when the counsellors are strongly linked with or connected to the provincial / territorial services: . they know the key staff within the provincial/ territorial mental health system including lead psychiatrist and other counselling and mental health crisis response staff, and any Aboriginal advocacy staff; . they understand and participate in the referral and discharge process for community members; . they participate in mental health service planning, training and professional development opportunities; and . they share care through communications and effective case management); . they can call on additional crisis support capacity from provincial / territorial services that they have established relationships with when needed; and . the counsellor is part of a community’s formal crisis response protocol or arrangement.

The Health Canada guide (2015) and website state that among other things enrolled providers making STCIMHC claims must: As part of their ongoing professional development, providers are encouraged to continue to enhance their knowledge of First Nations and Inuit cultures in order to better serve clients. This can include opportunities provided by their professional associations, through First Nations or Inuit communities or organizations, or other related training. The guide also states that the STCIMHC is offered in a way that: supports culturally competent mental health counselling.

The vast majority of the counsellors described by the communities were identified as non-Aboriginal and many participants agreed that this created a gap in availability of culturally competent counselling. Those whose first language was not English stated that they would prefer a counsellor who could speak their indigenous language however also acknowledged that this was a challenge. Many felt that more cultural training and ongoing development of knowledge and trauma-informed practice was needed for any counsellors enrolled and contracted by Health Canada and that this should become a mandatory requirement and not something that is simply ‘encouraged’ as described in the guide. They saw this as an essential and vital requirement for the effective delivery of STCIMHC services for their communities.

Counselling covered by STCIMHC The Health Canada guide (2015) and website state that the STCIMHC benefit provides ‘up to a maximum of 15 one- hour sessions per mental health crisis over a 20 week period, not including the initial assessment. Eligible services under the STCIMHC benefit include: initial assessment (maximum of 2 one hour sessions) performed by an enrolled provider; and counselling sessions on a fee-for-service basis as per Prior Approval Form (e.g. individual, family, or group counselling). Exceptions and Criteria for Approval: In addition to the initial 15 sessions, five sessions may be covered in order to support a client's transition to other type of mental health services. Furthermore the criteria for the STCIMHC outline a number of exclusions (Section 3.3 of guide) including the following: Psychiatric emergencies for person(s) at risk of harm to self or others…” This exclusion confused some of the community participants who felt that this meant no one who had suicide ideation, had attempted suicide or who was impacted or traumatized by a family member suicide attempt or completion, could be covered by the STCIMHC. Counsellors in other regions were however often using the STCIMHC to work with clients who were feeling suicidal after a crisis or who needed short-term help after being impacted by a friend or family member suicide. The wording was ambiguous for some and needed clarity. The Health Canada guide (2015) Mental Health Counselling Provider Reimbursement policy states that ‘Fees charged are in accordance with the ones approved in the Prior Approval Form. Under no circumstances are individual counselling fees to be charged when a client has received counselling as part of group, or family counselling’. This was interpreted to mean that no one could be reimbursed for any group, family or community counselling under the STCIMHC benefit. A gap noted by five of the communities was that group, family and

community healing processes developed to help people recover from short-term crises was not covered by the STCIMHC. A focus on holistic family and community counselling and healing was deemed critical amongst various audiences in the regions and is recognized explicitly by the IRS: RHSP benefit. Many participants commented that individual counselling sessions may be beneficial as an initial assessment however family and community members play a critical role in the long term healing pathway so group and family sessions should be covered (like the IRS: RHSP).

Alignment with the Indian Residential School (IRS): Resolution Health Support Program (RHSP)

Although the IRS: RHSP is delivered in all regions, there was limited awareness of the IRS: RHSP across the communities that were visited. Interviewees in five of the nine regions stated they did not provide the IRS: RHSP and some did not know who was providing the service. Some believed that it was being provided by independent non- government organizations (NGO’s) but could not name them. In two regions participants had heard that the IRS: RHSP program was sun-setting in March 2016 and were unsure of what would happen after this time so did not want to recommend starting someone on a journey that may not be sustainable. In three regions (Saskatchewan, Quebec and Alberta), participants were aware of the IRS: RHSP either through their tribal council who provide the program, or through their psychologist.

Alignment with the First Nations Mental Wellness Continuum Framework A brief analysis of the findings with the framework reveals close alignment of both current practices and aspirations of the participating communities. The framework includes a number of dimensions each of which was compared with the feedback received from communities and are summarized below: . Four directions (outcomes: Hope, belonging, meaning and purpose). Mental wellness is when these dimensions are in balance. Crises occur when these are out of balance. Effective, responsive and culturally appropriate crisis counselling should restore balance however crises impact families and the community and not just individuals. Community feedback was that STCIMHC should include group counselling like the IRS: HSP; . Community (Kinship, clan, elders, community). Many examples of kinship collaborations are in place where communities and tribal councils are working together to improve mental health service delivery (e.g. White Raven Healing Centre Crisis Intervention Stress Management (CISM) team in Saskatchewan; SERDC in Manitoba; Tui’kn Collaboration in Nova Scotia; New Brunswick 5-community collaboration; North Shore Tribal Council in Ontario; Stoney Tribal Council in Alberta); . Populations Focus on population sub-groups (e.g. women, LGBT). The evidence of the nine site reviews shows the array of models that exist for mental health services and crisis response. Arrangements have been tailored around the presence of a variety of service models and meeting needs of community members. Two communities identified gaps exist for specific counselling models for men and for the homeless. Further feedback from NFNHTN was that women affected by violence are also a sub-group of the population needing better access to STCIMHC. This is especially so when they need to leave a community for safety reasons and then need to access STCIMHC; . Specific population needs (Individuals with chronic conditions, acute mental health concerns). The more successful models of crisis intervention were those that linked well with other services especially primary care for chronic disease, communicable disease and maternity clients in crisis. The review reveals that where counsellors providing support under the STCIMHC are part of the local First Nations health team and strongly linked to the provincial / territorial services they are more effective for community members. This is often not the case when independently operating counsellors are operating privately, conducting sessions and billing FNIHB without any demonstration of such linkages existing for clients; . Continuum of essential services (From health promotion and prevention through to aftercare). This is definitely an area that the communities want to build on to create a continuum of mental wellness that does not just include NNADAP, Brighter Futures and Building Healthy Communities but strengthens and integrates the crisis response component and care planning and shared treatment approaches with provincial and territorial

services. While a requirement of the STCIMHC for linkages with other services this does not appear to be monitored or enforced; . Supporting elements (Governance, workforce development, self-determination). The most pressing and frequently mentioned need in this area is workforce development for Health Canada counsellors (cultural competency and trauma-informed practice) and for more First Nations community employed staff working in this field. There was a desire for Health Canada to be more proactive in supporting an increase in Aboriginal qualified mental health counsellors across the country; . Partners in implementation (NGOs, provincial and territorial governments, federal government). There are many positive collaborations between First Nations communities and provincial / territorial partners and often these have been proactively initiated and resourced by the health authorities. The results of these collaborations have led to a better understanding of each other’s systems and clients, but also have helped to improve service and patient pathways and experiences. While a requirement of the STCIMHC for linkages with other services this does not appear to be monitored or enforced. Additionally partners are often involved in community crisis response and although not part of the implementation of the STCIMHC benefit, the way a community and its partners respond when someone feels they are in crisis and needs counselling is critical. The more this collaborative effort has been pre-planned the better the crisis response will be; . Indigenous social determinants of health (Environmental, social services, language heritage and culture, urban and rural). Locally managed health services have more chance of being able to work closely with schools, RCMP, elders and language centers and many communities felt that counsellors employed by First Nations was an easier way to achieve this type of integration. Independent practitioners who visit infrequently were seen as less successful at integrating with other areas of the community such as schools, cultural centres and social services. . Key themes for mental wellness (Community development, ownership and capacity building, quality care system, competent service delivery, collaboration with partners, enhanced flexible funding ). Flexibility of funding for crisis intervention was a key issue. Communities across the site visits would rather see this type of mental health counselling funding being provided to communities to help strengthen the crisis response part of their mental health continuum of services, and to ensure they are better ready to respond to a crisis (crisis planning, protocols and communications). Also many want to strengthen the linkages with provincial services in order to provide a more seamless patient journey through mental health crises and care (including transport; linking with discharge units, organizing appointments). While a requirement of the STCIMHC counsellors for linkages with other services - this does not appear to be monitored or enforced. . Culture as foundation (Elders, cultural practitioners, kinship relationships, language, practices, ceremonies, knowledge, language and values). Many communities noted that there is a lot of cultural strength that can be found within their community that is key to addressing many of the mental health challenges currently found within the community. There was a need to allow the community to invest more in preventative measures that build off and strengthen the cultural capacity within the community. Several want to incorporate other means of helping someone through a crisis including Talking Circles, youth camps, healing journeys, etc and they also want to see elders, matriarchs, healers and cultural practitioners recognized for their role in counselling community members in crisis and being compensated by STCIMHC benefit when they do. There was also a call for more counsellors to develop their cultural competency since most were non-Aboriginal. A key area which the First Nations communities want strengthened is the cultural competency of counsellors. It was evident that First Nations want to ensure that enrolled counsellors are knowledgeable and aware of indigenous history, colonization, colonialism, systemic and institutional racism as they are root causes and contribute the overall malaise of social and mental health problems in communities. Many clients may have trauma, intergenerational impacts, depression and post-traumatic stress disorder as a result of their history with colonization. It is vital that counsellors are equipped and trained to work in First Nations communities safely, sensitively and appropriately.

Potential Changes to Transform Short-Term Mental Health Counselling

There were suggestions that in order to make a sustainable long term impact on addressing the complex and deep rooted mental health issues within First Nations communities, there was a need to invest in First Nations capacity to provide their own local mental health services. Support increases to counselling workforce The view of many community members and health centre staff was that a deliberate effort needed to be made nationally and regionally to increase the number of First Nations/ Aboriginal mental health counsellors. A strategy for recruitment of new First Nations students into psychology and mental health counselling from secondary schools and supporting students to graduate and work in First Nations communities was seen as an essential national strategy. This would in turn help to improve the cultural competency and appropriateness of mental health care for First Nations communities. Support Crisis Response Planning Information on community crisis response is not part of the implementation of the STCIMHC benefit but is related to how well the community responds when someone feels they are in crisis and needing counselling. Due to the distance required to access medical / clinical crisis services for many communities (especially fly-in communities) some have developed their own crisis response strategies and protocols to handle situations when they have no resident health professionals. Other communities – while they might not be remote or fly-in – also do not have crisis response plans or protocols in place but acknowledge they are necessary. Supporting the development of strong mental health crisis response protocols or a mental health crisis response plan that involves the health unit, primary health, child and family services, RCMP, victim services, local police, ambulance and other supports along with the community immediate responders and counsellors was seen as a necessary improvement to support effective mental health services. Provide Short-Term Crisis Intervention Mental Health Counselling Funding direct to community4 There were several communities who advocated for these types of funds to be transferred to communities to manage like other programs in their Contribution Agreements, and for this type of support not to be isolated as a ‘benefit’ arrangement. Converting STCIMHC to a program that could sit alongside the National Native Drug and Alcohol Abuse Program (NNADAP), Building Healthy Communities (BHC) and Brighter Futures (BF) programs would provide some communities with flexibility to use the funds for the administrative costs associated with supporting a client in crisis; supporting resiliency initiatives in communities; expanding health promotion and early intervention efforts including harm reduction to help avoid crises and support people to cope and manage crises in their lives better; developing crisis response protocols within community and with external agencies including provincial / territorial services; and emergency travel assistance for clients in crisis; and compensating key community leaders who helped to alleviate an individual, family or community crisis at the time the crisis occurred to recognize their contributions. A key factor for communities wanting more control over short-term crisis funding is the ability for the community to act quickly and cover costs immediately to support those in need when sudden crises occur and people need to respond quickly to support individuals and families. It was felt that this would also support the community to align the intent of this funding with other Health Canada funded First Nations mental health and addictions programs such as NNADAP, Brighter Futures and Building Healthy Communities programs. This would work successfully for some communities who have capacity, including urban organizations, and could be positioned as an option similar

4 While this review did not include participation of urban organizations, it is acknowledged that the NIHB has a large number of clients who live off-reserve, so this should be considered alongside any recommendation to convert STCIMHC to a community-based program. Urban First Nations organizations could for instance be considered to provide the service.

to other NIHB benefits where a mix of individual benefit claims and Contribution Agreements operate simultaneously across the country.

Recommendations for Improvement

Recommendations are organized into five priority areas for transformation that align with the contracted review outputs5 in the Statement of Work for this review, and aligned with the criteria and policies outlined in the guide for STCIMHC. It is recommended that the NIHB JRSC:

1. IDENTIFICATION OF STRENGTHS/WEAKNESSES IN THE BENEFIT AS IT CURRENTLY EXISTS a. NOTE that the strengths of the STCIMHC benefit were identified as being primarily provider-centric in that: • where counsellors know it is available, they can claim the STCIMHC (subject to criteria) to meet needs of clients with short-term mental health crisis counselling needs • claims appear to be processed relatively easily by FNIHB • counsellors can apply for extensions of sessions (five more above the 15 allowed) if clients require it b. NOTE that the weaknesses of the STCIMHC benefit were identified as: • Information about the STCIMHC is not reaching the First Nations health centre staff and communities (although there is wide knowledge of other NIHB benefits i.e. medical transportation, dental, pharmacy & vision benefits); • Information about the enrolled counsellors able to provide short-term crisis intervention mental health is not routinely available to First Nations health centers or to provincial / territorial mental health services; • Counsellors who are eligible are ‘encouraged’ to learn more about culture and history of First Nations for their practice in the communities however community feedback is that this remains a gap in the competency of counsellors serving communities. The lack of focus on cultural competency requirements of counsellors also impedes ability of the STCIMHC program to align with the First Nations Mental Wellness Continuum Framework; • Communities have no voice in endorsing or approving counsellors working in First Nations communities who are enrolled with FNIHB to ensure their acceptability from a cultural competency perspective; • Counsellors are required to prepare treatment plans and aftercare plans to link clients into community- based mental health care, but there does not appear to be any monitoring or enforcement to test that these important linkages with First Nations health services and provincial / territorial mental health services exist during client care planning, counselling and discharge / referral; • Coverage does not include group, family counselling or community healing from crises and trauma who may be experiencing a short-term mental health crisis (covered by IRS: RHSP but not STCIMHC) and this is seen as a gap for communities; • No data or information is shared with First Nations health centers (for independent non-employed provider claimants) that informs the community about levels of short-term mental health crisis experienced within the community requiring STCIMHC support , for community health planning purposes. This type of information would also be useful for mental health planning efforts by First Nations communities working with provincial / territorial services.

2. POTENTIAL POLICY AND PROGRAMMING INNOVATIONS a. RECOGNIZE & COMPENSATE community-endorsed first responders to crises such as Elders, healers, matriarchs and cultural practitioners if involved in a crisis (validated by the local health lead) and providing counselling during an individual’s short term mental health crisis (especially in the period up to formal counselling taking

5 Aligned with expected Review Outputs as outlined in the Terms of Reference for the Review 15

place). At present these persons would be considered ‘exceptions’ rather than core service providers who are recognized by First Nations communities; b. INCORPORATE in the approval process for counsellors enrolling with FNIHB, that a First Nations panel review applicants for suitability and experience in working with First Nations communities; c. REQUIRE all counselors who are on, or wish to register, as an STCIMHC counsellor to provide evidence of competency in working with First Nations individuals, families and / or communities. This may include evidence related to years of working with First Nations clients (e.g. in urban and/or on-reserve settings); completion of formal and on-line training; residency within a First Nations community; prior relevant learning and experience etc. The important thing is that counsellors provide evidence of their experience and commitment to First Nations mental health and wellbeing through their life and work experience, qualifications and previous learning(s); d. REGULARLY UPDATE AND DISSEMINATE the Health Canada enrolled counsellors schedule and information to Health Directors and Directors of mental health at all health authorities. Maintain data on gender, language(s) spoken, years working in First Nations communities and references; e. REQUIRE counsellors to actively work with and establish linkages with First Nations health services in the communities they operate in, and with relevant provincial / territorial mental health services as part of their treatment planning process and conduct regular practice reviews to ensure this is occurring; f. CLARIFY terminology in the ‘exclusions’ list for STCIMHC to ensure that short-term crisis intervention mental health counselling is available for those affected by suicide-related incidents. Also clarify what STCIMHC is not appropriate for so it is clear what does not constitute crisis intervention mental health counselling; g. CLARIFY in the description of coverage and exclusions that those who may be charged (with a crime) but are awaiting court proceedings are not excluded. At present the criteria states that exclusions include ‘Court- ordered assessment services to clients and services which are part of or to be used for legal actions’ which means those who may be charged but not proven innocent or guilty may be excluded from access to the STCIMHC benefit. This is an occasion where First Nations may feel they are in crisis but are unable to access counselling to help them through the process.

3. IMPROVING THE BENEFIT FROM FIRST NATIONS AND SERVICE PROVIDERS PERSPECTIVES a. INCREASE INFORMATION to communities on the STCMHC benefit (those that do not have a Contribution Agreement) in leaflet and poster for communities; b. EXPAND or clarify coverage to include group and family counselling (similar to IRS: RHSP) as well as community healing processes that involve counselling so that those impacted by crises are able to access support outside of individual processes. At present the policy states that “Under no circumstances are individual counselling fees to be charged when a client has received counselling as part of group, or family counselling” and this is being interpreted as exclusion of family and group counselling under the STCIMHC benefit.

4. BEST PRACTICES a. PROACTIVELY SUPPORT AND INVEST in crisis response planning by First Nations communities. Due to the distance required to access medical / clinical crisis services for many communities (especially fly-in communities) some have developed their own crisis response strategies and protocols to handle situations when they have no resident health professionals. Other communities do not have crisis response plans or protocols in place but acknowledge they are necessary. Supporting the development of strong crisis response protocols and crisis

response plans that involve the Health Unit, Primary Health, MCFD, RCMP, Victim Services, Local Police, Ambulance and other supports along with the community immediate responders and counsellors is seen as a necessary improvement to support effective mental health services. Resources for completing this planning and facilitation support would be necessary for many communities to help complete this necessary task but there are very good examples of communities who have done this with great success; b. PROACTIVELY SUPPORT AND ENCOURAGE collaborations in primary and mental health care between First Nations and between Nations and provincial / territorial services. Many regions have well developed successful collaborations that have demonstrated strong relationships and excellent coordination within communities between health (including Nation-employed staff as well as contracted counsellors and psychologists), RCMP, doctors / nurse practitioners, FNIHB nurses and social services to respond to needs in the community. Some have gone as far as developing a formal protocol including rapid communication mechanisms while others are in the process of developing these. Successful regions have also extended those local response mechanisms to the provincial services so that emergency rooms, psychiatric units and Aboriginal advocacy services can respond appropriately if someone needs to be transported out of community. An excellent example was provided in one region where the counsellor is treated as part of the provincial mental health service; has easy access to training, staff and clinical supervision; has shared case management and open communications; and has high levels of collegial support from their peers within the provincial system. It is clear that services work best for clients when the counsellors are strongly linked with or connected to the provincial / territorial services: . they know the key staff within the provincial/ territorial mental health system including lead psychiatrist and other counselling and mental health crisis response staff, and any Aboriginal advocacy staff; . they understand and participate in the referral and discharge process for community members; . they participate in mental health service planning, training and professional development opportunities; and . they share care through communications and effective case management); . they can call on additional crisis support capacity from provincial / territorial services that they have established relationships with when needed; and . the counsellor is part of a community’s formal crisis response protocol or arrangement.

5. POSITIVELY TRANSFORM THE STCIMHC BENEFIT. a. SUPPORT INCREASES TO COUNSELLING WORKFORCE: The view of many community members and health centre staff was that a deliberate effort needed to be made nationally and regionally to increase the number of Aboriginal mental health counsellors. A strategy for recruitment of new students into psychology and mental health counselling from secondary schools and supporting Aboriginal students to graduate and work in First Nations communities was seen as an essential national strategy. This would in turn help to improve the cultural competency and appropriateness of mental health care for First Nations communities. b. PROVIDE SHORT-TERM CRISIS INTERVENTION MENTAL HEALTH COUNSELLING FUNDING DIRECT TO COMMUNITY: There were several regions who advocated for these types of funds to be transferred to communities to manage like other programs in their Contribution Agreements, and for this type of support not to be isolated as a ‘benefit’ arrangement. Converting STCIMHC benefit to a program that could sit alongside NNADAP, Building Healthy Communities and Brighter futures would provide some communities with flexibility to use the funds for: . the administrative costs associated with supporting a client in crisis; . supporting resiliency initiatives in communities; . expanding health promotion and early intervention efforts including harm reduction to help avoid crises and support people to cope and manage crises in their lives better; . developing crisis response protocols within community and with external agencies including provincial / territorial services;

. emergency travel assistance for clients in crisis – at the time of the crisis; and . compensating key community leaders who helped to alleviate an individual, family or community crisis at the time the crisis occurred and to recognize their contributions. A key factor for communities wanting more control over short-term crisis funding is the ability for the community to act quickly and cover costs immediately to support those in need when sudden crises occur and people need to respond quickly to support individuals and families. It was felt that this would also support the community to align the intent of this funding with other Health Canada funded First Nations mental health and addictions programs such as NNADAP, Brighter Futures and Building Healthy Communities programs. This would work successfully for some communities who have capacity, including urban organizations, and could be positioned as an option similar to other NIHB benefits where a mix of individual benefit claims and Contribution Agreements operate simultaneously across the country.

INTRODUCTION Overview

The Assembly of First Nations (AFN), working in partnership with Health Canada, has agreed to initiate a national review of Health Canada’s First Nations and Inuit Health Branch (FNIHB) ‘Non-Insured Health Benefits’ (NIHB) program beginning with the review of the specific benefit: Short-Term Crisis Intervention Mental Health Counselling (STCIMHC). The primary purpose of this review is: a) to describe the current implementation of the STCIMHC benefit in each region including client perspectives on their experience in accessing the benefit and the barriers they may have faced; b) to review alignment or impact of Indian Residential School: Resolution Health Support program (IRS: RHSP); c) to review alignment or impact of community-based crisis intervention (including any provincial/territorial services delivered in the community) on the STCIMHC; and d) to define where the STCIMHC fits within the mental health continuum in each region/territory and nationally. The review is required to include recommendations on improvements to transform the benefit in a manner that will increase efficiency and alignment with local, regional and provincial/territorial services in the mental health continuum of care. This review incorporates a regional focus to ensure the unique characteristics of each region (excluding British Columbia6) and their client’s access to and utilization of this benefit, are reflected in the review findings. Nine regional sub-reviews are required to form the basis of the review findings and recommendations, and the nine regional review reports are included in the appendices.

Defining Short Term Crisis Intervention Mental Health Counselling7 For the purposes of this review it is considered important to define STCIMHC since participants in the community visits often raised issues and concerns about mental health services generally and often did not differentiate between crisis intervention mental health counselling, and other forms of mental health counselling. The JRSC may also find it useful to expand the definitions included in the guide, in particular to state what crisis intervention mental health counselling is not and what short-term mental health counselling is meant to support and what is not appropriate for. One definition of crisis intervention refers to this as the ‘methods used to offer immediate, short-term help to individuals who experience an event that produces emotional, mental, physical, and behavioral distress or problems’8. A crisis can refer to any situation in which the individual perceives a sudden loss of his or her ability to use effective problem-solving and coping skills. This might include situations or circumstances such as life- threatening situations (such as natural disasters, earthquakes or fires); sexual assault or other criminal victimization; medical illness; mental illness; thoughts of suicide or homicide; and loss or drastic changes in relationships (death of a loved one or divorce, for example). Crisis intervention aims to:  reduce the intensity of an individual's emotional, mental, physical and behavioral reactions to a crisis;  help individuals return to their level of functioning before the crisis (in fact effective counselling can help daily functioning to improve further by helping affected people to develop new coping skills, and eliminating ineffective ways of coping, such as withdrawal, isolation, and substance abuse; and

6 British Columbia’s NIHB program has been transferred to the governance and management of the First Nations Health Authority in BC as of October 1, 2013 - and is therefore not part of this national review 7 The majority of this definition is from http://www.minddisorders.com/crisis-intervention.html 8 Aguilera, Donna C. Crisis Intervention: Theory and Methodology. 8th ed. New York: Mosby, 1998. Dattilio, Frank M. and Arthur Freeman, eds. Cognitive-Behavioral Strategies in Crisis Intervention. New York: Guilford, 1994. 19

 help individuals to become better equipped to cope with future difficulties or crises, by developing coping and problem-solving skills. Effective crisis intervention counselling provided for someone who is experiencing a crisis supports the person to talk about what happened, and the feelings about what happened, while developing ways to cope and solve problems. Crisis intervention counselling helps the individual to recover from the crisis and to prevent serious long- term problems from developing. Suicide crisis intervention The goal of crisis intervention in suicide-related cases is to keep the individual alive so that a stable state can be reached and alternatives to suicide can be explored. In other words, the goal is to help the individual reduce distress and survive the crisis. Suicide intervention begins with an assessment of how likely it is that the individual will kill himself or herself in the immediate future. Much has been written on effective strategies for suicide prevention, intervention and postvention9. Different ways that individuals might react to crises The typical crisis intervention approach begins with an assessment of what happened during the crisis and the individual's responses to it. There are certain common patterns of response to most crises - an individual's reaction to a crisis can include:  emotional reactions (fear, anger, guilt, grief);  mental reactions (difficulty concentrating, confusion, nightmares);  physical reactions (headaches, dizziness, fatigue , stomach problems); and  behavioral reactions (sleep and appetite problems, isolation, restlessness). Assessment of the individual's potential for suicide and/or homicide is also conducted. Also, information about the individual's strengths, coping skills, and social support networks is obtained. How crisis intervention works Research10 shows that individuals are more open to receiving help during crises. A person may have experienced the crisis within the last 24 hours or within a few weeks before seeking help. Crisis intervention is conducted in a supportive manner. The length of time for crisis intervention may range from one session to several weeks. It can take place in a range of settings, such as hospital emergency rooms, crisis centers, counseling centers, mental health clinics, schools, correctional facilities, and other social service agencies. Often health systems make telephone hotlines available to address crises related to suicide, domestic violence, sexual assault, and other concerns and these are usually available 24 hours a day, seven days a week. A major focus of crisis intervention is exploring coping strategies. Coping skills may include relaxation techniques and exercise to reduce body tension and stress as well as putting thoughts and feelings on paper through journal writing instead of keeping them inside. In addition, options for social support or spending time with people who provide a feeling of comfort and caring are addressed. Another central focus of crisis intervention is problem solving. Cognitive therapy, which is based on the notion that thoughts can influence feelings and behavior, can be used in crisis intervention. In the final phase of crisis intervention, the professional will review changes the individual made in order to point out that it is possible to cope with difficult life events. Continued use of the effective coping strategies that reduced distress will be encouraged. Also, assistance will be provided in making realistic plans for the future, particularly in

9 Suicide Prevention, Intervention and Postvention Initiative of BC, 2008 www.suicidepipinitiative.wordpress.com 10 Aguilera, Donna C. Crisis Intervention: Theory and Methodology. 8th ed. New York: Mosby, 1998. Dattilio, Frank M. and Arthur Freeman, eds. Cognitive-Behavioral Strategies in Crisis Intervention. New York: Guilford, 1994.

terms of dealing with potential future crises. Information will be provided about resources for additional help should the need arise. Often a telephone follow-up may be arranged at some agreed-upon time in the future. What short-term crisis intervention is not Crisis intervention is not sufficient for individuals with long-standing mental health problems. In such cases individuals may need a variety of therapeutic and other interventions to learn to cope with their mental illness and in extreme cases, longer term residential mental health care may be needed.

Short-Term Mental Health Crisis Intervention in a First Nations Context

Like many other people, First Nations experience mental health crises and react in ways described in the previous section – both in terms of community crises such as natural disasters but also in regards to individual and family crises that often affect most or all of the community. When a First Nations community is relatively small, the impact can be even greater on the wider community as most people will inevitably know each other well. This review has shown that availability of supports such as counselling for people experiencing short-term mental health crises differs vastly from community to community. Some may have full-time, part-time and casual nurses, counsellors, other health workers, Royal Canadian Mounted Police (RCMP) staff, social workers, temporary houses or beds and ambulances available within the community. These workers may be a mix of the First Nations/Band Council employees, employees from the federal/provincial/ territorial government(s) or private practitioners – and in some cases they work well and communicate together effectively while in other cases this does not appear to happen. Other communities may have none or only some of these avenues for support available locally, and therefore they must rely entirely on access from outside the community. Accessing the support needed may be even more difficult if the community is a fly-in community, is remote or isolated, or is in a high altitude area that is affected frequently by inclement weather. It is unknown how many First Nations community members might access national phone hotlines for crisis support but this service is available to community members. The difficulties in accessing support during a crisis, and the variety of ways that service providers are accessed often makes navigation through the options very challenging for First Nations individuals and families. Health centre staff on-reserve and navigators employed to help individuals find their way through the choices, are a significant help. However often - due to the realities of geography and capacity - navigation support might not be available on a face to face basis, but by phone only.

The National Non-Insured Health Benefits (NIHB) Review

The NIHB JRSC made up of AFN appointees and FNIHB representatives has agreed on three pillars for their Joint Review Inquiry of the NIHB program: 1. Process: Review of all components of NIHB policies, guidelines etc);

2. Access: Analysis of access to include but not be limited to, access to services, information, choice, cultural appropriateness of the service. This will also be look at through the Social Determinants of Health lens. It will include a survey of clients of NIHB with specific questions to obtain client input on their experience in accessing NIHB and the barriers they faced. Access flow charts will be developed to demonstrate the accessibility of services as compared to non-First Nations individuals accessing the provincial system;

3. Cost: Cost analysis includes both prospective and retrospective costs, expenditures within the unique context of the population served including social and economic conditions.

The JRSC agreed to review all six benefits of the NIHB program including medical transportation, vision, dental, pharmacy, medical supplies and equipment and STCIMHC. The Committee began the national review by examining STCIMHC in 2015, the first of six benefits to be reviewed.

The review findings outlined in this report relate specifically to implementing Pillar 2 above in regard to the STCIMHC benefit, and do not include work related to Pillars 1 and 3 as it relates to STCIMHC.

NIHB Short Term Crisis Intervention Mental Health Counselling (STCIMHC) Benefit

To help First Nations individuals to access short-term counselling support for mental health crises, the STCIMHC benefit11 is one of several benefits available under the NIHB program offered by Health Canada. The benefit includes reimbursement for: • The initial assessment; • Development of a treatment plan; • Individual; conjoint (a couple); family; or group (with unrelated individuals) therapy sessions can be provided; and • Fees and associated travel costs for the professional mental health therapist when it is deemed cost- effective to provide such services in a community • Medical transportation assistance may be provided for clients to the nearest appropriate mental health counselling provider.

The STCIMHC benefit is available to any ‘registered Indian according to the Indian Act’ and an Inuk recognized by one of the Inuit Land Claim organizations. Each region maintains a list of registered mental health crisis intervention service providers (who must be registered therapists with a regulatory body for clinical psychology or clinical social work in the province or territory) enrolled with Health Canada to deliver the service under the benefit.

The NIHB Program covers STCIMHC on a temporary basis when no other services are available – so this is regarded as a ‘last-resort’ benefit. The benefit is not intended to resolve continuing or difficult issues, but to provide a temporary resource until other services (provincial programs, social programs) can be accessed.

Items which are not covered as a STCIMHC benefit under the NIHB program are as follows, but are not limited to: • Substance abuse counselling/therapy; • Court-ordered assessment/therapy services to clients; • Educational and vocational counselling; • Long-term counselling/non-crisis counselling; and • When another program or agency is responsible for providing the service.

The Indian Residential School: Resolution Health Support Program (IRS: RHSP)

One of the requirements of this review was to determine the impact of or alignment of the STCIMHC with the IRS: RHSP. The IRSHSP12 provides mental health and emotional support services to eligible former Indian Residential School students and their families throughout all phases of the Indian Residential School Settlement Agreement, including: . Common Experience Payments (CEP) . Independent Assessment Process (IAP), . Truth and Reconciliation Commission (TRC) events . Commemorative activities

11 Health Canada: www.hs-sc.gc.ca NIHB Program Definitions 12 Health Canada: www.hs-sc.gc.ca IRS: RHSP Program Description 22

Clients eligible for this program include all former Indian Residential School students (regardless of the individual's status or place of residence within Canada) who attended an Indian Residential School listed in the 2006 Indian Residential Schools Settlement Agreement13. They are eligible to receive services from the Resolution Health Support Program as well as their family members (spouse, partner, children raised in household, relatives impacted). Services available include: 1) Cultural Support: Provided by local Aboriginal organizations who coordinate the services of Elders and/or traditional healers. Cultural supports seek to assist former students and their families to safely address issues related to Indian Residential Schools as well as the disclosure of abuse during the Settlement Agreement process. Specific services are chosen by the former student and/or family member and can include traditional healing, ceremonies, teachings and dialogue. 2) Emotional Support: Services are provided by local Aboriginal organizations and are designed to help former students and their families safely address issues related to the negative impacts of the Indian Residential Schools as well as the disclosure of abuse during the Settlement Agreement process. A Resolution Health Support Worker will listen, talk and provide support to former students and their family members through all phases of the Settlement Agreement process. 3) Professional Counselling: Professional counsellors are psychologists and social workers that are enrolled with Health Canada, for individual or family counselling. A professional counsellor will listen, talk and assist individuals to find ways of healing from Indian Residential School experiences. 4) Transportation: Assistance with transportation may be offered when professional counselling and cultural support services are not locally available.

Provincial / Territorial Services

It has been acknowledged by the JRSC that each province / territory will have structured its own mental health services (and specifically crisis intervention) in a manner according to provincial/territorial standards, structures and resources. The review has incorporated recognition of these variations and sought to determine where the STCIMHC fits (or should fit) within the provincial/territorial mental health service continuum. This includes access to their community-based counselling; emergency and crisis support and psychiatric inpatient and outpatient services where needed. It is also noted however that provincial and territorial mental health services might also include child and adolescent specific services, mobile crisis teams and crisis phone lines.

The First Nations Mental Wellness Continuum Framework

The STCIMHC benefit review was also required to determine where the STCIMHC ‘fits’ within the First Nations Mental Wellness Continuum (2015) developed jointly by FNIHB and the AFN - and how this is reflected in practice. The First Nations Mental Wellness Continuum Framework14 has two main purposes: a) To strengthen federal mental health programming and support appropriate integration between federal, provincial and territorial programs, and b) To provide guidance to communities to adapt, optimize and realign their mental wellness programs.

The STCIMHC review aligns with the framework’s commitment to improve federal programs (since STCIMHC is a federal program) and to strengthen integration with provincial and territorial programs (since crisis mental health counselling is not only provided by this benefit but also by other government programs. Secondly the STCIMHC review focuses on capturing the First Nations voice into the broader review so that they are supported to align their mental wellness approaches using the framework as a guide.

The framework incorporates several elements which are considered a part of the STCIMHC review:

13 According to data held by AANDC on former students 14 First Nations Mental Wellness Continuum Framework, Health Canada and AFN, 2015 23

First Nations Mental Wellness Description Continuum Framework: Dimension Four directions (outcomes) Hope, belonging, meaning and purpose Community Kinship, clan, elders, community Populations Focus on population sub-groups (e.g. women, LGBT) Specific population needs e.g. Individuals with chronic conditions, acute mental health concerns

Continuum of essential services From health promotion and prevention through to early intervention, crisis response, care planning, treatment support and aftercare Supporting elements e.g. Governance, workforce development, self-determination Partners in implementation NGOs, provincial and territorial governments, federal government, regional entities, nations, communities and private industry Indigenous social determinants of e.g. Environmental, social services, language heritage and culture, urban health and rural Key themes for mental wellness Community development, ownership and capacity building, quality care system, competent service delivery, collaboration with partners, enhanced flexible funding Culture as foundation Elders, cultural practitioners, kinship relationships, language, practices, ceremonies, knowledge, land and values

The framework provides a full description and context for each of these dimensions. The First Nations Mental Wellness Continuum Framework is also represented in the following diagram:

METHODOLOGY

Kahui Tautoko Consulting Ltd (KTCL) was contracted to conduct the national operational review of the STCIMHC benefit and to report on access to the benefit in the sample communities in each region. The report is required to provide recommendations for transformation of the benefit to better link to community-based mental health crisis intervention (including community-delivered services as well as provincially/territorially-delivered services along the continuum of care).

Review Objectives The review is required to: 1) Determine what services exist by developing a snapshot of what services exist along continuum of mental health care (including overlap with other programs) in each region according to the mental health continuum of care generally adopted within the region by the region’s health system. This was to be achieved through engagement with First Nations and service providers;

2) Determine the steps that are required to access the benefit as experienced by First Nations to gain a better understanding of how the program operates from client perspective, including: a. An assessment of regional differences (remote, Northern, linguistic challenges, transferred communities); b. Identification of barriers to accessing the benefit (utilizing a determinants of health lens) and issues related to medical transfer if any; c. Investigation as to whether the benefit is responsive to cultural needs; d. Identification of any privacy concerns within the benefit area; e. Identification of barriers to uptake of the benefit (are clients aware of benefit and how can awareness be improved?); and f. Identification of what gaps/ barriers/ efficiencies may exist in accessing the service (as a point of comparison, evaluate the continuum in comparison to provincial/ territorial/other federal programs).

Review Output A report (with regional information) that includes: . identification of strengths/weaknesses in the benefit as it currently exists; . potential policy and programming innovations; . recommendations to improve the benefit from First Nations and service providers perspectives; . recommendations from best practices from similar programs; and . recommendations to positively transform the STCIMHC benefit.

Review Methods

In April 2015, the AFN working in partnership with Health Canada FNIHB contracted Kahui Tautoko Consulting Ltd (KTCL) to undertake the NIHB STCIMHC National Operational Benefit review. This review is only one part of the overall national review of the STCIMHC benefit.

Implementation Planning

KTCL developed an implementation work-plan that included the proposed scope, methods, timelines and report format. The work-plan was guided by a document review process and approval of this work plan was received by KTCL in early May 2015. A mapping tool and key questionnaire was then developed for use with First Nations community staff, community focus groups and provincial / territorial health authorities. The AFN provided edits on the draft tool and KTCL finalized the document as the primary data collection resource. It was discussed and agreed 25

that the tool would be seen as a guide and a certain amount of flexibility would be required when on site with community members.

Community Selection, Notification and Planning

Community Selection

After working with FNIHB and the NFNHTN, the AFN provided KTCL with a list of nine randomly selected First Nations communities (and alternates) for community visits – one from each of the nine regions. The sampling criteria included a selection of remote, urban and rural First Nations communities across the 9 regions.

Preparation & Notification

Once KTCL was notified of the selected communities and alternates, KTCL prepared a calendar of proposed site visit dates for each community that would ensure all visits were completed in time to allow analysis and draft reporting to be done by the due date of September 4, 2015. Due to some of these proposed dates not being convenient for some communities, visit dates were amended resulting in the draft report being deliverable on September 15th 2015.

Notification letters were drafted outlining the purpose and process of the STCIMHC review (with the Quebec letter translated to French), finalized and disseminated to the Chief and Health Directors of each selected First Nation community by the AFN during the period 21 May 2015 – 11 June 2015. The letters described the scope of the review, KTCL information including contact details, proposed visit dates, site procedure guidelines and post review procedures. NFNHTN members were also notified.

While the site visits were originally planned to begin on 25 May 2015, delays with releasing the notification letters moved the start date to 1 June 2015 to allow the first community more advance notice and preparation time for their visit. The AFN and NFNHTN then worked to seek agreement from the other selected communities to participate in the review on the understanding that it was a voluntary process and an alternate community could be selected if the original selection declined.

Coordinating with each community

KTCL followed up the community notification letters (for those who agreed to participate) with phone calls to each Health Director of the nine selected First Nation communities. These phone calls (and any subsequent emails) were used to: a) answer any questions pertaining to the review; b) confirm suitable dates for the site visit that were convenient to the community; c) gain confirmation that the Chief and Council had been informed of the review taking place, and to offer to meet with Chief and Council members if they so desired; d) gather advice on best modes of transport to the community and accommodation options (in some cases, the community hosted KTCL in their own housing normally used for visiting health professionals); e) coordinate staff participation (where possible, specific names and positions were sought for those staff members that Health Directors identified as essential to the review. This helped to schedule times for interviews and hours / days that needed to be spent in each community); f) gain information on the nearest (provincial / territorial) mental health service that was accessed by the community so that the relevant provincial/territorial health authority could be contacted; g) seek their support to coordinate a community focus group of up to 10 community members during the site visit period; and h) to confirm arrival and departure times.

Some communities requested changes to their proposed site visit dates and this was accommodated by the JRSC and KTCL, resulting in a new timeline being developed. 26

Courtesy Notifications to NFNHTN

As a courtesy KTCL contacted all of the NFNHTN members prior to each site visit by phone to ensure they were aware of KTCL’s presence in the region and to seek any additional contextual information that may have helped with the review process. Where they were not available voicemails were left. Three members of the NFNHTN responded to these messages and the remainder were sent follow-up emails to ensure they had the relevant information.

Planning and completing the Community Site Visits

Logistics Six of the site visits were confirmed according to the proposed dates that had been issued. Two regions, Manitoba and Yukon, requested alternative date options due to a Health Director being on vacation and a conflicting date with another meeting. This resulted in the scheduling of site visits being delayed by two weeks. The Garden River First Nation (Ontario) accommodated an earlier than planned site visit to replace a re-scheduled region. The alternate community from the Northwest Territories also replaced the original selection.

Upon approval by the AFN, KTCL subcontracted a French interpreter for the Quebec site visit to a francophone community. A subcontracting agreement was signed between KTCL and the French interpreter to ensure that both parties understood their roles and that review deliverables were aligned to the contract. This subcontractor made the pre-visit phone and email contact with the Quebec NIHB Navigator and the Quebec community representatives since communication was conducted in French – and the visit was subsequently confirmed.

Travel was organized and site visits conducted by two consultants from KTCL except one visit where only one consultant attended due to unexpected illness of the other.

On Site Process For each visit an introductory meeting was conducted at the outset and some sites provided a tour of the facility and community. The purpose and process of the STCIMHC review was explained at the introductory meeting and other interviews confirmed with staff. Participants were notified that information gathered would be written as summary report information and that no names would be used. For interviews the questions from the approved tool were generally used to guide discussions and feedback, with further exploration of points raised that related to the review. Handwritten notes were taken in most cases and then typed on return to the KTCL office.

During site visits, KTCL asked community and staff members if they were aware of the names or availability of the enrolled counsellors that had enrolled with Health Canada to provide this service in their areas. This was done to help identify counsellors that could be contacted and potentially interviewed during the site. The vast majority of participants did not know this information nor did they know there was even a list of enrolled counsellors held by Health Canada. In fact a few Health Directors had actually researched the STCIMHC benefit upon receiving the notification letter, and had requested the list of the enrolled counsellors from their Regional Health Canada office. Those who had attempted to obtain this information informed the review team that they were either still awaiting for a response or were declined this information. KTCL informed the AFN (during a project-related meeting in Montreal of these challenges) and they subsequently worked with FNIHB to access the lists of enrolled counsellors and disseminate them to the communities. However non-availability of the information prior to the site visits made it difficult for KTCL to engage with a selection of the counsellors during site visits. Despite this, several communities did have their clinical therapists, counsellors and psychologists (whether enrolled with Health Canada or not) available at the site meeting so the review team was able to gather some perspectives from these staff and contractors. Interviews with staff were conducted in places and ways that the community health team desired – sometimes individually and sometimes as a group. The focus of the review team was to ensure the participants were as comfortable as possible with the process, and if they preferred to respond as a group, the team accommodated these requests.

At the end of site visits, small gifts were also provided to the Health Directors and thank you emails were sent after each site visit on return to KTCL’s office.

In total, KTCL completed site visits to three remote, three urban and three rural First Nation communities across all nine provinces in the June – August 2015 period, as follows:

REGION COMMUNITY VISIT DATES Nova Scotia Waycobah First Nation 1-2 June 2015

New Brunswick Oromocto First Nation 8-9 June 2015

Saskatchewan Piapot First Nation 16-17 June 2015

Ontario Garden River First Nation 23-24 June 2015 (rescheduled from August)

Alberta Bearspaw Stoney First Nation 8-9 July 2015

Quebec Wemotaci First Nation 21-23 July 2015

Northwest Territories Lutsel K’e Dene Band (alternate) 5-7 August 2015

Manitoba Pauingassi First Nation 11-13 August 2015 (rescheduled from June 2015)

Yukon Vuntut Gwitchin First Nation 17-18 August 2015 (rescheduled from late July 2015)

Community Focus Group participation

KTCL sought the help of health leads in each community to recruit 8-10 community members to participate in the review. Of the targeted representation of 72 – 90 participants across the nine regions, KTCL held focus group workshops with a total of 35 community members from seven of the communities – an average of five per community.

Regrettably, the community members that had been recruited from Piapot First Nation, Bearspaw Stoney First Nation and Vuntut Gwitchin First Nation were unable to attend on the day due to unexpected circumstances (bereavements or other engagements). To ensure there was community participant from two of these communities, KTCL agreed with each Health Director that they could self-administer the questions to focus group workshops at a later date. The review tool and interview questions were adapted slightly for ease of administering the focus groups and sent to the Health Directors with an offer to pay any administrative costs associated with the undertaking of the community focus group. KTCL received seven of the community group responses from this process. Garden River First Nation had recently held a community group meeting with 22 attendees prior to KTCL’s site visit and therefore felt that community members would feel this was duplicating the process. Information from this meeting was reviewed at the site visit and included in the site report. The Health Director subsequently validated that the responses were accurately reflected in the report. These perspectives from 22 community members were not counted in the STCIMHC community focus group participation numbers however as they were not specifically recruited for the STCIMHC review. A consent and attendance form was signed by community group members to certify that participants understood their rights in participating in the review and an honorarium was provided. Table I below summarizes the total number of interviewees and community focus groups involved in the site visits and follow-up interviews.

Table I: Participation of First Nations community / Council and staff only

FIRST NATION COMMUNITY HEALTH DIRECTOR MENTAL HEALTH COMMUNITY FOCUS COMMUNITY TRIBAL COUNCIL OTHERS (internal to STAFF GROUP HEALTH First Nation)

Nova Scotia (Waycobah)    (6) - - -

New Brunswick (Oromocto)    (5)  (2) - 

Saskatchewan (Piapot)   - -  

Ontario (Garden River)   (3) - -   (NIHB Clerk)

Alberta (Bearspaw Stoney)   (3)  (3) - - -

Quebec (Wemotaci)   (4)  (4) - - 

Northwest Territories  -  (5) - - - (Lutsel K’e Dene)

Manitoba (Pauingassi)  -  (8)   -

Yukon (Vuntut Gwitchin)    (4) - - -

TOTAL 68 9 14 35 3 3 4

Percent 13% 21% 52% 4% 4% 6%

In total, 68 people participated in the review from the 9 First Nation communities including three members from the associated tribal council. All nine First Nation Health Directors (or key contact) and a total of 14 mental health staff participated in the review making up 65% of the total interviewees. A total of 52% of these participants were from the community focus groups however it should be noted that many of the staff members that were interviewed, were also from the community. KTCL attempted to meet with as many mental health staff as were available at the time of the visit and to follow up with those who were absent on the day. Other participants were made up of administration, community health care staff, elders and volunteers – the vast majority of whom were from the First Nations community that was visited.

Engagement with Provincial and Territorial Services

KTCL sought to reach key stakeholders from provincial and territorial mental health services within each of the nine regions to provide their perspectives on the benefit, and to identify the ways in which short term crisis intervention mental health counselling was aligned with provincial / territorial services. It was acknowledged that each province / territory mental health service (and specifically crisis intervention) would be different and it was important to capture this in relation to the selected community. The gathering of this information was also considered important to help identify alignment with the First Nations Mental Wellness Continuum – one of the review objectives.

In order to identify appropriate provincial / territorial personnel to connect with, the Health Directors were asked during pre-visit communication if there were key people that KTCL should engage with specifically related to mental health services. Only a few sites provided name and contact details for KTCL to pre-organize interviews during site visits. In other areas KTCL researched health authority websites and mental health service information to find key personnel who could be followed up with phone interviews and these were undertaken from KTCL offices.

Table II below summarizes the total number of regional interviewees from provincial and territorial services, involved in the site visits and follow-up phone interviews.

Table II: Regional Participation of Provincial / Territorial staff in the STCIMHC Benefit review

REGION Health Authority Health Canada RCMP Ministry of Child OTHER (including and Family management Development (or and/or medical / similar) nursing Staff)15 Nova Scotia  -  - -

New Brunswick   -  (2) -

Saskatchewan  (3)  - - -

Ontario  - - - 

Alberta  (3) - - -  (3)

Quebec  -  - 

Northwest  (3)  - -  (2) Territories

Manitoba  (2)  - - -

Yukon  (2)  - - 

TOTAL 34 17 5 2 2 8

In total, 34 people were interviewed from the provincial and territorial systems with the majority coming from the regional health authority and/or territorial government. A total of 12 interviews were conducted by phone with the remaining 22 interviews being held in person, typically at their regional location.

15 While NWT and YT do not have Health Canada nurses, there was an interview conducted with a Health Canada manager in Ottawa with responsibilities for northern region. 30

In five regions, KTCL took the opportunity to interview Health Canada nursing staff members who were based within the community at FNIHB nursing stations. The perspectives of these staff and their role in crisis intervention was considered as important as the provincial / territorial service linkages. In Nova Scotia and Quebec, KTCL interviewed members from the local RCMP who were able to provide information related to their role when someone in the community was in crisis. The two child and family service interviews conducted in New Brunswick were organized by the Health Director and they provided a youth lens to mental health service provision within the community.

The remaining eight interviews were made up of staff from the North East Local Health Integration Network (Ontario); members involved in the Mental Health Program (Alberta); the Center for Health & Social Services of Upper Saint-Maurice (Quebec); Northwest Territory Government Health & Social Services representative and the Council of Yukon First Nations. Most of these people were recommended to be interviewed based on information provided by health staff during site visits.

In Nova Scotia, KTCL attempted unsuccessfully to connect with one of the clinical therapists and doctors who served the community after the site visit as they were unavailable for interview during the time on site. The psychologist assigned to deliver services to the New Brunswick community was contacted after the site visit, however his personal assistant advised that he was on vacation during the summer period. In Saskatchewan two provincial staff in Native Health services were briefed in person at Regina Hospital and agreed to respond to emailed questions, but despite reminders, did not do so. The psychiatrist at Regina that worked with the First Nation community clients (suggested by the therapist at Piapot) was sent the questions by email and asked for a phone interview. Despite reminders he also did not respond. Two additional interviewees were due to be interviewed in the Yukon however after numerous phone and email attempts, it was discovered that one person (a mental health nurse) was away on vacation. The other interviewee was no longer required to be interviewed as her responsibilities had been assigned to someone else.

Where information on crisis intervention services was not able to be acquired from staff interviews, regional health authority / provincial / territorial government websites were reviewed by KTCL to gather information on available mental health services including crisis counselling, crisis response, toll-free hotlines, mobile crisis and psychiatric services. This information was incorporated into the region-specific reports to help build a picture of available services for First Nations communities.

Mental Health Service Delivery in Northwest Territories

Short Term Crisis Intervention Mental Health Counselling (STCIMHC) is not available as a benefit under the federal NIHB program in Northwest Territories (NWT). Instead short term crisis intervention mental health counselling is provided by the Government of Northwest Territories (GNWT) through regional health and social service authorities. A 1954 Cabinet decision gave FNIHB responsibility for the delivery of health services to all residents of the Yukon and Northwest Territories. Early in the 1980s discussions were held with the GWNT and the Inuit Tapiriit Kanatami with the aim of developing an arrangement for the transfer of service responsibilities to the GWNT. Several universal health programs and services were transferred to the government of the Northwest Territories during the 1980s. The transfer of the remainder of universal federal health services in the territories to the GNWT was completed by March, 1988, and became effective on April 1, 198816 While the federal government retained responsibility for the NIHB Program after the 1988 transfer, the GNWT administers certain portions of the NIHB Program under contribution agreement with Health Canada. Health and social services are fully integrated for all territorial residents. This includes all aspects of health service delivery such as primary care, acute care, mental health and addictions (including crisis counselling) and medical transport. There is no direct interaction between First Nations community members and NIHB in the NWT, as NIHB is delivered and

16 Extract from http://www.hc-sc.gc.ca/fniah-spnia/pubs/finance/_agree-accord/10_years_ans_trans/index-eng.php 31

administered in a seamless fashion with all aspects of care coordination remaining a responsibility of the GNWT. The Health and Social Services Department is primarily responsible for the delivery of care to residents of the NWT.

While KTCL visited NWT to conduct the selected community site visit, it was not until after the visit that the 1988 transfer came to light. As a result of a discussion with FNIHB Regional Executive for the Northern Region it was clarified that there had been the 1988 transfer and that the STCIMHC was not provided in the NWT. It was further clarified that the GNWT had fully integrated crisis intervention counselling into its service delivery across the territory (including to the selected community). Results of the regional and community site visit, including information from the Yellowknife Health and Social Services Authority staff interviews, are included in this report.

Engagement with Enrolled Counsellors

While many interviews were unable to be organized with a selection of the counsellors enrolled with Health Canada who provide STCIMHC services, KTCL was conscious of incorporating the perspectives of enrolled counsellors involved in crisis intervention counselling to add to information provided directly by communities, territorial and provincial services and Health Canada nurses. During site visits interviews were conducted with three counsellors in Nova Scotia, Saskatchewan and Quebec. Their responses have been incorporated into the community-specific report.

Enrolled counsellor lists for the Atlantic, Quebec, Manitoba, Saskatchewan and Ontario regions were provided to KTCL by the AFN midway through the review process on July 8, 2015. Due to the minimal timeframe remaining for the review to be completed, an email with information on the review and key questions was disseminated to a sample of the counsellors from these lists. KTCL emailed four counsellors from each of these five regions. From the sample of 20 it was hoped KTCL could receive a high response rate. An option to respond by email or by way of a scheduled phone interview was offered.

Due to impact on private practice costs associated with making time available for such interviews, KTCL simplified the questionnaire tool to three questions:  A description of how First Nation clients accessed their mental health services;  Gaps / barriers they felt existed (if any) for clients accessing the STCIMHC benefit; and  Areas they felt could be improved with the STCIMHC benefit. Of the 20 participants invited to participate, KTCL received one response.

Overall Participation in the review

On average, KTCL interviewed between 8 - 14 participants in each region – a total of 102 participants. New Brunswick and Manitoba regions both had 14 participants. The least amount of interviews conducted was in Saskatchewan and Ontario regions due to no community focus groups being held. However of note is that 22 community members had recently participated in a related workshop in Ontario, and the Health Director ensured the perspectives from this gathering were encapsulated in their report. Specifically in relation to the First Nation community participation, all nine current Health Directors (or nominated delegates) participated in this review, along with 14 Mental Health staff. The community focus group members (35 in total) made up over half of the participants from the communities. Four other key stakeholder groups also contributed to the review - provincial / territorial health authority mental health personnel; Health Canada nursing staff; RCMP members and tribal council staff. These four groups made up 27% of the total number of interviews with the remaining 10 participants being from other sectors. Table III below summarizes the total number of regional interviewees including provincial and territorial representatives, from both site visit interviews as well as post-site visit phone interviews.

Table III: Total Participation in the STCIMHC Benefit Review

PROVINCE / Health Director Mental Community Others Province / Primary Care RCMP / Police Tribal Council Other* TERRITORY / Health Staff Focus Group (internal to Territory / / Medical First Nation Administration Members First Nation) Health staff Authority Nova Scotia    (6) -  -  - -

New Brunswick  (2)   (5)  (2)   - -  (2)

Saskatchewan   -   (3)  -  -

Ontario  (2)  (3) - -  - -  

Alberta   (3)  (3) -  (3) - - -  (3)

Quebec   (4)  (4)   -  - 

Northwest  -  (5) -  (3)  - -  (2) Territories

Manitoba  -  (8)   (2)  -  -

Yukon    (4) -  (2)  - - 

TOTAL 102 11 14 35 5 17 5 2 3 10

Percent 11% 14% 34% 5% 16% 5% 2% 3% 10%

*New Brunswick (child and family services); Ontario (North East Local Health Integration Network; Alberta (Mental Health Program Edmonton); Quebec (Center for Health & Social Services of upper Saint-Maurice); Northwest Territory (FNIHB Regional Executive Northern Region) and Yukon (Council of Yukon First Nations).

Analysis and Reporting

After sufficient time had been allowed for responses to post-visit emails and phone interview requests (i.e. with provincial / territorial staff or counsellors), KTCL completed the nine regional reports in draft form using a standard format for each - based on the approved information gathering tool:  Community context: a mini profile of each community to provide context including photos wherever possible. Some information came from the community and this was combined with data sourced from the community’s website) to identify size (population) and availability of community resources / facilities;  Description of the overall health services / programs, staff and health centre facilities to identify capacity;  Description of current mental health crisis ‘system’ or process for the community including connection with provincial / territorial services and any Health Canada-FNIHB services operating on-reserve (with information from community interviews, focus groups and provincial / territorial staff, websites and counsellors);  Knowledge of and access to the Indian Residential School: Resolution Health Support Program (gathered from interviews);  STCIMHC benefit awareness and ideas for improvements to process and access (with information from community participant interviews, focus groups, provincial/territorial staff and counsellors); and  Other pertinent information relevant to the specific community to reflect the diversity or uniqueness of the region (provided by any of the participants). Draft reports for the community component were then sent to Health Directors to validate. They were not asked to validate provincial / territorial information that had been provided. Most Health Directors were sent their draft reports approximately 2-4 weeks after the site visit and were given 2 weeks to respond. Edits were requested for three of the nine draft reports and were made. On completion of the nine individual reports (which are in the appendices) these were then reviewed internally for consistency in format and content and used to develop themes for each of the NIHB STCIMHC review objectives. This report includes an overall summary of key themes against the review objectives. The conclusions at the end of this report are drawn from the analysis, and recommendations made to transform the benefit according to the review goals.

Limitations of the Review

The primary limitation of the review was that 85% or 53 out of 62 First Nations staff and community members (excluding NWT where STCIMHC is not offered) were not aware of the STCIMHC benefit. A further 17 (61%) people out of 28 other participants (provincial / territorial / health authority / RCMP etc) staff members were also not aware of the STCIMHC benefit (these figures exclude NWT personnel). As a result there was little information that many participants could provide on how they felt about accessing the benefit, and whether there were gaps, barriers or areas for improvement. In fact the vast majority felt that more information was needed mainly on the existence of this benefit so that people could access it in the future. This limited the feedback and perspectives on the STCIMHC benefit that KTCL could capture according to the agreed questionnaire tool. As a default option, KTCL reviewed the STCIMHC process, eligibility criteria and components of the STCIMHC with participants and asked for their perspectives on these - but these opinions were not based on practical experience of the STCIMHC benefit. In situations where communities had no knowledge or experience of the STCIMHC benefit, KTCL asked participants to describe how current mental health crisis intervention processes were working and to offer perspectives on how these could be improved inclusive of STCIMHC being part of the continuum. Another limitation of the review was the lower than expected number of community participants that attended the focus groups. It was evident that the local health staff had worked hard to recruit participants – often using the honoraria and ability to influence positive change in mental health services as an incentive. KTCL had offered to have community meetings in the evenings if it was more convenient. However with so many other events occurring and community members or staff being on vacation (especially during summer) it was often difficult for Health Directors

to recruit ten people. Despite this most did manage to get some members to attend and their information was just as valuable. The themes and issues that each raised were fairly consistent across all regions, so it does not appear that this has impacted significantly on the outcomes of the review. It should also be acknowledged that health directors and staff were almost all First Nations community members as well so their perspectives add to the ‘community voice’ expected from this review. Finally KTCL reached out to 20 enrolled counsellors from the schedules of enrolled practitioners held by Health Canada in five regions. This was to seek their views to supplement those obtained from counsellors who had been part of the community-based information gathering process. Only one response was received to this request. More perspectives from Health Canada’s enrolled counsellors may have offered further recommendations to improve the processes associated with the STCIMHC from a practitioner perspective.

ANALYSIS OF FINDINGS

How access to the STCIMHC is expected to work The process map on the opposite page outlines how access to the existing STCIMHC benefit is expected to operate according to the Health Canada ‘Guide to Mental Health Counselling Services (NIHB Program and IRS: RHSP) 2015. Since the STCIMHC benefit is not offered in NWT the process does not apply to NWT. The policies and procedures for the STCIMHC outline that the eligible community member would access STCIMHC only if other services are not available. Access to counsellors for those experiencing a short-term mental health crisis is either through existing counsellors who may be operating in the community (as employees of the Nation; contractors to the Nation or visiting specialists contracted or paid by FNIHB or the provincial / territorial government). If there are existing services available, counselling services may be provided by First Nations employed counsellors; provincial / territorial employed counsellors or FNIHB-contracted counsellors (some of whom may be eligible to claim STCIMHC benefits for their work). In the case of an immediate critical event such as a suicide, homicide or other crisis that has affected an individual and their family, the response may involve the counsellor(s) as well as others such as RCMP, Health Directors, physicians, patient travel administrators and drivers, ambulance and emergency responders. If there are no existing services available to the community, then a community member (if eligible) would be able to contact their local FNIHB office to access one of the counsellors who have enrolled with the STCIMHC program. From this point on the counsellor arranges approval of sessions with FNIHB after conducting the initial assessment with the affected person. The counsellor would then make claims to FNIHB for the sessions. In time it would be expected that either the person would be discharged from the service having no further need for counselling, or the counsellor will have arranged for connection of the person into local Mental Health services. In some cases, counsellors may re-apply for STCIMHC if the person is still considered to be eligible and requiring more support to overcome the impacts of the crisis.

Exclusions The criteria for the STCIMHC outline a number of exclusions (Section 3.3 of guide):

 Psychiatric emergencies for person(s) at risk of harm to self or others;  Non-crisis counselling;  Services funded by another program or agency including IRS: HSP;  Psychiatric and family physician services;  Psychoanalysis;  Psychoeducational assessments;  Educational and vocational counselling  Substance abuse counselling / therapy;  Life skills training;  Early intervention programs for infants;  Assessment services for issues such as FADS, learning disabilities and child custody;  Expressive art therapy;  Hypnotherapy;  Court-ordered assessment services to clients;  Services which are part of or to be used for legal actions;  Sex therapy; and  Incarcerated clients.

This section draws on the findings from the interviews and focus groups conducted with participants from the nine First Nations communities as well as other key stakeholders.

Knowledge of – and access to - the STCIMHC Benefit Knowledge of the STCIMHC Benefit

Results from the interviews in all regions (except NWT) overwhelmingly affirmed that there was no or limited awareness, knowledge or access to the STCIMHC benefit. Since NWT does not offer STCIMHC their responses are not included. Of 62 First Nation staff and community group members interviewed at eight of the nine sites (excluding NWT), only nine participants (three Health Directors and six staff) were aware of the STCIMHC benefit. Of 28 other personnel interviewed (provincial / territorial / RCMP etc) 17 were also not aware of the STCIMHC benefit. There were no community group members who were aware of STCIMHC and while many had awareness of the NIHB program, particularly for medical transport, dental and pharmacy – none knew about the STCIMHC or had heard of it prior to KTCL’s site visit. It was difficult also for First Nations health staff including Health Directors to make comments on knowledge or access to the STCIMHC benefit, as the majority do not necessarily have any records of these types of claims, and may not be aware of clients who access the benefit directly through regional office since the most common way that clients access fee-for-service providers is by calling NIHB regional offices directly. In Saskatchewan for instance, the Health Director reviewed previous records and emails over five years but there was no records or communications related to the STCIMHC benefit. In another region the Health Director had found record of one claim being made in the previous five year period. Some staff acknowledged that they had turned to the Health Canada website to research the STCIMHC when they received the notification letters of the review. The majority of staff who were not aware that the STCIMHC was available considered that although they may not have a role in organizing counselling or the claiming process, they would make referrals for community members in need, if they had awareness of the STCIMHC benefit. While six participants in Ontario and Alberta were aware of the STCIMHC benefit, all commented that they were concerned by the limited availability of information pertaining to the STCIMHC benefit. One only had knowledge of a client accessing the benefit as she personally knew one of the therapists delivering the program. Another staff member had awareness of the Health Canada enrolled counsellors, but did not know they were possibly being funded from this program. In Ontario, one participant stated that they had made ‘numerous requests’ for a copy of the STCIMHC benefit criteria and a list of the enrolled counsellors but had not received the information at the time of KTCL’s visit. The Health Director in Nova Scotia accessed the benefit with approval from Health Canada for a community healing event following a suicide that had impacted multiple family and community members. A few of the provincial health authority participants acknowledged that they knew Health Canada funded counsellors and that they could provide support in times of crisis but did not link this to the STCIMHC benefit specifically. Overall their concern was that in general, the counsellors often operated independently of provincial mental health services thereby impeding effective shared care arrangements and assurance of a continuum of care for clients. STCIMHC Enrolled Counsellors

The vast majority of communities visited did not know who the counsellors were that provided short term crisis intervention counselling under the STCIMHC benefit. Some had requested the list of enrolled counsellors from their regional Health Canada office after they received the notification letter of the review as they had not seen it before and did not know who was on the list that their community could connect with. Some did not know if their current counsellors were enrolled to deliver STCIMHC or not. Others had Health Canada funded psychologists already working in their communities, but since they claimed payment direct from Health Canada the community Health Director or staff did not know if they were funded from other programs or the STCIMHC or both. The main barrier to knowing whether there was access to this benefit is that often the transaction was between the client/counsellor and

Health Canada directly - while First Nations health staff were more focused on ensuring community members received the counselling rather than what fund or program Health Canada was using to pay for it. Additionally the nature of the service is that it is confidential between the counsellor and the community member, so the First Nations health staff would likely not be privy to knowing whether any of the counsellor appointments were STCIMHC-claimed sessions or not. Sometimes counselling was provided under other programs such as Brighter Futures or by way of a psychologist contract put in place by Health Canada for one or more communities. Quality of counselling provided varied across regions – although as mentioned above it is difficult to differentiate between counselling provided under the STCIMHC and other programs if the health lead is not privy to the claims made by counsellors direct to Health Canada. If the counsellors had been in the community for a long time providing broader mental health counselling services, then often they were trusted and relied upon in times of crises. The very effective counsellors were fully engaged with the provincial services and their peers within the system including Chief Psychiatrists and psychiatric unit staff. Many community focus group members commented that often the counsellors enrolled with Health Canada were non-First Nations and did not have a good understanding of First Nations communities, so they did not access them. Some were concerned that counsellors were employed who did not speak their first language and this created barriers. There was a concern that where a male counsellor was being sent to a community, there was not enough thought given to ensuring a female was made available, and vice versa. One participant said they had seen the list of counsellors but the nearest was two hours away and this would present transportation barriers for clients. One participant in Alberta found that there was a constant turnover of enrolled counsellors which made it difficult to build relationships and collaboration with both clients and other service providers. Some felt that having the Federal government make decisions on enrolling who works in a community was ‘paternalistic’ and undermined the strengths and capabilities of communities to decide who is best to work with their community members. There was also a feeling that many Health Canada enrolled counsellors were not culturally sensitive or responsive and lacked the necessary training and understanding to be effective in dealing with intergenerational First Nations trauma. Two participants noted that there is a perception that some counsellors have had no formal cultural training (or only limited online training) or had not have spent any time in a First Nation community and therefore may not have a clear understanding of First Nation protocols. Another participant felt that there was a lack of understanding of the First Nations worldview yet this was critical to effective healing processes from trauma and crisis. Another participant made a recommendation that Health Canada should incorporate compulsory cultural training and criteria for being able to enrol with Health Canada to work in First Nations communities. There were mixed views on whether counsellors were better if they came from the community. Local knowledge and experience was considered vitally important to gain trust among community members, but confidentiality and privacy were equally important. Some felt that it was better to have someone external come in as they had no association with local residents and families and would be less likely to share information (gossip). Another suggestion from multiple regions was that the criteria for practitioners who could be paid under the Health Canada STCIMHC program (and others) should be expanded to include traditional healers, traditional therapists, elders, matriarchs and other trusted leaders from within the community. This was raised because often these were already the people who lived in the community, and who responded first to a crisis. Counsellors from Health Canada’s enrolment list would often come later (perhaps within days) after much of the stabilization work had already been done by these local responders. Many participants said the benefit should have the flexibility to compensate these persons in the community especially where their specific intervention had been instrumental to settling someone down and preventing them from hurting themselves or others. Another concern identified by one province was that enrolled counsellors were seen as taking advantage of First Nation communities, with some seen as travelling around communities getting “well paid to provide intermittent ‘crisis’ services that had limited impact or effectiveness”. In some cases counsellors would not travel to the community or do home visits, requiring the client to travel to receive service which created barriers for those most in

need. There was a perception that the STCIMHC benefit was more geared towards the interests of the enrolled counsellors than serving the needs of the client. Paperwork / Approvals

In five provinces, participants commented that many people could benefit from access to STCIMHC however they felt that completing paperwork for pre-approving counsellors and then waiting for an assessment and approval of the STCIMHC sessions – would deter people from accessing the STCIMHC benefit. They also did not think people in crisis would be in a good state of mind to go through the process of applying fearing even more frustration or trauma. The majority of First Nations community respondents were not aware that the initial assessment was able to be done without prior approval and that often decisions and claims were processed relatively quickly. This was validated by the counsellors who were interviewed. Participants from three regions commented that they did not think people would take the time to complete paperwork and pre-approval processes and would find it faster to deal with the crisis by going straight to the Emergency Department for crisis intervention and referral to inpatient or outpatient psychiatric units or crisis teams. In New Brunswick there has been a reduction in claims largely due to the burdensome nature of the administrative requirements. In Ontario, two participants commented that large amounts of administrative processes and paperwork for community members in crisis can be a barrier and is very burdensome. As a general comment, participants from two regions commented that there are extensive delays with responses, approvals and follow up from Health Canada for any matter related to NIHB and that with this program had become a very frustrating exercise. The views of participants related to STCIMHC approvals and claims processes seem to be generic views of administrative delays with other benefits that they believe would also apply to STCIMHC based on their interpretation of the process description provided in the guide for mental health counselling. With the low awareness of this particular benefit - the perspectives clearly come from assumptions about the STCIMHC process based on negative experiences with other benefits. Appropriateness of the STCIMHC for real-life crisis situations

It was identified across five regions that the description of the STCIMHC benefit did not seem to align with a mental health ‘crisis’ which was often immediate and dealt with as an emergency response, most often dealt with by the provincial system. They felt that counselling and healing after the ‘crisis’ was often managed over time through counselling by the clinicians – but not at the time of the crisis. In Alberta, it was felt that the current STCIMHC program was largely seen as lacking responsiveness to clients who find themselves in crisis. By the time clients are able to get access to an enrolled counsellor “if they can persist with the Health Canada approval process”, they are often no longer in crisis. Another participant from the Yukon noted that if a person was in crisis then they were probably not going to call a stranger such as a Health Canada enrolled counsellor. They suggested that it would be more effective to fund someone to facilitate the process and make it easier for the community member. As one participant stated “It takes too damn long to access. When people reach out for help they need it right away, not 3 days or a week later.” In Ontario, one participant felt that more investment is required in addressing mental health issues earlier, rather than waiting for crisis situations to occur. ”The benefit doesn’t apply to crisis it’s about counselling sessions after the fact”. It was believed that devoting more resources to promotion, early identification and the implementation of wellness programs was a better utilization of funds to prevent future crisis situations. In the majority of regions, participants commented on the need for crisis counselling support to be strongly linked and integrated with provincial services, much like it currently is in the NWT. It was noted that the STCIMHC benefit was run totally independent of community-based mental health services including those provided by provincial authorities. This often meant that clients were not linked to locally-based aftercare following the crisis because some independent practitioners were operating completely outside of the provincial system. Many commented on the ‘individualized’ nature of the STCIMHC benefit and lack of flexibility of the criteria to cover family, group or community approaches to healing during and after a crisis. Individualized counselling at an

individual level was also seen as a “very western model of practice”. The scope of practice needed to be broadened to a holistic approach to service provision. “Counsellors don’t get that drugs are a family disease…..they need someone who understand the individual within the family, within the culture”. Inadequate number of STCIMHC counselling sessions

The 15 sessions / 20 week cap on the number of counselling sessions available was another area of concern raised in a number of regions. Participants from four regions asserted that the number of counselling sessions and the length of time for counselling to take place were inadequate, particularly for clients who were often experiencing many complex and life-long issues and crises. In one region, the Manager of Mental Health & Addictions suggested the need for after care service provision once clients have received clinical services. “We need to move away from just putting out fires in the moment and nothing to support afterwards”.

Current crisis intervention services and models

The STCIMHC benefit is intended to be a last resort benefit – available only when “no other services or funding are available” (Section 3.0 of Guide). In the majority of the communities visited for this review there was no knowledge or awareness of the benefit, which may imply that communities have not had a need to access it because they do have services available to them. The following summarizes the findings of the review relative to the current service landscape and how it operates in the specific communities that were visited. Each community across the country is different however and within regions, even communities within one region operate different models based on their location and capacity. The services and models described are therefore not representative of the entire province or region, but of the communities that were visited. Capacity

In the vast majority of First Nation communities that were visited, the communities employed at least one Mental Health Promotion staff member. Of the nine sites, six communities employed a full time NNADAP worker who predominantly provided peer counselling services or undertook mental health awareness and prevention activities through campaigns and education programs. The Manitoba community NNADAP worker also provides post treatment sessions and the 12 step program (including AA groups). However none of these workers are qualified clinical staff. The majority of these staff are funded from the Brighter Futures; NASYPS: NNADAP or Building Healthy Communities programs. Many were however working to have more of their staff gain formal qualifications. Provincial / territorial health Authorities, such as that in Nova Scotia, employs a qualified clinical therapist who is assigned to serve two First Nations communities and is a member of the provincial team able to leverage further supports for clients from peers, as well as clinical supervision and professional development from within the health authority. Stony Health Services in Alberta has a structure consisting of three clinical therapists offering mental health support services including crisis management as part of their community driven ‘Turning Point’ program that provides services to three communities including Bearspaw First Nation. Turning Point is a community based mental health service treatment planning discussions; goal setting service provision and follow-up services for emotional and mental health disorders. Other specific services include individual psychotherapy with adults and children, marital therapy and family therapy. The ‘Turning Point’ team are located in their own private location and are funded through the NIHB STCIMHC benefit. In Garden River (Ontario), the mental health workers are complemented by a traditional cultural worker who provides traditional healing and counselling services typically delivered at the Dan Pine Healing lodge. In the community visited in the Yukon, they utilize a family support worker and a native court worker. Waycobah (Nova Scotia) has a ‘Suicide Prevention and Crisis Intervention Framework’ that evolved from a community suicide that describes the support available from all agencies for community members in crisis.

Many counsellors are employed or contracted to serve multiple communities. For example, a clinical therapist in New Brunswick serves 5 communities within the Sunbury region while another clinical therapist in Nova Scotia serves 3 communities. It is common that these clinical staff visit the communities primarily on a monthly basis for a set amount of days. There is a visiting psychologist in Alberta who provides services one half day per week on- reserve in Bearspaw however in the Yukon the visiting community mental health nurse visits Old Crow for approximately 2-3 days every month. In Alberta the qualified psychiatrist visits the community one day per month, as well as 2 psychologists that visit the community bi-weekly. Northwest Territories

The STCIMHC benefit is not available as a benefit from NIHB in NWT and mental health counselling is provided by the territorial government through regional health and social service authorities. The Lutsel K’e First Nation does not deliver any health services or programs itself. The YHSSA provides a visiting clinical psychologist that delivers services to Lutsel K’e 3 days every 2 weeks. Linkages with Provincial and Territorial Services

All Health Directors that were involved in the review reported that it was important to establish, build and maintain a good relationship with the local health authority and provincial staff. While there are varying degrees of relationships, ‘both good and bad’ across the regions - for those who held a positive relationship, the client pathway tended to be more seamless and stress-free for the client. In Nova Scotia the regional health authority provides clinical supervision, training and resources to the clinical therapist and this supports the effectiveness of his work with clients. Additionally, the health authority also organized for the clinical therapist to work within the hospital on various days over a 2 month period as part of the induction process. This not only provided an opportunity to understand the system within a provincial context but also allowed an opportunity to build relationships with key staff. The health directors in the Yukon and Quebec had good working relationships with provincial / territorial staff which supported key elements such as communication with discharge processes and immediate access requirements. Two regions where the relationships could be enhanced faced challenges with transportation to provincial meetings or felt there was a perceived lack of support for culturally relevant approaches for First Nations people. Since there were little or no claims for STCIMHC, participants were asked for information on how Mental Health crisis support was currently provided. Generally the process encompasses the following stages described in the diagram below which are a visual summary of the processes described during the review:

INDIVIDUAL AND Individual in crisis accesses FAMILY Traumatic event / counselling on incident / crisis / Balance of Hope, belonging, their own reaction meaning & purpose impacted

INFORMAL IMMEDIATE COUNSELLING RESPONSE Community, provincial, private (STCIMHC) Family, elder, matriarch, healers, friends etc

PROVINCIAL / TERRITORIAL EMERGENCY ROOM & FORMAL RESPONSE PSYCHIATRIC UNIT RCMP, Social Worker, Nurse, Assessment and care and possible Ambulance Aboriginal advocates in hospital / unit

Transport options: Family, health van, taxi, ambulance, RCMP, medivac, security workers

Depending on the time and type of crisis or incident, a client may be transported to the closest hospital (typically Emergency room) by one of several means:  Family / Family Matriarchs / Friends / Health Director  First Nations medical transportation vans (if available)  RCMP  Taxi vouchers  Ambulance This can be a lengthy and in some cases an arduous exercise for some communities. For example, in Pauingassi (Manitoba), which is a fly-in only community, the closest hospital with psychiatric services is located in Selkirk 200kms away. If Medivac services are required for someone in crisis, the client needs to be transported to another community (Little Grand Rapids) by boat which is 30 minutes away and then medivac’d to Selkirk. The 3 remote communities that were part of the review all have similar challenges. Across all sites, the client’s care for patients in crisis at the emergency department is typically the same. A physician or nurse will triage the patient and refer the person to the psychiatric unit for more detailed assessment. Some communities specifically mentioned that First Nations support staff are available to help with First Nation clients in

some hospital settings (Whitehorse, Regina). The psychiatric assessment will usually determine if a client is admitted to a psychiatric unit or referred to mental health crisis services as an outpatient, community counselling team or sent back to the community. Where there is a good relationship with the hospital, the discharge process works effectively and staff members on-reserve are notified by the psychiatric unit to make after care arrangements. Alignment with the Indian Residential School: Resolution Health Support Program

It was evident through the participant interviews in most regions that there was limited awareness of the IRS: RHSP even though the program is provided in all regions. Across five regions the First Nations community health services did not themselves provide the IRS: RHSP and some did not know who was providing the service. Some believed that it was being provided by independent non- government organizations (NGO’s) but could not name them. In two regions participants had heard that the IRS: RHSP was sun-setting in March 2016 and were unsure of what would happen after this time so did not want to recommend starting someone on a journey that may not be sustainable. In Ontario and Quebec the First Nations that were visited did not provide the IRS: RHSP program but do have funding to undertake activities that align to the IRS: RHSP program. This includes various activities for elders and IRS survivors that are facilitated on reserve – such as the Dan Pine Healing Lodge in Ontario. In Manitoba, the Tribal Council is currently recruiting two positions to provide cultural support to community members, including cultural ceremonies, spiritual support and counselling that also align to the IRS: RHSP. In three regions (Saskatchewan, Quebec and Alberta), participants were aware of the IRS: RHSP either through their Tribal Council who provide the program, or their psychologist. One psychologist in Quebec is able to access the IRS: RHSP benefit as around 20-25% of his client consultations are eligible.

CONCLUSIONS

The review of STCIMHC in the nine regions has revealed a number of weaknesses in the awareness and access to this benefit but has also highlighted a number of operational mental health crisis intervention arrangements that are working in various regions.

Strengths and Weaknesses of current implementation of the STCIMHC Benefit

Community Perspective on Short-Term Crisis Intervention Mental Health Counselling

There were generally three forms of events or triggers that initiated the need for short-term mental health crisis counselling that were identified by communities: • immediate high impact crises (such as a suicide or attempt in the community, homicide, shooting, accidental / unexpected death; an infant or child death) that affects an individual, the immediate family (e.g. spouse, child, parent, grandparent) and often the broader community; or • a short-term mental health crisis affecting one or more individuals, especially family members, several days, weeks or months after a high impact crisis such as those described above during the grieving / bereavement process; or • an environmental catastrophe that impacts the whole community (fire, flood) and traumatizes individuals for a short-term period. Community feedback during the review – including feedback from First Nation health centre staff – indicated that effective short-term crisis intervention counselling was most useful when it could respond to any of the above events at an individual, family and / or community-wide level. Based on community feedback, an ideal scenario for counselling for those experiencing a short-term mental health crisis that would be very effective would be where certain pre-conditions exist:  Regular counselling services already exist in the community (and did not require travelling away to access); and  the existing counsellors have developed trusting relationships with the community, elders, Chief and Council and the First Nations health centre staff, and  the existing counsellors are Aboriginal and accepted as culturally competent (ideally from the Nation and speak the local language); and  the existing counsellors are strongly linked with or connected to the provincial / territorial services i.e.: o they know the key staff within the provincial/ territorial mental health system including lead psychiatrist and other counselling and mental health crisis response staff; o they understand and participate in the referral and discharge process for community members; o they participate in mental health service planning, training and professional development opportunities; and o they share care through communications and effective case management); and  the existing counsellors can call on additional crisis support capacity from a tribal council or collective body or provincial / territorial service that they have established relationships with when needed; and  the counsellors and health team (including any FNIHB or Territorial Nursing station staff) have a formal crisis response protocol or arrangement in place with the community’s Doctor/NP, RCMP , victim services, ambulance or local emergency room; and local social workers; and  there is ability for those involved to make individual short-term mental health crisis counselling; family counselling and community healing ceremonies or events available when desirable for those impacted by any crisis.

The communities that were visited during the course of this review had several of these ‘success factors’ in place in order to make short-term crisis intervention mental health counselling successful for community members. The NWT for instance had many of these conditions in place because they operate a fully integrated health system from the territory’s health authorities. The review in Nova Scotia also revealed that many of these success factors were in place and that this was working successfully for the community. The success factor that was most challenging to put in place was the availability of Aboriginal counsellors, particularly those who spoke the local language. In summary, the review found that the more of these pre-conditions that existed, the more seamless and effective the counselling services were for the specific community.

Information and Awareness of the STCIMHC

A key fact about this benefit is that it is only applicable ‘when no other mental health services are provided or available” - so this is considered a ‘last resort’ benefit. Where communities who were part of this review did not know about or access the STCIMHC, one could either assume that they did not need to access it because existing services were available OR that they could have benefitted from the STCIMHC because they did not have existing services, but did not know it was available. Health Canada’s Guide describes how ‘eligible recipients access Short-Term Crisis Intervention Mental Health Counselling’ and states that ‘NIHB clients should: a) first contact their local community organizations (health centre, friendship centre, or primary health care provider) to determine if community mental health programs are available b) If other mental health crisis counselling services are not available, clients may contact their Health Canada regional office for a list of mental health counselling providers close to their community of residence’. The results of this review show that overall NIHB clients were seeking help from their local mental health counselling service and/or health centre – and that where these were not available – they were not aware that the STCIMHC benefit was available for them to access counselling through FNIHB’s enrolled counsellors. The majority of feedback from the communities was that someone in crisis would not be in a state to look up Health Canada’s website to find crisis counselling help and to work through the process outlined in the guide. Targeting the information about accessing the STCIMHC benefit at NIHB recipients in crisis was seen as highly impractical. Furthermore the majority of First Nations health team staff did not know about the STCIMHC either so did not refer clients to access it where they felt they were eligible. The other means by which First Nations health staff became aware of the STCIMHC was when they approached FNIHB for help with a community crisis and learned from FNIHB that they could make funding available to them to help, from the STCIMHC fund. The review found that access to and use of the STCIMHC benefit was determined primarily by enrolled counsellors who knew of its’ availability and who claimed the benefit for clients who met the criteria. The review team did not learn of any occasion where a community member had directly contacted FNIHB for the names of enrolled counsellors, and accessed the STCIMHC themselves. Another factor related to this lack of awareness is that the crisis counselling sessions are confidential between the counsellor and the client, and the claims are sent by counsellors straight to FNIHB so there is often no role for the client or First Nations health team in the process. Most community members who had counsellors assumed they were paid by Health Canada but were not aware what the fund was that was used to do this. The counsellors could have been claiming STCIMHC but the clients and First Nations health staff did not appear to be aware of whether this was the case or not. No data on crisis counselling claims for community members is provided to or shared with the First Nations health team and unless the community member accesses the counsellor for crisis purposes through the health centre, they have no knowledge of how many community members routinely access short-term crisis counselling. The

First Nations health teams were unaware of how many clients needed short-term crisis intervention mental health counselling in any given year and how many claims were made by a counsellor direct to FNIHB for STCIMHC. From a provider perspective, having the STCIMHC available for them to provide additional counselling for clients in crisis appeared to be positive from the interviews that were conducted with counsellors. Where counsellors are enrolled with FNIHB they are aware of the STCIMHC (and IRS: RHSP benefit) that they can claim, and most stated that they did not have difficulty with processing or payment provided they produced the required paperwork. Overall therefore there is very limited knowledge of this benefit by the sample communities. Participants feel that this gap in information needs to be addressed in order for the communities to access it appropriately. Of 68 First Nation staff and community group members interviewed at the nine sites, only nine participants (three Health Directors and six staff) were aware of the STCIMHC benefit. Enrolled Counsellors providing short-term crisis intervention mental health counselling

Provider Eligibility According to the Health Canada guide (2015) and website, enrolment of mental health counselling providers for NIHB and IRS RHSP is managed by the NIHB Program. All mental health counselling providers wishing to serve clients for reimbursement by either of these two Programs must first enroll with the NIHB Program. To be enrolled, mental health counselling providers must be registered with a legislated professional regulatory body and eligible for independent practice in the province/territory in which the service is being provided. Eligible mental health providers include Psychologists and Social Workers, with clinical counselling orientation; or Mental health counsellors with education and training comparable to psychologists or social workers.

In exceptional circumstances, other mental health counselling providers who do not meet these requirements may be accepted subject to the following conditions: • There are no other mental health counselling providers enrolled with the NIHB Program in the vicinity and access to services is limited; or • Where there is an emergency situation such that the health and safety of the client or other persons is at immediate risk. Four of the communities considered that elders, matriarchs, traditional healers and cultural practitioners should also be eligible to be compensated under this benefit for providing crisis intervention counselling as often they are the ‘immediate responders’ called upon in the communities when a crisis occurs, or when someone is in crisis. This occurs especially when there are no resident counsellors or RCMP on-reserve. While these community leaders are not recognized by Health Canada’s STCIMHC criteria they may be considered ‘exceptions in an emergency situation’ even though their title may not be ‘mental health counsellor’. It is believed that non-recognition of these important community responders, healers and counsellors removes choices for clients and does not acknowledge or respect the skills and experience of these community leaders. Communities would like to see them recognized (perhaps with a form of health centre endorsement) and not treated as exceptions, so that they can be compensated for their time and experience, and positive impact on de-escalating crisis situations for those involved.

There were generally three categories of counsellors providing services to the communities: • Those employed or contracted to routinely provide counselling on a semi / permanent basis; and / or

• Those who were independent practitioners providing services to communities (and being paid on a contract or claims basis by FNIHB) often on as as-required basis; and / or • Those employed by provincial / territorial authorities who were located in or near the community or made frequent scheduled visits. The review involved a number of counsellors some of whom were enrolled with FNIHB (and who had claimed STCIMHC in the past) and some of whom were not but who still provided counselling services to the community under another funding or employment arrangement. Counsellors who worked regularly in the community were clearly more trusted by community members and the vast majority stated that it was much better being able to see a regular counsellor in the community and not have to travel – especially in a crisis where they would be away from family support. Challenges with travel were mentioned by four of the communities. Counsellors who worked regularly in the community were also more likely to have established relationships with the First Nations health centre staff and with RCMP, social workers, nursing station staff and doctors who worked in the community. An additional benefit of a regularly operating counsellor in the community was the opportunity for them to become part of the local health ‘team’ and to benefit from broader relationships that the community has with neighbouring First Nations communities and tribal Councils / collectives. Sometimes the tribal Councils / collectives provided additional services for member communities (e.g. White Raven Healing Centre Crisis Intervention Stress Management (CISM) team in Saskatchewan; SERDC in Manitoba; Tui’kn Collaboration in Nova Scotia; New Brunswick 5-community collaboration; North Shore Tribal Council in Ontario; Stoney Tribal Council in Alberta) and supported communities with extra capacity in times of need. Sometimes they offered collective training for member communities and other collaborative initiatives. Counsellors who part of these processes are able to provide additional benefits for community members through being able to access this extra support. Community participants also supported a mechanism for local health leadership to have a role in deciding which counsellors work with their community members so that they are a good “’fit” with both the health team and the community culture, dynamics and protocols.

Communicating Availability of Enrolled Providers The Health Canada Guide (2015) states that ‘Health Canada will communicate any updates to this Guide, or related policies and benefits, to clients, providers and stakeholders in a timely manner’ During the course of the review it became evident that the vast majority of community Health Centres (as key stakeholders) were not aware of whom the enrolled providers were in their region or that FNIHB maintained a schedule of enrolled providers17. Only one region visited (Manitoba) had an arrangement whereby the local health authority received the latest schedule of enrolled service providers on a routine basis from FNIHB for circulation to their mental health team, while the others did not receive it or had not seen it at all. A mechanism is needed whereby the provincial / territorial authorities can be provided with a schedule of the enrolled service providers on a regular basis for referral and discharge purposes, and, where needed, case management purposes.

Provider Roles and Responsibilities The Health Canada guide (2015) and website state that among other things enrolled providers making STCIMHC claims must: . Complete a client assessment and discuss the recommended counselling and sessions schedule with the client;

17 During the course of the review this was raised and the AFN and FNIHB arranged for all regions to provide their latest schedules of enrolled providers and circulated it to the communities. 48

. Complete a treatment plan to be kept on the client's file. As part of the treatment plan, develop an aftercare plan that links the individual to community based mental health services or culturally appropriate services during and/or after the counselling; The guide also states that the STCIMHC is offered in a way that: . Recognizes STCIMHC benefit is a component of a mental wellness continuum that includes other FNIHB community-based and provincial / territorial mental health programming and services…. In order to meet the requirement to develop treatment plans, aftercare plans and to link clients to community- based mental health services it was considered by communities (members as well as health staff) as well as provincial health services, that to achieve this, the counsellors needed to have an established relationship with provincial mental health services. This included crisis mental health services and any Aboriginal health services located within the provincial / territorial system. It was also considered that any new counsellors should be required to complete an orientation with the provincial / territorial mental health services so that the person could build links with those services to provide more integrated care for clients. A strong relationship with provincial / territorial mental health and emergency services was seen as critical to effective treatment planning; case management; referral and discharge and client outcomes. Many regions have well developed successful collaborations that have demonstrated strong relationships and excellent coordination within communities between health (including Nation-employed staff as well as contracted counsellors and psychologists), RCMP, doctors / nurse practitioners, FNIHB nurses and social services to respond to crises. Some have gone as far as developing a formal protocol including rapid communication mechanisms while others are in the process of developing these. Successful regions have also extended those local response mechanisms to the provincial services so that emergency rooms, psychiatric units and Aboriginal advocacy services can respond appropriately if someone needs to be transported out of community. An excellent example was provided in one region where the counsellor is treated as part of the provincial mental health service; has easy access to training, staff and clinical supervision; has shared case management and open communications; and has high levels of collegial support from their peers within the provincial system. In other regions the continuum is not as effective. Three regions were concerned that the large number of private practitioners (counsellors) enrolled with FNIHB were not connecting with either the local health team or the provincial services. In fact some provincial / territorial health services did not know who the enrolled counsellors were and how to access the schedule of enrolled counsellors. This meant there was little shared case management or information sharing in the interests of the client, Nevertheless, it was noted that communication and collaboration with provincial partners continues to strengthen as health authorities continue to build capacity and to build relationships with First Nation communities – and vice versa. It is clear that services work best for clients when the counsellors are strongly linked with or connected to the provincial / territorial services: . they know the key staff within the provincial/ territorial mental health system including lead psychiatrist and other counselling and mental health crisis response staff, and any Aboriginal advocacy staff; . they understand and participate in the referral and discharge process for community members; . they participate in mental health service planning, training and professional development opportunities; and . they share care through communications and effective case management); . they can call on additional crisis support capacity from provincial / territorial services that they have established relationships with when needed; and . the counsellor is part of a community’s formal crisis response protocol or arrangement.

The Health Canada guide (2015) and website state that among other things enrolled providers making STCIMHC claims must: . As part of their ongoing professional development, providers are encouraged to continue to enhance their knowledge of First Nations and Inuit cultures in order to better serve clients. This can include opportunities

provided by their professional associations, through First Nations or Inuit communities or organizations, or other related training. The guide also states that the STCIMHC is offered in a way that:  Supports culturally competent mental health counselling. The vast majority of the counsellors described by the communities in all three categories were identified as non- First Nations/ Aboriginal and many participants agreed that this created a gap in availability of culturally competent counselling. Those whose first language was not English stated that they would prefer a counsellor who could speak their indigenous language however also acknowledged that this was a challenge. The language was seen as an area that with further investment would have a significantly positive long term influence on mental health outcomes and the process of healing during a crisis through improved communication and understanding. Many felt that more cultural training and ongoing development of knowledge and trauma-informed practice was needed for any counsellors enrolled and contracted by Health Canada and that this should become a mandatory requirement and not something that is simply ‘encouraged’.

This exclusion confused some of the community participants who felt that this meant no one who had suicide ideation, had attempted suicide or who was impacted or traumatized by a family member suicide attempt or completion, could be covered by the STCIMHC. Counsellors in other regions were however often using the STCIMHC to work with clients who were feeling suicidal after a crisis or who needed short-term help after being impacted by a friend or family member suicide. The Health Canada guide (2015) Mental Health Counselling Provider Reimbursement states that . ‘Fees charged are in accordance with the ones approved in the Prior Approval Form. Under no circumstances are individual counselling fees to be charged when a client has received counselling as part of group, or family counselling’. This was interpreted to mean that no one could be reimbursed for any group, family or community counselling under the STCIMHC. A gap noted by five of the communities was that group, family and community healing processes developed to help people recover from short-term crises was not covered by the STCIMHC. A focus on holistic family and community counselling and healing was deemed critical amongst various audiences in the regions. Many participants commented that individual counselling sessions may be beneficial as an initial assessment however family and community members would play a critical role in the long term healing pathway so group and family sessions should be covered (like the IRS: RHSP).

Alignment with the Indian Residential School: Resolution Health Support Program (IRS: RHSP)

There was limited awareness of the IRS: RHSP across the regions that were visited. Five of the nine regions stated they did not provide the IRS: RHSP and some did not know who was providing the service. Some believed that it was being provided by independent NGO’s but could not name them. In two regions participants had heard that the IRS: RHSP was sun-setting in March 2016 and were unsure of what would happen after this time so did not want to recommend starting someone on a journey that may not be sustainable. In three regions (Saskatchewan, Quebec and Alberta), participants were aware of the IRS: RHSP either through their tribal Council who provide the program, or their psychologist.

Alignment with the First Nations Mental Wellness Continuum Framework

A brief analysis of the findings with the framework reveals close alignment of both current practices and aspirations of the participating communities:

First Nations Mental Description Link with STCIMHC Wellness Continuum Framework: Dimension Four directions Hope, Mental wellness is when these dimensions are in balance. Crises occur (outcomes) belonging, when these are out of balance. meaning and purpose Effective, responsive and culturally appropriate crisis counselling should restore balance however crises impact families and the community and not just individuals – so STCIMHC should include group counselling like the IRS: HSP

Community Kinship, clan, Many examples of kinship collaborations are in place where First elders, Nations communities and tribal councils are working together to community improve mental health service delivery (e.g. White Raven Healing Centre Crisis Intervention Stress Management (CISM) team in Saskatchewan; SERDC in Manitoba; Tui’kn Collaboration in Nova Scotia; New Brunswick 5-community collaboration; North Shore Tribal Council in Ontario; Stoney Tribal Council in Alberta)

Populations Focus on Services need to be flexible to meet the diverse needs. The evidence of population sub- the nine site reviews shows the array of models that exist for mental groups (e.g. health services and crisis response. Arrangements have been tailored women, LGBT) around the presence of a variety of service models (i.e. FNIHB nursing stations, local First Nations-led services; visiting services of health professionals; provincial services including tele-health; services of private practitioners and counsellors) and meeting needs of community members. Two communities identified gaps exist for specific counselling models for men and for the homeless. Further feedback from NFNHTN was that women affected by violence are also a sub-group of the population needing better access to STCIMHC. This is especially so when they need to leave a community for safety reasons and then need to access STCIMHC

Specific population needs e.g. Individuals The more successful models of crisis intervention link well with other with chronic services especially primary care for chronic disease, communicable conditions, disease and maternity clients in crisis. The less successful models treat acute mental mental health and addictions as separate and do not value the need for

First Nations Mental Description Link with STCIMHC Wellness Continuum Framework: Dimension health concerns communication with primary care to benefit the client. The review reveals that where counsellors providing support under the STCIMHC are part of the local health team and strongly linked to the provincial / territorial services they are more effective for community members. This is often not the case when independently operating counsellors are operating privately, conducting sessions and billing FNIHB without any demonstration of such linkages existing for clients.

Continuum of essential From health This is definitely an area that the communities want to build on to services promotion and create a continuum of mental wellness that does not just include prevention NNADAP, Brighter Futures and Building Healthy Communities but through to strengthens and integrates the crisis response component and care aftercare planning and shared treatment approaches with provincial and territorial services. While a requirement of the STCIMHC for linkages with other services this does not appear to be monitored or enforced.

Supporting elements e.g. Governance, Aspirations of self-governance in health were expressed by one workforce community, development, self- The most pressing and frequently mentioned need in this area is determination workforce development for Health Canada enrolled counsellors (cultural competency and trauma-informed practice) and for more First Nations- employed staff working in this field. There was a desire for Health Canada to be more proactive in supporting an increase in First Nations qualified mental health counsellors across the country.

Partners in NGOs, provincial There are many positive collaborations between First Nations implementation and territorial communities and provincial / territorial partners and often these have governments, been proactively initiated and resourced by the health authorities. The federal results of these collaborations have led to a better understanding of government each other’s systems and clients, but also have helped to improve service and patient pathways and experiences. While a requirement of the STCIMHC for linkages with other services this does not appear to be monitored or enforced. Additionally partners are often involved in community crisis response and although not part of the implementation of the STCIMHC benefit, the way a community and its partners respond when someone feels they are in crisis and needs counselling is critical. The more this collaborative effort has been pre-planned the better the crisis response will be;

Indigenous social e.g. Locally managed health services have more chance of being able to determinants of health Environmental, work closely with schools, RCMP, elders and language centers and many social services, communities felt that counsellors employed by the Nations was an language easier way to achieve this type of integration. Independent practitioners heritage and who visit infrequently were seen as less successful at integrating with culture, urban other areas of the community such as schools, cultural centers and and rural social services. In the Northern Region they have already seen the benefit of merging health and social serviced under one umbrella so that services for communities can be coordinated and resources used more efficiently.

First Nations Mental Description Link with STCIMHC Wellness Continuum Framework: Dimension Being able to address transport needs of clients in crisis is a key determinant for access and outcome.

Key themes for mental Community Flexibility of funding for crisis intervention was a key issue. Communities wellness development, across the site visits would rather see this type of mental health ownership and counselling funding being provided to communities to help strengthen capacity the crisis response part of their mental health continuum of services, building, quality and to ensure they are better ready to respond to a crisis (crisis care system, planning, protocols and communications). competent service delivery, Also many want to strengthen the linkages with provincial services in collaboration order to provide a more seamless patient journey through mental with partners, health crises and care (including transport; linking with discharge units, enhanced organizing appointments). While a requirement of the STCIMHC flexible funding counsellors for linkages with other services - this does not appear to be monitored or enforced.

Elders, cultural Culture as foundation Many communities noted that there is a lot of cultural strength that can practitioners, be found within their community that is key to addressing many of the kinship mental health challenges currently found within the community. There relationships, was a need to allow the community to invest more in preventative language, measures that build off and strengthen the cultural capacity within the practices, community. ceremonies, knowledge, Several want to incorporate other means of helping someone through a language and crisis including Talking Circles, youth camps, healing journeys, etc. values Several communities also want to see elders, matriarchs, healers and cultural practitioners recognized for their role in counselling community members in crisis and being compensated by STCIMHC benefit when they do. A key area which the First Nations communities want strengthened is the cultural competency of counsellors. It was evident that First Nations want to ensure that enrolled counsellors are knowledgeable and aware of indigenous history, colonization, colonialism, systemic and institutional racism as they are root causes and contribute the overall malaise of social and mental health problems in communities. Many clients may have trauma, intergenerational impacts, depression and post-traumatic stress disorder as a result of their history with colonization. It is vital that counsellors are equipped and trained to work in First Nations communities safely, sensitively and appropriately.

Potential Changes to Transform Short-Term Mental Health Counselling

Support increases to counselling workforce The view of many community members and health centre staff was that a deliberate effort needed to be made nationally and regionally to increase the number of Aboriginal enrolled mental health counsellors. A strategy for recruitment of new students into psychology and mental health counselling from secondary schools and supporting First Nations/ Aboriginal students to graduate and work in First Nations communities was seen as an essential national strategy. This would in turn help to improve the cultural competency and appropriateness of mental health care for First Nations communities. Support Crisis Response Planning Due to the distance required to access medical / clinical crisis services for many communities (especially fly-in communities) some have developed their own crisis response strategies and protocols to handle situations when they have no resident health professionals. Other communities – while they might not be remote or fly-in – also do not have crisis response plans or protocols in place but acknowledge they are necessary. Supporting the development of strong crisis response protocols and crisis response plans that involve the health unit, primary health, child and family services, RCMP, victim services, local police, Ambulance and other supports along with the community immediate responders and counsellors was seen as a necessary improvement to support effective mental health services. Resources for completing this planning and facilitation support would be necessary for many communities to help complete this necessary task but there are very good examples of communities who have done this with great success. Provide Short-Term Crisis Intervention Mental Health Counselling Funding direct to community18 There were several regions who advocated for these types of funds to be transferred to communities to manage like other programs in their Contribution Agreements, and for this type of support not to be isolated as a ‘benefit’ arrangement. Converting STCIMHC to a program that could sit alongside NNADAP, Building Healthy Communities and Brighter Futures programs would provide some communities with flexibility to use the funds for the administrative costs associated with supporting a client in crisis; supporting resiliency initiatives in communities; expanding health promotion and early intervention efforts including harm reduction to help avoid crises and support people to cope and manage crises in their lives better; developing crisis response protocols within community and with external agencies including provincial / territorial services; emergency travel assistance for clients in crisis; and providing funds direct to communities to compensate key community leaders who helped to alleviate an individual, family or community crisis to recognize their contributions. A key factor for communities wanting more control over short-term crisis funding is the ability for the community to act quickly and cover costs immediately to support those in need when sudden crises occur and people need to respond quickly to support individuals and families. It was felt that this would also support the community to align the intent of this funding with other Health Canada funded First Nations mental health and addictions programs such as NNADAP, Brighter Futures and Building Healthy Communities programs. This would work successfully for some communities who have capacity, including urban organizations, and could be positioned as an option similar to other NIHB benefits where a mix of individual benefit claims and Contribution Agreements operate simultaneously across the country.

18 While this review did not include participation of urban organizations, it is acknowledged that the NIHB has a large number of clients who live off-reserve, so this should be considered alongside any recommendation to convert STCIMHC to a community-based program. Urban First Nations organizations could for instance be considered to provide the service. 54

RECOMMENDATIONS

Recommendations are organized into five priority areas for transformation that align with the contracted review outputs19 in the Statement of Work for this review, and aligned with the criteria and policies outlined in the guide for STCIMHC. It is recommended that the NIHB JRSC:

1. IDENTIFICATION OF STRENGTHS/WEAKNESSES IN THE BENEFIT AS IT CURRENTLY EXISTS a. NOTE that the strengths of the STCIMHC benefit were identified as being primarily provider-centric in that: • where counsellors know it is available, they can claim the STCIMHC (subject to criteria) to meet needs of clients with short-term mental health crisis counselling needs • claims appear to be processed relatively easily by FNIHB • counsellors can apply for extensions of sessions (five more above the 15 allowed) if clients require it b. NOTE that the weaknesses of the STCIMHC benefit were identified as: • Information about the STCIMHC is not reaching the First Nations health centre staff and communities (although there is wide knowledge of other NIHB benefits i.e. medical transportation, dental, pharmacy & vision benefits); • Information about the enrolled counsellors able to provide short-term crisis intervention mental health is not routinely available to First Nations health centers or to provincial / territorial mental health services; • Counsellors who are enrolled are ‘encouraged’ to learn more about culture and history of First Nations for their practice in the communities however community feedback is that this remains a gap in the competency of counsellors serving communities. The lack of focus on cultural competency requirements of counsellors also impedes ability of the STCIMHC program to align with the First Nations Mental Wellness Continuum Framework; • Communities have no voice in endorsing or approving counsellors working in First Nations communities who are enrolled with FNIHB to ensure their acceptability from a cultural competency perspective; • Counsellors are required to prepare treatment plans and aftercare plans to link clients into community- based mental health care, but there does not appear to be any monitoring or enforcement to test that these important linkages with First Nations health services and provincial / territorial mental health services exist during client care planning, counselling and discharge / referral; • Coverage does not include group, family counselling or community healing from crises and trauma who may be experiencing a short-term mental health crisis (covered by IRS: RHSP but not STCIMHC) and this is seen as a gap for communities; • No data or information is shared with First Nations health centers (for independent non-employed provider claimants) that informs the community about levels of short-term mental health crisis experienced within the community requiring STCIMHC support , for community health planning purposes. This type of information would also be useful for mental health planning efforts by First Nations communities working with provincial / territorial services.

19 Aligned with expected Review Outputs as outlined in the Terms of Reference for the Review 55

place with an enrolled counsellor). At present these persons would be considered ‘exceptions’ rather than core service providers who are recognized by First Nations communities; b. INCORPORATE in the approval process for counsellors enrolling with FNIHB, that a First Nations panel review applicants for suitability and experience in working with First Nations communities; c. REQUIRE all counselors who are on, or wish to register, as an STCIMHC counsellor to provide evidence of competency in working with First Nations individuals, families and / or communities. This may include evidence related to years of working with First Nations clients (e.g. in urban and/or on-reserve settings); completion of formal and on-line training; residency within a First Nations community; prior relevant learning and experience etc. The important thing is that counsellors provide evidence of their experience and commitment to First Nations mental health and wellbeing through their life and work experience, qualifications and previous learning(s); d. REGULARLY UPDATE AND DISSEMINATE the Health Canada enrolled counsellors schedule and information to First Nations health directors and directors of mental health at all provincial/ territorial health authorities. Maintain data on gender, language(s) spoken, years working in First Nations communities and references; e. REQUIRE counsellors to actively work with and establish linkages with First Nations health services in the communities they operate in, and with relevant provincial / territorial mental health services as part of their treatment planning process, and conduct regular practice reviews to ensure this is occurring; h. CLARIFY terminology in the ‘exclusions’ list for STCIMHC to ensure that short-term crisis intervention mental health counselling is available for those affected by suicide-related incidents. Also clarify what STCIMHC is not appropriate for so it is clear what does not constitute crisis intervention mental health counselling; i. CLARIFY in the description of coverage and exclusions that those who may be charged (with a crime) but are awaiting court proceedings are not excluded. At present the criteria states that exclusions include ‘Court- ordered assessment services to clients and services which are part of or to be used for legal actions’ which means those who may be charged but not proven innocent or guilty may be excluded from access to the STCIMHC benefit. This is an occasion where First Nations may feel they are in crisis but are unable to access counselling to help them through the process.

necessary improvement to support effective mental health services. Resources for completing this planning and facilitation support would be necessary for many communities to help complete this necessary task but there are very good examples of communities who have done this with great success; b. PROACTIVELY SUPPORT AND ENCOURAGE collaborations in primary and mental health care between First Nations and between Nations and provincial / territorial services. Many regions have well developed successful collaborations that have demonstrated strong relationships and excellent coordination within communities between health (including Nation-employed staff as well as contracted counsellors and psychologists), RCMP, doctors / nurse practitioners, FNIHB nurses and social services to respond to needs in the community. Some have gone as far as developing a formal protocol including rapid communication mechanisms while others are in the process of developing these. Successful regions have also extended those local response mechanisms to the provincial services so that emergency rooms, psychiatric units and Aboriginal advocacy services can respond appropriately if someone needs to be transported out of community. An excellent example was provided in one region where the counsellor is treated as part of the provincial mental health service; has easy access to training, staff and clinical supervision; has shared case management and open communications; and has high levels of collegial support from their peers within the provincial system. It is clear that services work best for clients when the counsellors are strongly linked with or connected to the provincial / territorial services: . they know the key staff within the provincial/ territorial mental health system including lead psychiatrist and other counselling and mental health crisis response staff, and any Aboriginal advocacy staff; . they understand and participate in the referral and discharge process for community members; . they participate in mental health service planning, training and professional development opportunities; and . they share care through communications and effective case management); . they can call on additional crisis support capacity from provincial / territorial services that they have established relationships with when needed; and . the counsellor is part of a community’s formal crisis response protocol or arrangement.

5. POSITIVELY TRANSFORM THE STCIMHC BENEFIT a. SUPPORT INCREASES TO COUNSELLING WORKFORCE: The view of many community members and health centre staff was that a deliberate effort needed to be made nationally and regionally to increase the number of Aboriginal enrolled mental health counsellors. A strategy for recruitment of new students into psychology and mental health counselling from secondary schools and supporting Aboriginal students to graduate and work in First Nations communities was seen as an essential national strategy. This would in turn help to improve the cultural competency and appropriateness of mental health care for First Nations communities; b. PROVIDE SHORT-TERM CRISIS INTERVENTION MENTAL HEALTH COUNSELLING FUNDING DIRECT TO COMMUNITY: There were several regions who advocated for these types of funds to be transferred to communities to manage like other programs in their Contribution Agreements, and for this type of support not to be isolated as a ‘benefit’ arrangement. Converting STCIMHC to a program that could sit alongside NNADAP, Building Healthy Communities and Brighter futures would provide some communities with flexibility to use the funds for: . the administrative costs associated with supporting a client in crisis; . supporting resiliency initiatives in communities; . expanding health promotion and early intervention efforts including harm reduction to help avoid crises and support people to cope and manage crises in their lives better; . developing crisis response protocols within community and with external agencies including provincial / territorial services; . emergency travel assistance for clients in crisis – at the time of the crisis; and

. compensating key community leaders who helped to alleviate an individual, family or community crisis at the time the crisis occurred and to recognize their contributions. A key factor for communities wanting more control over short-term crisis funding is the ability for the community to act quickly and cover costs immediately to support those in need when sudden crises occur and people need to respond quickly to support individuals and families. It was felt that this would also support the community to align the intent of this funding with other Health Canada funded First Nations mental health and addictions programs such as NNADAP, Brighter Futures and Building Healthy Communities programs. This would work successfully for some communities who have capacity, including urban organizations, and could be positioned as an option (similar to other NIHB benefits where a mix of individual benefit claims and Contribution Agreements operate simultaneously across the country).

APPENDICES

SITE REPORTS

The following table provides a brief overview of the nine First Nation communities that participated in this review:

Table IV: Characteristics of selected communities participating in the STCIMHC review

FIRST NATION REMOTE / URBAN RURAL POPULATION RCMP ON FIRST COMMUNITY FLY-IN (on and off RESERVE (or LANGUAGE reserve) located ENGLISH nearby) Waycobah First  975   Nation, Nova Scotia

Oromocto First  660   Nation, New Brunswick

Piapot First Nation,  2326   Saskatchewan

Garden River First  2812   Nation, Ontario

Bearspaw Stoney  1897   First Nation, Alberta

Wemotaci First  1874  Nation, Quebec

Lutsel K’e Dene  768  Band, Northwest Territories

Pauingassi First  634 Nation, Manitoba

Vuntut Gwitchin  543   First Nation, Yukon

TOTALS 3 3 3 12,489 8 6

NOVA SCOTIA / NEWFOUNDLAND REGION: WAYCOBAH FIRST NATION

JOINT REVIEW OF NON-INSURED HEALTH BENEFITS

SHORT-TERM CRISIS INTERVENTION MENTAL HEALTH COUNSELLING (STCIMHC) BENEFIT Operational Benefit Review

NOVA SCOTIA / NEW FOUNDLAND REGION

SITE: WAYCOBAH FIRST NATION, Cape Breton, Nova Scotia

COMMUNITY DESCRIPTION

Waycobah (head of the waters) First Nation is a historic Mi’kmaq community established in the early 1800’s, located along the shores of Bras d’Or Lakes in Cape Breton, Nova Scotia. Waycobah is one of five Mi'kmaq communities located within the tribal district of Unamaki (Cape Breton Island). There are thirteen (13) Mi'kmaq communities throughout the Province of Nova Scotia, represented by the Grand Council, the government of the Mi'kmaq Nation.

According to the AANDC20 May 2015 data, the total Waycobah First Nation registered population is 975.

Economic and social development remains a priority for the community as Chief and Council work to enhance Waycobah’s natural attributes. Some of the community services and facilities are:  Rod’s One Stop, a convenience store and gas bar  Waycobah Gaming Centre  Negemow Basket Shop, offers many beautiful and unique crafts such as baskets, beadwork and leather made by local Mi’kmaq crafts people.  A new school (opened in 2008) Elementary (Kindergarten to Grade 6) and Secondary School (Grades 7 – 12) under one roof  Fitness Centre  Daycare facility

20 Aboriginal Affairs and Northern Development Canada 61

 Theresa Cremo Memorial Health Centre (opened in 2010) including doctors days, nurse practitioner, full time clinical therapist, prenatal classes, lab collection, Reiki treatments, an Alcohol and Drug counselor, midwifery clinics, well women and men clinics, a dietician, teen health clinic and a variety of other programs  Modern Band administration building: provides a wide variety of services such as the social administration office, finance department, Native employment office, housing authority, fisheries department and economic development department.

In partnership with national universities and colleges, Waycobah provides university programming as well as trades and technical programs.

WAYCOBAH HEALTH CENTRE AND SERVICES

The Theresa Cremo Memorial Health Centre opened in June 2010 providing a full range of services and programs in primary care, health promotion and mental health services. The health center is a healthcare provider accredited by Accreditation Canada and are well supported with documented policies and procedures such as: - Cultural Safety - Duty to report abuse - Health Emergency Response Plan - Client safety Identification - Mental Health Wellness - Substance Use and Misuse - Well Adult Health Policy

- Well Elderly health Policy - Health and Community Care service and access to service policies - Client Abuse

Health Department Staff

Waycobah Health Centre is a department of the Waycobah First Nation administration and the Health Director reports to the Chief Executive Officer. Staffing includes:

SERVICE GROUP POSITIONS Management /  1 Health Director Administration  1 receptionist  1 Maintenance / Janitor  6 casual drivers in community to drive the Waycobah Patient Transport Van Mental Wellness and Employed by Waycobah Substance Use  2 Addiction Workers (diversion)  1 Addiction Coordinator  1 Clinical Therapist (full time)

Employed by Nova Scotia Health Authority – based in and serves two communities: part-funded by Waycobah (serves 19 years & over)  1 Clinical Therapist (2.5 days p.w. shared with Wagmatcook First Nation nearby) NB: The school has its own Counsellor for 18 years and under Primary Care & Employed by Waycobah Community Health  1 medical receptionist  1 medical receptionist / Maternal Child health  1 Nurse Practitioner (funded 50/50 Waycobah with Nova Scotia Health Authority) Employed by Nova Scotia Health Authority – serves two communities  1 Doctor (2 days per week Tue / Thu) shared with Wagmatcook FN  1 Doctor (1 day per week Wed) Home Care Employed by Waycobah  1 Foot Care / Public Health worker  1 CHR / Home Care Supervisor / CCA  1 Home Care / Foot Care worker  1 Home Care Coordinator

There are two Clinical Therapists, one part time and one full time. Waycobah fully funds the full time Clinical Therapist from their Health Canada Brighter Futures and Building Healthy Communities programs. The part time Clinical Therapist is employed by Nova Scotia Health Authority ((NSHA) and assigned to serve two First Nations communities including Waycobah. One has a Masters in Counselling and the other has a Masters in Social Work. Clinical supervision is provided by the Health Authority and staff members have access to all training opportunities, on line and tangible resources, best practice research and evidence offered by the provincial system. They are also able to undertake shared case management, case conferencing and to access information and staff from within the Health Authority. The Therapists maintain all of their patient information at Waycobah on their Practimax EMR system and only summary data is provided to NSHA. A full orientation to all services and staff within the provincial Mental Health and Addictions Unit was provided to the Therapists which has made their service provision much more effective according to one of the therapists. It was noted that this orientation helped the therapist to form solid relationships with their peers in the mental health unit as evidenced by a statement made by one of the therapists “I have an excellent relationship with NS Health Authority and staff in the units because I am considered part of the team.” The orientation enabled the therapists to gain an understanding of how crisis management works at the hospital and what services, supports and personnel are available to provide additional support to the therapists and to clients.

The Therapists use multiple methods when working with clients including Cognitive Behavior Therapy’ Narrative Therapy; anger addiction approaches and music – applying an Aboriginal lens to the work as much as possible. Working closely with, and being based in, the community enables the therapist to build trust and draw from strengths in the community to use appropriate methods when working with clients. The same approach of using best available clinical practice while applying an Aboriginal lens is used for longer term mental health clients as well as those in crisis. Waycobah community has a ‘Suicide Prevention and Crisis Intervention Framework’ that evolved from a community suicide. The framework aims to prevent suicide rather than intervene after the fact. It recognizes that staff capability, cultural program planning, risk assessment and community support are key prevention areas. The framework also describes the support available for community members in crisis. This includes the immediate establishment of a crisis space / centre, staff availability process for support, daily debriefs and application for the STCIMHC benefit if the need arises.

Waycobah noted that they have a very good relationship with the Senior Director of Mental Health and Addictions services in the Health Authority based in Sydney (2 hours’ drive away) who has been extremely supportive and responsive to addressing the mental health and addictions needs of local First Nations communities. The creation of three positions that have been recruited across three First Nation communities (Waycobah, Eskasoni and Wagmatcook) has created ‘a real nice feeling across the communities - there is a good feeling and relationship with all’ according to the Mental Health and Addictions representative from the Nova Scotia Health Authority (NSHA).

Access to Provincial Services: Nova Scotia Health Authority

The closest hospital is located 20 minutes north of the community on a good sealed road in Baddeck however this facility is very small with only three beds and does not have any psychiatric inpatient or outpatient service. If Waycobah (or Wagmatcook) have a mental health crisis, the client is transported directly to Sydney via Highway 105 – a 2 hour drive on good roads, however affected by heavy snow during winter. Depending on the time of the crisis or incident, the client may be transported by one of several options:  Family member  Waycobah patient transportation (if during business hours M – F)  RCMP based on-reserve (either during business hours or after hours)  Emergency Medical Service (EMS) Ambulance service based in nearby village at Whycocomagh (24/7 service)

The NSHA is the recent result of the merger of nine formerly distinct District Health Authorities and some services have been reconfigured as a result of the merger and review of fragmented services. There are four Mental Health and Addictions units at Sydney Hospital – one Addictions Withdrawal unit and three mental health inpatient units.

There is also a Crisis Emergency Department which is open 12 hours a day 7 days a week. The emergency department takes most of the crisis clients and includes a physician or nurse assessment, diagnosis and referral to the mental health crisis service. Typically the referral would go to a psychiatric nurse or social worker / counsellor in the community. Depending on the assessment, if someone needed to be admitted they would be referred to one of the psychiatric units which are available 24/7. If the client was not admitted to a psychiatric unit from the Emergency Department they were discharged and a follow up process implemented with a local provider (in this case, the Waycobah therapist). It is estimated by NSHA that around 1/3 of the total number of clients including First Nations are not admitted to the psychiatric unit.

Access to Indian Residential School: Resolution Health Support Program (IRS: RHSP)

Waycobah does not provide the IRS: RHSP as this is provided by an independently contracted non-government organization (NGO) based at Sydney who have their own cultural and clinical counsellors. Referrals are made to this service if needed however with the regular availability of the clinical therapists in the community Waycobah does not find that they need to refer community members out to the IRS: RHSP service, although individual clients are always able to access it directly themselves if they prefer.

Tui’kn Initiative Collaboration

Funded by Health Canada's Primary Health Care Transition Fund, the five First Nations Bands in Cape Breton, Nova Scotia have embarked upon an historic partnership — the Tui'kn (Dw-ee-gun) Initiative. This means "passage" in the Mi'kmaq language — an apt description of the journey our communities are making to renew their primary health care system and to achieve the well-being of their people. The Tui'kn Initiative is about removing barriers, creating partnerships and building capacity in order to achieve a model of primary health care that is holistic, multi-disciplinary, comprehensive, and supportive of the vision of improved health and quality of life in the five member communities.

Waycobah’s Health Director is actively involved in the Tui’kn Initiative. The combined population of the five bands is approximately 4,860 who are all members of the Mi’kmaq First Nation. The partnership works closely with the Health Authorities, the Nova Scotia Department of Health, First Nation Inuit Health Branch of Health Canada and Dalhousie University. Projects have included: - Securing a team of family physicians - Secured access to the right provider at the right place at the right time

- Controlling the real killer: Chronic disease - Putting the power of data into local hands - Putting the lid on prescription drug misuse - Embracing new technologies to manage patient information - The development of community action plans for the issues of non-traditional tobacco use, diabetes, child-hood injury prevention and prescription drug misuse.

This collaboration has resulted in several benefits to the Waycobah and other communities in Cape Breton. One of the projects “Give us Wings” was a result of a focus on mental health services and configuring these to be more responsive to, and accessible by, First Nations communities. Along with development of the various protocols for crisis response and the strengthened relationship between the clinical therapists working on-reserve and the provincial mental health team, this initiative has helped to improve primary care services, prevention and early intervention in mental health.

REVIEW OF THE SHORT-TERM CRISIS INTERVENTION MENTAL HEALTH COUNSELLING (STCIMHC) BENEFIT

Awareness and Use of the STCIMHC Benefit

The review team interviewed the Health Director, one of the Clinical therapists (the other was committed to client appointments at the time of the visit) and three members of the Addictions team. While the Health Director was aware of one specific benefit claim in the 5 year’s she had been there, the Clinical Therapist and Addictions workers were not aware of the availability of this benefit. A community focus group was held and all six participants were not aware of the STCIMHC benefit until the site visit. They asked for a description of the eligibility criteria, the benefit and website information to find out more information. The Senior Director of NSHA had awareness of the benefit but did not feel it adequately addressed community needs without strong linkages to the provincial system and broader support being put in place for clients alongside the individual counselling.

The one STCIMHC claim that was processed was used to support family and affected community members impacted by a suicide in the community. It was identified that more than one person was affected by the suicide crisis, and that a community healing ceremony and event was needed. The Health Director approached Health Canada for funding support to cover the cost of counsellors attending the community healing event to provide support to community members, and Health Canada agreed to fund this from the STCIMHC benefit. Funding was paid on a daily rate to the counsellors who were able to counsel several community members during the healing ceremony over several days. The Health Director noted that “If the suicide (incident) didn’t happen, I wouldn’t have known about the benefit”. Client access to the STCIMHC benefit Since there was only one claim (that itself had been paid differently to the Health Canada description of the process to access the benefit) the stakeholders were asked for information on how Mental Health Crisis support was currently provided; and

how/whether the STCIMHC benefit could be a useful part of that continuum. They were also asked if they had ideas on how to improve access to the benefit.

Clients access mental health services through various means including self-referrals, referrals from RCMP, probation services, correctional facilities, hospital, and referrals from internal services such as the Addictions team or from community members who know the health centre therapists. Depending on the level of crisis, there are a variety of options for clients:  Utilization of the provincial crisis line (there are several in Nova Scotia) although the extent to which:  Mental Health Mobile Crisis Team (MHMCT): Telephone intervention throughout Capital District, mobile response for Halifax, Dartmouth, Bedford. Crisis intervention & short term crisis management. Available 24 hours a day, 7 days a week  Pictou County Help Line: Serving New Glasgow. Crisis 12 noon - 12 midnight 7 days/week: email: [email protected]  FEED NOVA SCOTIA Helpline: Toll Free in NS Halifax. The Helpline is open 24/7 including holidays and offers supportive empathetic listening and referrals, relationship counselling, mental health issues, addictions, parent support, food and housing concerns.  Eastern Regional Help Line: Serving eastern region of Nova Scotia Sydney; Crisis 6pm - midnight, 7 days/week. Crisis 6pm-midnight, 7 days/week  SOS Cape Breton ~ Survivors of Suicide: Toll-free line

Originally there was a Mi’kmaq crisis line but funding for this ceased and the service was merged with the provincial crisis line which is able to provide a Mi’kmaq translator.

If there is a mental health crisis in the community, community members are transported to Sydney Hospital to the ‘1A / 1st Floor’ Inpatient Crisis Psychiatric Unit. On discharge clients are referred by the Nova Scotia Health Authority (NSHA) in Sydney to one of the two Clinical Counsellors working at Waycobah and Wagmatcook. Since the counsellors are members of the NSHA Mental Health / Psychiatric Care team, these referrals work very well.

Perspectives on the STCIMHC Benefit

STCIMHC Enrolled Counsellors

Stakeholders were made aware that to access the STCIMHC benefit, the counsellor being used had to be enrolled with Health Canada and on their enrolment list to ensure they held the right credentials from a professional college. Of the 38 enrolled mental health providers in Nova Scotia authorized by Health Canada to deliver the service under the STCIMHC benefit, it was noted that 33 were more than 2 hours away from Waycobah, with five being 90 minutes away based in Sydney (3), North Sydney (1) and Howie Centre (1). Waycobah did not consider that they would access any of these counsellors since they were not ‘regulars’ in the community unlike the current counsellors assigned by NSHA who have built trust and confidence in the community. They also did not think that with the paperwork and pre-approval process, they could get someone there for a crisis any faster than driving someone to the Sydney Emergency Department for crisis intervention and referral to inpatient or outpatient counsellors already working in the community. One person in the focus group had a prior experience with trying to access the enrolled counsellors for their own need. There was no one available from the Health Canada enrolled mental health counsellor list. Two were unable to be contacted despite messages left, and “one person on the list no longer worked as a counsellor and was retired” so the list was considered to be unhelpful and out of date. “This is not crisis support due to distance and the time it would take for them to come.” While they agreed that many people could use access to community-based therapy they felt that completing paperwork for pre-approving counsellors that were already trusted, then waiting for an assessment and approval of the STCIMHC sessions – would deter people from accessing the STCIMHC benefit. It was faster for them to see one of the locally trusted counsellors or to go directly to the psychiatric service in Sydney.

Accessing Help in a Crisis

The community focus group identified that their community had good police (RCMP), crisis responders / EMS ambulance in the village and access to the Waycobah medical van to transport people to Sydney Crisis support if needed. The RCMP confirmed they had a prior incident whereby transport was provided to a client to Baddeck Hospital who was deemed as being a threat to themselves or others but mentioned that the EMS Ambulance is usually the first point of call. Some utilize the ambulance or go directly to the Sydney Hospital emergency room and are then admitted to the 1st floor psychiatric unit if needed. The community focus group did acknowledge that there was nothing specific to use of language, cultural practices, sweat lodge options, smudging or resilience programs at the hospital psychiatric unit but felt they could promote more of this through their partnership with NSHA.

It was also identified that the description of the STCIMHC (15 sessions over 20 weeks) did not seem to align with a mental health ‘crisis’ which was often immediate and dealt with as an emergency response – but counselling and healing from the ‘crisis’ was often managed over time through counselling by the Clinical Therapists. The Therapists still had opportunity to refer to the inpatient unit if they felt someone needed something more intensive. Suggested Improvements to the STCIMHC Benefit / Short Term Crisis Mental Health Counselling

Mobile Psychiatrist to do assessments

The focus group identified that better use of the STCIMHC funds would be to make these available for psychiatrist time if needed – but not just for crises. They considered that while they had Clinical Counsellors and Addictions Workers, often some people needed a psychiatrist to support often long journeys of healing and pain. One of the reasons that they felt a mobile psychiatrist would be useful is because wait times are long for people to get assessed at the inpatient psychiatric unit. Apparently the Antogonish Hospital had a mobile psychiatrist and this service worked well previously but no longer operates.

Fund Resiliency Efforts instead

Other ideas from the focus group were to re-direct funding toward resiliency rather than have it set aside just for crisis intervention:  support “journey of healing” resilience projects and similar resiliency initiatives;  support Aboriginal based therapy (CBT) e.g. To cover connectedness, empowerment and enrichment;  to have a youth worker;  visiting dietician to help people to eat well and maintain good physical health; and  counsellor available 24 hours or on call.

A question arose as to what the STCIMHC benefit expenditure or budget was for the Nova Scotia region and whether there was opportunity to work with Health Canada to look at this investment and determine if something more effective could be done with the funds. It was considered there is often so much emphasis on crisis response that this has created gaps in dealing with health determinants, promotion and prevention activities such as resilience building or creating effective response systems in communities that could be initiated early and prevent crisis situations from spiralling out of control.

The community focus group also agreed with a focus on resiliency by looking at crafting, events, cooking and budgeting classes, youth events, culturally based events, language classes, sports, meals and feasts where education can be provided, and dances. They were trying very hard to reverse the trends in prescription addiction, IV Drug use and other effects of drug use (e.g. High heels to Moccasins program for women).

Improve Paperwork & Approvals

The focus group also noted the forms and pre-approvals that were needed for the STCIMHC when the process was explained to them. They felt that the paperwork needed to be user friendly and paper friendly otherwise it would deter people from using it: “Clients are put off by too many forms”. They also felt that the process as described in the Health Canada guideline

seemed to place responsibility on the client in crisis to apply for help through STCIMHC when most likely they were not in the best state to do this, viz: “No one in crisis is going to think oh I must call Health Canada and see is there is a counsellor on their list that I can see now”.

They suggested that communities be supported to develop strong crisis response protocols with their provincial health authority like Waycobah had, and that the community be able to manage the crisis immediately. Any forms needed to be made ‘user friendly’ (one pager) that could be used to obtain approval by phone quickly to proceed. They could then write a full report after the crisis was managed and propose an approach that would help the person, family and community heal from the crisis (such as the community event they had implemented after a community suicide). “The priority should be to take care of the crisis and paperwork done later due to the vulnerability of clients” as stated within the focus group.

The Clinical Therapist also noted that paperwork can be a barrier to accessing a benefit such as this, noting that sometimes the inability to complete extensive paperwork can produce further trauma for people already in crisis. He noted that even with 15 sessions over 20 weeks, there was no ‘one size fits all’ approach and that it would have to be adapted for each individual case. As he stated ‘one cannot stretch out the therapy to use up the 15 sessions but you also cannot restrict it too much irresponsibly and deny people the care they need’. It was suggested that there needed to be more flexibility in the model so that people needing only one or two sessions could benefit as much as those needing one or two years’ worth of support over a longer period of time recovering from a significant crisis on their life.

Independent Practitioners do not align with Continuum of Care

NSHA noted that the STCIMHC benefit was supporting / registering a large number of private practitioners (counsellors) who may or may not know about the larger Mental Health continuum of care being provided within the province. It was felt that sometimes they would have different practices, ideas and approaches to communicating about local client needs with others involved in their care (e.g. the First Nations health centre and the provincial system). The independence of the practitioners enrolled as counsellors with Health Canada and not the province, meant they often were not linked into the overall mental health continuum of care “system” between First Nations and provincial services. Further they were often less willing to share case management or information that would enable a better outcome for the client since they were funded by Health Canada and not the province. It was considered that this has led to further fragmentation of services for First Nations communities.

It was also felt that a single benefit like this makes one person (counsellor) responsible for dealing with the crisis rather than a health system connected with programs and supports for an individual and their family. The model of having local counsellors works well within the provincial system and communities know and trust these people.

NEW BRUNSWICK / PRINCE EDWARD ISLAND REGION: OROMOCTO FIRST NATION

JOINT REVIEW OF NON-INSURED HEALTH BENEFITS

SHORT-TERM CRISIS INTERVENTION MENTAL HEALTH COUNSELLING (STCIMHC) BENEFIT Operational Benefit Review

NEW BRUNSWICK / PRINCE EDWARD ISLAND REGION

SITE: OROMOCTO FIRST NATION, New Brunswick

COMMUNITY DESCRIPTION Oromocto First Nation is located on the west bank of the St. John River at the mouth of the Oromocto River, approximately 20 kilometers southeast of Fredericton, New Brunswick. The town’s name is derived from the name of the Oromocto River which is thought to have originated from the Maliseet word Wel-a-mook-took which means “deep water”. Oromocto is one of fifteen First Nations in New Brunswick, and is one of four Maliseet communities that belongs to the St John River Valley Tribal Council (along with Madawaska Maliseet First Nation, Woodstock First Nation and St. Mary’s First Nation). The Oromocto First Nation has a land base of 26 hectares.

Oromocto is the headquarters for the Gagetown Military Camp, now known as the Canadian Forces Base Gagetown (CFB Gagetown) which opened in 1955 and is the largest military reservation in the Commonwealth of Nations. Oromocto’s entire economy is dominated by CFB Gagetown.

According to the AANDC21 May 2015 data, the total Oromocto First Nation registered population is 660.

Oromocto First Nation is governed by an elected Council comprising of a Chief and five (5) Councilors serving for a two-year term.

Some of the community services include the Health Centre; Child & Family Services; Forestry; Great Spirit Canoe handcrafting; Headstart Program; Fuels (Gas Bar); and the Oromocto First Nation Lounge.

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WEL-A-MOOK-TOOK HEALTH CENTRE The Wel-a-mook-took Health Centre opened their new building in 2012, providing a variety of services and programs22 including: - Immunizations - Communicable Disease Control - Medical Disabilities - Physical Disabilities - Psychiatric (Mental) Disabilities - Dependency-based Disabilities - Learning Disabilities - Drug and Alcohol Intervention - Drug and Alcohol Youth Prevention

- Foot Care to Elders and Diabetics - Canada Pre-natal Nutrition Program - Pre-natal classes - Diabetic Clinics - Blood Pressure / Blood Sugar clinics - Dental Float Program - Renewal of Medicare - Hospice - Environmental Health - Water Testing - Meals-on-wheels - Home Care

Wel-a-mook-took Health Centre has a block flexible funding agreement. The specific community-delivered mental health programs and services provided by the Wel-a-mook-took Health Centre are:

 Psychiatric Services (One day every 5-6 weeks)  Alcohol and Drug peer counselling through the NNADAP worker  Mental Health nurse (funded by the province)  Mental Health counsellor for Youth (1 day per week - funded by MCFD)  Cultural volunteer (1 day per week)  Methadone program  The Health Director also provides front line support 24/7

Health Department Staff Wel-a-mook-took Health Centre is a department of the Oromocto First Nation administration and the Health Director reports to the Chief. Staffing includes:

SERVICE GROUP POSITIONS Management /  1 Health Director (who is also a front line worker) Administration  1 Receptionist  1 Medical Transport Driver to drive the Oromocto Patient Transport Van  1 Cleaner / Maintenance Worker Mental Wellness and Employed by Oromocto Substance Use  1 NNADAP Worker who provides peer counselling (not clinical

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SERVICE GROUP POSITIONS counselling) Employed by Horizon Health Authority  1 Psychiatrist (1 day every 5-6 weeks shared with 4 other First Nation communities nearby)  1 Mental Health Counsellor (.5 FTE counsellor shared with 4 other First Nation communities nearby – half day per week) Employed by Ministry of Child & Family Development (MCFD)  1 Mental Health Youth Counsellor (who works with schools and utilizes the Wel-a-mook-took Health Centre one day per week) Volunteer  1 Volunteer nurse / Mental Health Counsellor (1 day per week)  1 Elder from another First Nation community who provides cultural support and knowledge (availability varies)

A .5FTE Mental Health Drug and Addiction Clinician and dietician are due to start shortly who will be shared across 5 First Nation communities. Primary Care & Employed by Oromocto Community Health  1 Community Health Nurse  1 Community Health Representative  1 Nurse Practitioner (1 day per week walk in clinic)

There are currently no qualified clinical staff specifically employed by Oromocto Wel-a-mook-took Health Centre to deliver mental health services to the community. The NNADAP staff member is working towards their Masters in Counselling and therefore is currently providing peer counselling services only. There is a .5FTE Clinical Mental Health Counsellor (half day per week in each community) and a .2FTE Psychiatrist (one full day every five weeks in each community) employed by Horizon Health Network (HHN) assigned to serve five First Nations communities including Oromocto. The Psychiatrist usually visits Oromocto every five -six weeks and therefore access to this service is limited. There is also a Mental Health Youth Counsellor based in Fredericton funded by the Ministry of Chid and Family Development (MCFD) who undertakes half day counselling for youth in Oromocto Schools and utilizes the facilities of Wel-a-mook-took Health Centre one day per week. The creation and establishment of these positions and more imminent mental health service provision, has been supported by the collaboration of five First Nation Health Directors and their communities in Sunbury, New Brunswick. They are:  St Mary’s First Nation  Kingsclear First Nation  Woodstock  Tobique  Oromocto The Oromocto Health Director is actively involved in this collaboration and believes it has created a solid foundation towards recruiting workers for mental wellness. The combined population of the five bands is approximately 6,742. Wel-a-mook-took Health Centre is also fortunate to have a Registered Nurse volunteer her time for one day per week. This person was originally a professor and has experience providing nursing education. Her role can vary from day to day but is predominantly made up of crisis intervention work, home visits, health promotion and varying prevention work.

There is also a First Nation Elder from another First Nation community who volunteers to provide cultural support to community members, including smudging and providing support at the recently built Sweat Lodge building. Given the voluntary nature of this role, this Elder is not always available and does not live in the community. It was advised that there were limited numbers of Elders within the Oromocto First Nation community who are able to provide cultural support. Access to Provincial Services: Horizon Health Network (HHN) New Brunswick provides comprehensive addiction and mental health services, including a range of acute, inpatient, outpatient, and community services. New Brunswick currently operates, through two regional health authorities, eight psychiatric units, one child and adolescent psychiatric unit, two tertiary care psychiatric hospitals and more than a dozen community mental-health-care centres. New Brunswick also operates seven regional addiction centres, offering services that include detoxification, out-patient services and community prevention services. Two short-term residential services and one long-term residential service are available.

Oromocto falls within the coverage area of Horizon Health Network (HHN), which operates 12 hospitals. Oromocto Public Hospital is located a few minutes from Oromocto First Nation and is a community hospital serving the residents of the town of Oromocto and surrounding communities. The Oromocto Public Hospital has 45 beds but there is limited mental health capacity at this facility with a mental health counsellor service one day per week. The main regional hospital with mental health and addictions services is located 25 minutes north east of the community based in Fredericton at the Dr. Everett Chalmers Regional Hospital. The Dr. Everett Chalmers Regional Hospital in Fredericton offers 24/7 emergency room and there are approximately 55 inpatient acute care beds including some psychiatric and addictions services. The hospital also offers emergency mental health services. The psychiatric inpatient unit has a proportionally high intake of aboriginal patients according to the Manager Adult Mental Health and Addictions.

In addition there are three Addiction and Mental Health Services centres in the Fredericton area and one Mobile Mental Health Crisis Intervention Team. Fredericton Addiction and Mental Health Services provide a range of services for individuals, youth, and family members affected by substance abuse, problem gambling and mental health issues. These are free, voluntary services which can be accessed with or without a referral. Initial appointments are offered within 3 business days.

Through an intake process, clients are connected with a social worker, nurse, psychologist, occupational therapist, community support worker, or psychiatrist. Specialized mental health services include:  Assessments  Individual counselling  Psycho-educational and/or therapeutic groups  Auricular acupuncture  Psychiatric consultation  Crisis services (e.g. Mobile Crisis Services, Emergency Mental Health and Inpatient Psychiatry)  Early psychosis programs  Forensic psychiatric assessment (mental health issues related to criminal charges)  Outreach services to various communities  Community-based agencies/services or self-help groups  Critical Incident Stress Management for First Responders

The Fredericton Mobile Crisis Services provide interventions to diffuse crisis situations in the community to individuals and families outside of the usual hours of operations including evenings and weekends. Based at the Victoria Health Centre, the Mobile Crisis Team is available by phone or the Intake Team are on duty 24/7 with an on-call psychiatrist. If the patient is deemed a high risk, they are transferred to the Regional Hospital inpatient psychiatric unit. If the patient is low risk and not admitted to a psychiatric unit they are discharged and HHN endeavours to book mental health counselling appointments within three months. There is also a Child and Adolescent Psychiatric Unit (CAPU) based 2 hours away from Oromocto in Moncton, which is a six-bed, provincial-based, inpatient psychiatric unit, serving children and adolescents from six to sixteen years of age. Patients must be referred from the Community Mental Health Centres or physicians only when all regional resources have been exhausted in addressing psychiatric diagnoses and treatment recommendations.

Oromocto clients access mental health services through various means including self-referrals, referrals from RCMP, MCFD, and Hospital, referrals from internal services such as the Psychiatrist or nurse practitioner or from community members. It is known by the Health Director that some community members also utilize the Chimo provincial crisis phone line that is accessible 24 hours a day, 365 days a year to all residents of New Brunswick. Access to Indian Residential School: Resolution Health Support Program (IRS: RHSP) Oromocto does not provide or have access to the IRS: RHSP and only one person in the community is known to be a residential school survivor, according to the Health Director. The community focus group participants have all heard of the IRS: RHSP and feel that ‘there is a lot of shame carried by residential school survivors and their family, which inhibits many from accessing support services or speaking openly about their experiences’.

SHORT-TERM CRISIS INTERVENTION MENTAL HEALTH COUNSELLING (STCIMHC) BENEFIT

Awareness and Use of the STCIMHC Benefit The review team interviewed the Health Director, Nurse Practitioner, Community Health Nurse and Community Health Representative. The Health Director has utilized the STCIMHC benefit over a number of years, however the claims have decreased recently, largely as a result of the administrative challenges with accessing the benefit and the perceived long- term ineffectiveness of the services offered through this program. All other staff within Wel-a-mook-took Health Centre were not aware of the availability of the benefit and refer all mental health crisis patients directly to the Health Director. The volunteer registered nurse and the HHN Manager Mental Health & Addictions were aware of the NIHB program, but not specifically STCIMHC benefit.

All five participants of the community focus group were not aware of the STCIMHC benefit until the KTCL visit. They asked for a description of the eligibility criteria and description of the benefit and this information was provided. Participants said that there is a real need in the community for such services with a very high usage of drugs, traffic accidents, sexual abuse, depression and suicide ideation in the community. One participant noted that there have been 4-5 deaths in the community over the past two months and that there is a strong need for community support and healing.

There was no mention from HHN that they referred to a counsellor by accessing the STCIMHC benefit. All remaining interviewees were not aware of the STCIMHC benefit.

Client Access to Mental Health Crisis Support If there is a mental health crisis within the Oromocto First Nation community, all employees of the Health Centre commented that the process is usually to refer to or ring the Health Director, irrespective of the time of day. While not paid to undertake this on-call role, with over 30 years’ experience the Health Director is both trusted in the community and seen as having the health expertise to be able to determine the most appropriate course of action in a timely fashion. She determines if the person needs to be transferred to the psychiatric inpatient unit in Fredericton and organizes transportation. Depending on the type and time of the crisis or incident, the client may be transported by one of several options:  Family member  Wel-a-mook-took Health Director – taxi vouchers or drives them personally  Oromocto patient transportation (if during business hours Monday – Friday)  RCMP (either during business hours or after hours)  Ambulance Service While there is a range of crisis intervention and mental health support services available through the provincial health system, staff and focus group participants felt that community members tried to avoid utilizing these services unless absolutely necessary due to a range of factors including: long delays and waiting lists for accessing services; fear of leaving the reserve; the perceived lack of aboriginal cultural sensitivity and awareness by provincial health staff; cost barriers and a lack of transportation; and childcare challenges. Two interviewees stated that there is a significant shortage of youth mental health supports – including the CAPU which has a significant waitlist – and that young people are falling into “gaps” in the system due to the lack of transitional supports between adolescent and adult psychiatric services. Most interview participants noted that the relationships with Oromocto Hospital, Fredericton Hospital and Mental Health & Addiction Services was very limited. “People don’t access (hospital services) unless it is a last resort or the psychiatrist refers them”. According to one staff member: “The waiting time is the biggest issue (in accessing provincial mental health services). The response needs to be immediate when someone is in crisis and that’s why everyone goes to the Health Director”. While some felt there was a need to increase the availability of locally-based mental health services in the Oromocto area, some participants felt that the Oromocto Hospital services did not meet the needs of First Nation people, and that very few community members went to the hospital as a result of a number of community members having had poor experiences of accessing the Hospital’s services. “There is an attitude that First Nations people are drug users… Our people don’t use this service unless they are very very unwell. It is not a welcoming place for First Nations”.

Two participants commented that there is a lack of dedicated Aboriginal supports integrated within the provincial mental health system, which was a barrier in facilitating increased access for First Nations members to the range of services available. The hospitals were seen as unwelcoming environments for First Nations people and largely dismissive of culturally relevant approaches to healing. The community focus group felt that a stronger partnership was needed with HHN to promote

greater inclusiveness of Aboriginal culture and practices such as the use of Aboriginal language, cultural ceremonial practices, sweat lodge options, smudging or resilience programs, especially within the hospital settings.

There was a feeling of persistent stigmatization amongst staff towards local First Nation people as well as systemic racism embedded within the hospital processes and systems that alienated First Nations people. One interviewee provided an example of an attempt to undertake a sacred smudging process and items being taken away. “I have heard so many ill- treatment issues and lots of racism at Oromocto and Fredericton Hospitals”.

Despite this the Health Director did note that she has been working alongside neighbouring First Nation communities to establish stronger relationships with the provincial health system. The visiting shared Psychiatrist and Mental Health Counsellor were seen as collaborative initiatives and a step in the right direction. However, much more work was needed to ensure the provincial health system was responsive to the needs of First Nations people and ultimately addressed the significantly disproportionate health inequities faced by First Nations communities. Health staff recommended that provincial health staff undertake regular visits to the community to help build relationships and awareness, and that all provincial health staff undertake comprehensive cultural competency training as well as trauma-informed practice training.

The Health Director and community focus group participants noted that a more effective approach to relying on external mental health clinicians or the provincial programs, was to increase locally-based mental health capacity within the Oromocto First Nation community. Importantly, it was seen that locally based workers were better able to build trust and strong relationships in the community therefore increasing their effectiveness in supporting those dealing with mental health challenges. Increasing local capacity also served to reinvest resources into more preventative and early intervention strategies, therefore reducing the incidence of crisis within the community.

Health staff and community members suggested that due to the complexity of needs, social constructs and dynamics within the community, that community members required access to both on-reserve and off-reserve options when requiring mental health supports. For some there was a fear and insecurity about leaving the reserve or receiving services from people who were unknown or unfamiliar. For others, there was a perceived inability to access support from the Well-a-mook-took Health Centre or within the community because of privacy and confidentiality concerns and the stigma attached to those seeking mental health support services.

Perspectives on the STCIMHC Benefit

Health Director and Staff Perspective The Health Director was asked for information on how the STCIMHC benefit was accessed. While there have been a number of STCIMHC benefit claims accessed in past years, it was noted that this has reduced over recent years. According to the Health Director, this was largely due to: clients not following through with making the appointments; the burdensome nature of the administrative requirements; an increasing number of claims being declined; or services not provided by local indigenous people who community members trust. This latter point was stressed by another staff member that commented that all Health Canada enrolled counsellors are non-First Nation Fredericton based counsellors who use clinical language and are therefore difficult for people to understand. “They use big words and it puts people off”.

The Health Director noted that the structure of the STCIMHC benefit was not responsive to the needs of a client who is experiencing a crisis situation. “It takes too damn long to access. When people reach out for help they need it right away, not three days or a week later.” There was a need for Health Canada to improve the turnaround time for getting assessments done, which could be better facilitated by providing the funding for 1-3 counselling sessions directly to the Nations to administer, to ensure timely assessments are undertaken for those in crisis. Approvals would then be sought from Health Canada for the remaining sessions that the client is entitled to.

The Health Director and staff also commented that the both the number of counselling sessions (up to 15) and the length of time (20 weeks) for the counselling to take place was inadequate, particularly for clients who are often experiencing many

complex issues. The fact that the STCIMHC program was run totally independent of Oromocto’s community-based mental health services, also meant that clients were not linked to locally-based ongoing support services after they had completed their STCIMHC funded counselling sessions, which usually resulted in clients ending up back at square one.

Community Perspective The community focus group were asked for information on how mental health crisis support was currently provided; and how/whether the STCIMHC benefit could be a useful part of that continuum. They were also asked if they had ideas on how to improve access to the benefit. Stakeholders were made aware that to access the STCIMHC benefit, the counsellor being used had to be enrolled with Health Canada and on their enrolment list. Two focus group members said they would consider utilizing the counsellors as long as they were someone they could trust and who would welcome the opportunity to undertake cultural training. There is a perception that some counsellors have had no formal cultural training (or only limited online training) and/or have not have spent any time in a First Nation community and therefore may not have a clear understanding of First Nation protocols. One stakeholder felt that there is lack of worldview understanding by enrolled counsellors and that this is of key importance through the healing process. The stakeholder mentioned that it may be beneficial for counsellors to undertake education that looks at the history of Aboriginal people and its cultures and the history of colonization. This would then allow for a better appreciation of what communities were going through. “If they (counsellors) are going to be paid by Aboriginal money, then they should be doing Aboriginal training”. Furthermore, the stakeholder felt that some counsellors only provided counselling at an individual level which is a very western model of practice. They felt that the scope of practice needed to be broadened to a holistic family type of service provision. “Counsellors don’t get that drugs are a family disease…..they need someone who understand the individual within the family, within the culture”. The community focus group also felt that the STCIMHC paperwork and pre-approval process was challenging and that community members would either not bother or would give up trying, as the process was too lengthy and not suitable for the crisis they would be in. “Crisis is within 12 hours not 12 months, so you need support immediately”. The community focus group commented that community members in crisis are supported with the resources available however transportation is a challenge when community members wish to access immediate help. A high number of community members do not own their own cars and the band transportation is only available from Monday to Friday 9am to 3pm. Consequently, some community members decide not to access services at all or have no choice but to access the ambulance or RCMP. The Health Director has also purchased taxi vouchers from their own resources as a contingency to this.

It was also identified that the description of the STCIMHC (15 sessions over 20 weeks) was not flexible and was narrowly focused on the provision of individually-based counselling sessions as opposed to family, group or community approaches. One focus group member, who had a prior counselling experience felt that more than 15 sessions was needed and that every person has varying needs. One person felt that it is more ideal to have a community as a whole attend to a person in crisis, therefore community education was required to raise awareness around supporting those experiencing mental health crises.

Suggested Improvements to the STCIMHC Benefit / Short Term Crisis Mental Health Counselling

Incorporate Administration funding to improve access The Health Director, staff and focus group members identified that clients would not follow through on making their STCIMHC appointments and that the process was extensive. An administration resource could allow the Health Centre to make immediate appointment bookings, complete the necessary forms and ensure that transportation was organized for the client. These processes could tend to be difficult for a client to undertake if they are in crisis and the Health Centre may be a trusted community resource who could confidently assume these administrative functions.

The Health Director also noted that paperwork can be a barrier to accessing a benefit such as this, noting that sometimes the inability to complete extensive paperwork can produce further trauma for people already in crisis.

More in-depth Cultural Education for Counsellors The focus group and staff interviews identified that better use of the STCIMHC funds would be to make these available for cultural competency education for counsellors. Suggested competencies could incorporate training around the history of Aboriginal people and sacred traditions as well as sensitivity training. According to the comments received, this would allow counsellors to have a better understanding of community crisis situations and to relate better for community members to access the benefit. One community focus group member commented that enrolled mental health professionals should complete mandatory localized cultural training or community engagement – not online – and that this should be part of Health Canada’s criteria.

Greater alignment between STCIMHC counselling and local mental health services There was a need for greater alignment between the STCIMHC counselling program and services offered locally on-reserve, as well as those able to be accessed off-reserve through the provincial health system. Clients who did access support through the STCIMHC program, were often left without any ongoing support after they had completed their allotted counselling sessions. It was felt that Health Canada’s enrolled counsellors should have to work closely with the Nation’s local health workers to ensure there is an ongoing care plan in place to support clients working through mental health challenges.

Re-scope and fund local health promotion or early intervention programs Another idea from the focus group was to re-direct funding towards their own crisis intervention worker who focuses on early intervention; prevention or promotion work or could also respond immediately to any community crisis. One person noted that a clinical / cultural worker would also be beneficial to the community but acknowledged that finding this right person would be a challenge. The review identified a number of comments that supported the appointment of a local resource who could build trust and confidence in the community and who could respond quickly.

Holistic family counselling – not individualised The community focus group and a few staff interviewees agreed with a focus on holistic family counselling, whereby all members of the family or close relatives were involved in the healing process of the individual in crisis. One interviewee commented that individual counselling sessions may be beneficial as an initial assessment however family members would play a critical role in the long term healing pathway.

Minimal alignment with Continuum of Care The review identified that there is fragmentation between First Nations and provincial services. There is minimal willingness to participate in joint ventures or meetings as participants appear to have their own agenda they wish to discuss. The Health Director also commented that when collaborative meetings do occur, the action items from these meetings are continually delayed and thus causing frustration when attempting to get things done. The Adult Mental Health & Addictions Manager noted that their relationship with St Mary’s First Nation is more effective and systems were working effectively (than their relationship with Oromocto) however acknowledged that St Mary’s was a larger health centre serving a larger community and therefore likely had more capacity. A number of participants commented that there is a lack of Aboriginal support within the provincial system, both at Oromocto and Fredericton Hospitals. They felt that the provincial system were often less willing to support sacred Aboriginal processes to enable a better outcome for the client and therefore not linked in the overall mental health continuum of care system between First Nations and provincial services.

SASKATCHEWAN REGION: PIAPOT FIRST NATION

JOINT REVIEW OF NON-INSURED HEALTH BENEFITS

SHORT-TERM CRISIS INTERVENTION MENTAL HEALTH COUNSELLING (STCIMHC) BENEFIT Operational Benefit Review

SASKATCHEWAN REGION

SITE: PIAPOT FIRST NATION, Saskatchewan

COMMUNITY DESCRIPTION Piapot First Nation is one of four Cree communities located around the Qu'Appelle Lakes in southern Saskatchewan 29km north and 11km east of Regina. The Cree have four Reserves which make up the Qu'Appelle Lakes Reserve (Muscowpetung, Pasqua, and Standing Buffalo are the other three).

Registered Population

Official Name: Piapot

Registered Population as of May, 2015

Residency # of People Registered Males On Own Reserve 339 Registered Females On Own Reserve 263 Registered Males On Other Reserves 39 Registered Females On Other Reserves 42 Registered Males On Own Crown Land 0 Registered Females On Own Crown Land 0 Registered Males On Other Band Crown Land 0 Registered Females On Other Band Crown Land 0 Registered Males On No Band Crown Land 0 Registered Females On No Band Crown Land 0 Registered Males Off Reserve 779 Registered Females Off Reserve 864 Total Registered Population 2,326

The Piapot First Nation has a school, Band Office and the health centre on-reserve as well as a water treatment plant. The main road into Piapot is unsealed and access is from the main highway north of Regina.

FILE HILLS QU’APPELLE TRIBAL COUNCIL Piapot First Nation is one of 11 communities that belongs to the File Hills Qu’Appelle Tribal Council which itself is a member of the Federation of Saskatchewan Indian Nations (FSIN). The Tribal Council in conjunction with the communities and the province operates the All Nations Healing Hospital at Fort Qu’Appelle.

AFN

Federation of Saskatchewan Indian Nations (FSIN)

SENATE Appointed Elder advisors

ALL NATIONS File Hills Qu'appelle Touchwood Agency HEALING HOSPITAL Tribal Council Tribal Council

13 bed FN Health acute + Services 11 individual FN 4 individual FN Women’s Health communities communities (birthing White Raven pending) Healing + ER + Centre: diagnostic MH&A, IRS cultural

FHQ Tribal Council – governance offices adjacent to All Nations Healing Hospital

The Tribal Council health programs complement the programs that exist on-reserve through each Nation’s own FNIHB contribution agreements (if any). The Agreement is with the FHQTC Tribal Council from FNIHB to cover these programs. The usual Federal programs including Environmental Health, HCC, Health Promotion, Youth services, Brighter futures, FASD, HIV, Maternal Child Health, Suicide Prevention, Canada Prenatal Nutrition Program] which are provided on-reserve in the various communities for First Nations The White Raven Healing Centre includes the IRS Resolution Health Support program, as well as Counselling (including visiting psychologist); Addictions outpatient and outreach [NNADAP]; gambling prevention; Cultural services (healing room, traditional medicines, elders, smudging, sweat lodge). All of these services are funded primarily by Health Canada and IRS funds. They also provide mobile trauma treatment, crisis intervention and response and healing - as well as providing care an All Nations Healing Hospital site. White Raven operates the “Crisis Intervention Stress Management” (CISM) team to respond to mental health crises including providing support to Piapot First Nation if needed.

PIAPOT HEALTH CENTRE AND SERVICES The Kapamutahat Health Centre in Piapot opened in June 2011 and provides a range of services and programs in health promotion, maternal child health and mental health & addictions services. The health centre is a healthcare provider accredited by Accreditation Canada.

Health Department Staff Piapot Health Centre is a department of the Piapot First Nation administration and the Health Director reports to the Band Manager. Staffing includes:

SERVICE GROUP POSITIONS Management /  1 Health Director (since 2001) Administration  1 receptionist  1 Medical Transport coordinator  1 Support Services Clerk Mental Wellness and Employed by PIAPOT Substance Use  1 NNADAP Worker (17 years in role)

Contracted by Health Canada – serves three communities  1 Clinical Therapist (1 day per week at Piapot) and has been working with these communities for 19 years Community Health  Community Health Nurse provided by Health Canada 7.2FTE  Maternal Child Health Worker Home Care  1 CHR  1 Home Care Supervisor  Home Care Workers  Home Care nursing provided by Health Canada

The Clinical Therapist uses multiple methods when working with clients including Cognitive Behavior Therapy; one on one and group therapy; sweat lodge; and incorporates Elders and traditional approaches as much as possible. She works in evenings and flexible hours to ensure community needs are met when they need her most. Working closely with the community enables her to build trust and draw from strengths in the community to use appropriate methods when working with clients. For clients affected by suicide or those with suicidal tendencies, she applies a process of intervention and postvention including debriefing. Piapot noted that they have a good relationship with the Mental Health and Addictions services based in Regina (30 minutes’ drive south) mainly due to the determination and advocacy of the Clinical Therapist to ensure community members receive good care, and also due to the existence of the ‘Native Health Service’ (NHS) at Regina Hospital. As the NHS is based within the hospital campus, they can support community members when they are admitted for assessment to the psychiatric unit, and ensure services are supportive and responsive to addressing the mental health and addictions needs of the First Nations communities.

ACCESS TO PROVINCIAL SERVICES: REGINA QU’APPELLE HEALTH REGION The closest hospital with Mental Health and Addictions Services and a psychiatric unit is located 30 minutes south of the community at the Regina Qu’Appelle Health Region’s hospital in Regina.

RQHR Mental Health & Addiction Services provides acute inpatient, transitional day treatment and follow-up outpatient mental health care for children, youth and adults, in both urban and rural settings. It also provides a wide range of treatment options for adolescents and adults with addictions. Mental health promotion and education programs are available for the public and human services professionals. In addition, Mental Health & Addiction Services funds eight community based organizations that provide valuable programs and services in the community.

Mental Health & Addiction Services: Inpatient Mental Health Services

. Inpatient Nursing Station - coordinates and receives all intakes as a central coordination point . Adult Inpatient Unit - Unit 1D of the Inpatient Mental Health Services facility, 50 inpatient beds for adults (usually, age 18 and over) experiencing severe mental health problems that cannot be managed in a community setting. . Outpatient Programs . Adolescent Inpatient Unit . Mental Health Day Hospital Program - provides care to patients during their transition from hospital care to community care. In some cases, the Day Hospital Program can be an alternative to inpatient care. . RGH Emergency Department Mental Health Service - The Emergency Department at the Regina General Hospital now has an Emergency Psychiatric Nurse Coordinator on staff, to assist in individualized assessment and care of individuals who present to the Emergency Department with mental health or addictions concerns. The Emergency Psychiatric Nurse Coordinator works closely with the emergency room physicians, on-call psychiatrists, the Mental Health Inpatient Unit, Community Mental Health, Addiction Services and other Region and community stakeholders to deliver high quality, coordinated services for these patients. In addition, the Coordinator provides patient and family education and support while the patient is in the emergency department. . The Care Team - All Inpatient Mental Health Services Programs are made up of multi-disciplinary teams including registered psychiatric nurses; registered nurses; licensed practical nurses; psychiatric attendants; recreation therapists; psychiatrists; social workers; psychologists; dietitians, pharmacists, family physicians, medical specialists and spiritual care workers. . The Crisis Response Team (CRT) is a special unit designed to respond to mental health crises in the Regina community - Like all Mental Health Clinic programs, calls to the CRT must go through Intake whether during office hours or after hours. Mobile Crisis Services responds to all after hour’s calls.

Native Health Services – Regina Hospital Native Health Services assists clients in finding and maintaining a healthy, well-balanced lifestyle. Responding to clients with an awareness of cultural and spiritual diversity, Native Health Services provides an alternative for clients seeking traditional Aboriginal approaches to health care. NHS was put in place to help Aboriginal clients based on a concern that those receiving health care in a hospital often found it a stressful experience. It was even harder if the person was not from the majority culture, spoke a language other than English and had different beliefs about how to deal with personal well-being. Noting that these difficulties were being faced by Aboriginal patients requiring hospital care, NHS was set up to help avoid these stresses. Using the wellness model, counselling services are designed to reflect the importance of nature, spirituality, prayer and the circle. They speak to the four primary points of the medicine circle - physical, mental, spiritual and emotional. They promote the traditional, humble way of life. An Elder plays a key role in counselling on lifestyle management. Instead of being built like standard counseling offices, the centres are circular, in keeping with the traditional medicine wheel or circle which is an ancient symbol used by almost all the indigenous people of North and South America. The Centres facilitate healing, prayer, teaching and other assistance required to maintain wellness in the individual and the community. While designed specifically to help Aboriginal people deal with the hospital environment, Native Health Centre services are available to all those seeking an alternative method of healing the physical, mental, spiritual or emotional aspects of their lives.

ACCESS TO INDIAN RESIDENTIAL SCHOOL: RESOLUTION HEALTH SUPPORT PROGRAM (IRS: RHSP) White Raven Crisis Intervention Stress Management (CISM) Team is based at Fort Qu’Appelle about an hour east from the community. The White Raven service is part of the Tribal Council’s services that are available to Piapot First Nation. White Raven also provides the IRS: RHSP for the 11 communities in the Tribal Council. Not many referrals were known to be made to the IRS: RHSP counsellors since the community already had a clinical therapist and drew on the strengths of local Elders to provide support to IRS survivors and their families.

REVIEW OF THE SHORT-TERM CRISIS INTERVENTION MENTAL HEALTH COUNSELLING (STCIMHC) BENEFIT

Awareness and Use of the STCIMHC Benefit The review team interviewed the Health Director, the Clinical Therapist and the NNADAP Worker. The Health Director had reviewed their records back five years and noted they had not made a claim for this benefit and had not received any communication or information about the availability of this benefit from Health Canada in that time. The Clinical Therapist and NNADAP worker were not aware of the availability of the benefit. As a result of not knowing about the benefit, and having their own therapist and crisis support system in place, Piapot First Nation had not made a claim to this benefit. The therapist did state however that she was on the Health Canada enrolment list for counselling and sometimes provided IRS: RHSP counselling as a result.

Client Access to Mental Health Crisis Support Since there were no claims made, the stakeholders were asked for information on how Mental Health Crisis support was currently provided, and how/whether the STCIMHC benefit could be a useful part of that continuum. They were also asked if they had ideas on how to improve access to the benefit.

Clients access mental health services through various means including self or family referrals, referrals from Elders or from community members who know the health centre counsellors. Depending on the level of crisis, the process involves: . Using the strengths of the community by involving Elders to counsel and settle people in crisis; THEN . Contacting the Clinical Therapist who can be there within an hour if elsewhere or who may be on site during their 1 day per week visit; THEN . If the crisis needs more support – they have the option of contacting White Raven CISM team from Fort Qu’Appelle or driving the community member into Regina 30 minutes away to be supported at the psychiatric unit within the hospital. Once at the hospital the community member also has access to the support of the Native Health Services team. The Clinical Therapist will often drive / escort the person if needed and stay with them in the hospital until they are safely assessed and admitted, however if they are discharged the clinical therapist continues to provide care.

The Clinical Therapist advised that she works to link with the Psychiatrist at the hospital to ensure continuity of care and shared case management can occur. On discharge clients are referred back to the therapist for ongoing support. Since the Therapist has been working with Piapot community for many years she is trusted in the community and knows many of the families and clients well.

Perspectives on the STCIMHC Benefit

STCIMHC Enrolled Counsellors Stakeholders were made aware that to access the STCIMHC benefit, the counsellor being used had to be enrolled with Health Canada and on their enrolment list. The current Clinical Therapist said she was on the Health Canada list, but had not been used in a STCIMHC capacity. There was concern from both the Piapot health staff as well as the Native Health Service staff at Regina hospital, that Elders were not recognized as ‘traditional therapists’ who should have the same status and eligibility to provide counselling and be reimbursed from STCIMHC to cover their time and expertise. This was seen as a huge gap in the program and yet noted as acknowledged within the ‘Truth and Reconciliation’ process. It was found in a NNAPF study that counselling by Elders had greater impact for First Nations healing from IRS trauma than clinical counselling alone. There were also concerns raised that Health Canada had the power to approve counsellors for First Nations communities based entirely on clinical qualifications when they did not have the knowledge of who could work well with First Nations and in particular who could work well with Piapot community. They felt that having the Federal government make decisions on

who works in a community solely on professional grounds was ‘paternalistic’ and undermined the strengths and capabilities of communities to decide who is best to work with their community members.

Accessing Help in a Crisis It was identified that ‘completing paperwork’ before being able to support someone in crisis was an impractical process and the description of the STCIMHC (15 sessions over 20 weeks) did not seem to align with a mental health crisis which was often immediate and dealt with as an emergency response. They felt that counselling and healing from the crisis was often managed over time through counselling by the Clinical Therapist and that each person needed a tailored approach which may take longer than 20 weeks.

Suggested Improvements to the STCIMHC Benefit / Short Term Crisis Mental Health Counselling

Provide Crisis Intervention Funding direct to community It was considered that funding for mental health crisis intervention should be provided direct to community within the Contribution Agreement mental health funding, enabling the community to decide how best to structure crisis intervention, and who they want to provide it. This would enable them to set up a formal system, integrate the approach within current mental health services and use the resources in a tailored way for community members’ specific needs.

Fund Resiliency Efforts instead Staff also said that funding should be directed toward resiliency and strengths-based efforts rather than having it set aside just for crisis intervention. This would include:  Talking circles;  Youth leadership and development;  Increasing therapist hours for the community;

A question arose as to what the STCIMHC benefit expenditure or budget was for the Saskatchewan region and whether there was opportunity to work with Health Canada to look at this investment and determine if something more effective could be done with the funds. It was considered there is often so much emphasis on crisis response that this has created gaps in dealing with health determinants, promotion and prevention activities such as resilience building or good systems in communities.

The Clinical Therapist also noted that paperwork can be a barrier to accessing a benefit such as this, noting that sometimes the inability to complete extensive paperwork can produce further trauma for people already in crisis. A comment was made that a ‘seamless approval process is needed’. She noted that there was no ‘one size fits all’’; approach and that it would have to be adapted for each individual case – some people only need short term support while others need longer times to heal. There needed to be more flexibility in the model so that people needing only 1 or 2 sessions could benefit as much as those needing 1 or 2 years’ worth of support over a longer period of time.

Independent Practitioners should be approved by community It was felt that the practitioners should be approved by the community (even after being reviewed by Health Canada who check their qualifications only) and that Elders should be recognized on the list of those who can be compensated.

Patient Travel One issue that was raised related to patient travel. Most Piapot community members travel to Regina using their own private car and claim mileage from NIHB Patient Travel however there have been issues with people not having claims approved, and with a lack of communication by Health Canada regarding claims. Originally Piapot had looked at having a community van for transporting community members, but Elders did not want to travel with clients attending the Methadone clinic in Regina. This is the main reason a van option was not chosen and private mileage was applied instead. However this has put

barriers in place for some people not being able to see their GP for prescriptions; or not being able to attend specialist (including psychiatrist) appointments in Regina.

Improve Provincial and First Nations Service Planning Currently there is no forum or process for the Piapot Health Director to sit with those in charge of Mental Health and Addictions services at Regina to undertake collaborative service planning, to ensure that services meet the needs of Piapot community members. Having this in place would help to ensure the team at Regina was more responsive to the needs of Piapot, and give Piapot a voice in service planning across the mental health and addictions continuum.

Undertake Broader Mental Health and Addictions service review It was noted by one stakeholder (who is on Council at Piapot) that this is a narrowly focused review and that there is a need for a thorough review of mental health and addictions to be done in the area which includes reviewing Mental Health and Addictions at Regina Hospital, and in communities (including gathering elder voices) and with Regina Native Health Services. This is needed to more thoroughly assess ‘real gaps’ in this area for First Nations people. It was considered that many community members are not accessing services unless there is support from Native Health Services and elders.

ONTARIO REGION: OJIBWAYS OF GARDEN RIVER FIRST NATION

JOINT REVIEW OF NON-INSURED HEALTH BENEFITS

SHORT-TERM CRISIS INTERVENTION MENTAL HEALTH COUNSELLING (STCIMHC) BENEFIT Operational Benefit Review

ONTARIO REGION

SITE: OJIBWAYS OF GARDEN RIVER FIRST NATION, Sault Ste. Marie, Ontario

COMMUNITY PROFILE Garden River First Nation (also known as Ketegaunseebee) was created in 1850 with the signing of the Robinson Huron Treaty. The name stems from the days of the fur trade in which the people of the area were well known for growing vegetables. Garden River First Nation is an Ojibwa band located along the beautiful shores of the St. Mary’s River at Garden River 14, approximately 20 minutes from Sault Ste. Marie, Ontario. The community borders the United States, with members residing on both the American and Canadian sides. The area spans 163 square kilometers within the District of Algoma in Northern Ontario, Canada. The largest number of people with Aboriginal ancestry in Canada live in Ontario (242,495). Almost half of the registered Indian population in Ontario lives on reserve and there are 126 bands including Garden River First Nation. According to the AANDC23 May 2015 data, the total Garden River First Nation registered population is 2,812.

Garden River First Nation is governed by a Council consisting of a Chief and twelve (12) Councillors. Garden River First Nation administers a variety of programs and services, and employs approximately 120 people. The principal office is the Administration Centre centrally located in the community and surrounded by the Community Centre, Wellness Centre, Fire Hall, Public Works Garage, and the locally established Anishinabek Police Services Headquarters. Other community facilities located on-reserve are the Ojibway Tent and Trailer Park, Dan Pine Healing Lodge, Baseball Field, Recreation Centre, Bingo Hall, Golf Course and the Garden River Development Corporation Centre. Garden River First Nation belongs to the Mamaweswen North Shore Tribal Council along with six other First Nations.

23 Aboriginal Affairs and Northern Development Canada 90

The community is well supported by a number of family matriarchs in the community who can provide guidance and support for those in crisis, amongst other key characteristics. These people are unique in their attributes and are key people who can coordinate all of the cultural supports and who have the ability to organize instant social structures to support communities. The community has a fairly young population some of whom make up a high number of young teenage parents. There are a number of challenges but Garden River First Nation has been resilient in terms of its community transformation over the past number of years.

MAMAWESWEN, THE NORTH SHORE TRIBAL COUNCIL (NSTC) The NSTC represents seven First Nations including Garden River First Nation, Batchewana First Nation, Thessalon First Nation, Mississauga First Nation, Serpent River First Nation, Sagamok Anishnawbek and Atikamekshen Anishinawbek, as well as the urban aboriginal population of Sault Ste. Marie, through the NTSC’s partner site housed within the Indian Friendship Centre. NSTC meet monthly and the Mental Health & Addictions program of the NSTC is funded by the North East Local Health Integration Network (NELHIN).

NSTC FIRST NATION CHIEFS

NSTC BOARD EXECUTIVE CEO MEMBERS COMMITTEE

Naadmaadwiiuk / Economic Technical HEALTH Administration Education Niigaaniin Ahrda Development Services PROGRAM

7 HEALTH DIRECTORS

All First Nations are situated along the North Shore of Lake Huron within the Robinson-Huron Treaty area and the head office is located at the Serpent River First Nation in Cutler, Ontario. NSTC provides regional planning and technical advisory services to communities in the areas of health services, second level education services, administration, financial management, economic development, employment and training services. A key focus for NSTC is to ensure that there is more provider driven processes implemented across the community.

NSTC has developed a new primary health service delivery model in collaboration with the affiliated seven First Nations and the Indian Friendship Centre. The new model incorporates a continuum of care that looks to strengthen integrated support services for community members.

GARDEN RIVER WELLNESS CENTRE AND SERVICE The Naan Doo We’an Garden River Wellness Centre opened in 1990 and has since been upgraded in 2004 and 2007. The Health Director has worked in the community for 37 years and in her Health Director role for 26 years, the Mental Health & Addictions worker has worked within the community for 7 years and the psychologist has worked in the community for 12 years, all of whom hold extensive local knowledge of the community.

Garden River Wellness Centre has a block flexible funding agreement and provides a variety of services and programs including Mental Health & Addictions, Maternal Child Health, Diabetes Education Program, Sexual Health Education, Life Long Care Program, Health Promotion, Nutrition, Physiotherapy, telemedicine through Ontario Telemedicine Network (OTN) and Medical Transportation Services. The specific community-delivered mental health programs and services provided by Garden River Wellness Centre are:  Psychology Services (One on One counselling provided half a day every week and who can also undertake licensed assessments)  Mental Health Crisis Intervention and Prevention including Education and awareness through the NNADAP worker (known as the Mental Health worker / Addictions worker)  Traditional Cultural Services focusing on the promotion of culture and language  Social Services Addiction Worker (funded through the Garden River First Nation Ontario Works Program)  The Wellness Centre partners with the recreation centre and provides “The Right to play” programs (funded through the Ministry of Recreation and Mental Health & Addictions) some of which are focused on Health Prevention and Promotion. Such activities include presentations provided by external speakers as an example. The Health Director advised that in recent planning meetings with the North Shore Tribal Council it was identified there is a gap in service provision for Crisis Intervention and Mental Health Counselling. The group are in the early stages of designing a framework that recognizes the challenges the communities are facing and what strategies are required to address these shortfalls. A draft version of the plan was in development at the time of the review and therefore it was too early in the piece for our review to obtain any outcomes data from this process.

Health Department Staff The Garden River Wellness Centre is a department of the Garden River First Nation administration and the Health Director reports to the Band Manager. Staffing includes:

SERVICE GROUP POSITIONS Management /  1 Health Director Administration  1 Clinical and Health Services Supervisor (includes managing Nursing staff, Visiting Providers and Primary Care)  1 Community Outreach Supervisor (oversees community support services, maternal child health, health promotion/education)  1 Finance / Personnel Supervisor (oversees administrative services including reception, maintenance and finance)  Receptionist  Medical Transport Drivers Mental Wellness and Employed by Garden River Substance Use  1 Mental Health and Addictions worker (NNADAP) who provides Crisis intervention and prevention services (not clinical counselling)

SERVICE GROUP POSITIONS

 1 Cultural worker who provides traditional healing and counselling (funded by the Building Healthy Communities program)  1 NIHB Clerk – An administration role primarily responsible for medical transportation but does administer all NIHB functions  1 Social Services Addiction Worker (managed by the Garden River First Nation Ontario Works Program) Contracted  Psychologist (owns private practice) – provides one on one counselling half a day per week Primary Health Employed by NSTC  Nurse Practitioner (4 days per week)  Physician (half day per week)  Registered Dietician (one day per week)  Occupational Therapy (on contract as required)  Physiotherapy (half day per week) Contracted  Dental (half day per week) Community Health Employed by Garden River  Maternal Child Health  Early Childhood Development  Chronic Disease Care / Diabetes Education Program  Community Support Program  Sexual Health Education  Life Long Care Program  Health Promotion  Elders Health  Youth Program

There are currently no qualified clinical staff specifically employed by Garden River Wellness Centre to deliver mental health services to the Garden River First Nation Community. The Addictions Mental Health worker (NNADAP) undertakes addiction prevention activities through campaigns and education programs, and also undertakes drug and alcohol assessments and assisting clients into treatment (if required). The role also focuses on Mental Health primarily through raising awareness and education on Mental Health issues. This has incorporated video presentations, healthy minds workshops or collaborative activities with the Traditional Cultural worker. Any clinical or counselling services are referred to the psychologist. There is a psychologist contracted by GRWC and NSTC who provides services one half day per week on reserve to serve the community. Therefore access to this service is limited with a current waiting list. The psychologist typically visits every Tuesday however is available at his own private practice in Sault Ste Marie, should the client require off-reserve services. Majority of the psychologist role is undertaking clinical assessments due to the long waitlist within the public system. The psychologist’s own capacity is full and he is unable to increase his allocation of time for the Garden River First Nation community.

Garden River First Nation is fortunate to have their own “Dan Pine Healing Lodge” with accompanying sweat lodge located on-reserve near the Ojibway Tent and Trailer Park. The Dan Pine Healing Lodge is immaculate in stature and provides a gathering place for community members to socialise and take part in various programs and cultural healings. The Dan Pine Healing Lodge are in the early stages of implementing a newly introduced healing program which is due to start next fiscal year with a full capacity and an increasing waiting list, demonstrating a high need for such programs.

Access to Provincial Services: Ontario Region The Ministry of Health and Long-Term Care acts in a stewardship role to provide direction and leadership for the healthcare system in Ontario. Fourteen Local Health Integration Networks (LHINs) were created in March 2006 and are responsible for: hospitals, long-term care homes, Community Care Access Centres, Community Support Services, Community Health Centres and Addictions & Mental Health Agencies. They do not have responsibility for: physicians, Public Health, ambulance services, or provincial networks (e.g., Cancer Care Ontario).

Garden River First Nation falls within the North East Local Health Integration Network (North East LHIN) which is one of the largest LHIN’s in Ontario, responsible for planning, integrating and funding health care services for more than 553,000 people in the North East region with a $1.5 billion front-line care budget. The North East LHIN invests $75 million in 48 organizations to deliver a wide range of mental health and substance abuse services throughout the region. The North East LHIN region is divided into five “Hub” planning areas based on hospital referral patterns, and Garden River First Nation is located within the Algoma Hub. Within the Algoma area there are: 5 hospitals; 7 long-term care homes; 18 community support services and 14 community mental health & addictions services.

Sault Ste. Marie Hospital is the closest hospital to the Garden River First Nation community, located approximately 20 minutes away on a sealed road. The Mental Health and Addictions services provided through the Sault Ste Marie Hospital consists of a myriad of in-hospital and community-based programs, however it is suspected that these services are not fully utilized by GRFN members because the services are not culturally sensitive and/or transportation is an issue. Services include: Inpatient care, Outpatient Psychiatry and Psychology, Transitional Care, Crisis/Mobile Crisis, Eating Disorders Clinic, Sexual Assault Care Centre & Partner Assault Clinic, Program for Assertive Community Treatment (PACT), Addictions Treatment Clinic, Residential Withdrawal Management Services, Transition House, Safe Beds, Ventures Transitional Employment and Seniors Mental Health Services.

Clients from Garden River First Nation access mental health services through various means including self-referrals, referrals from local Police, hospitals and from internal services from the Garden River First Nation. There is no crisis lines available in Garden River however there is a Sault Ste. Marie Mental Health Crisis line available 24/7. The Crisis Services Team consists of crisis intervention workers, psychiatric nurses, and mobile crisis response workers and is available to all residents of the Algoma district who are experiencing a serious mental illness or are in crisis.

Should a mental health crisis occur within Garden River First Nation Community and depending on the time of the crisis or incident, a client may be transported by one of the several options:

 Family member or Family Matriarchs  Garden River Wellness Centre Transportation during working hours (although Mental health is not eligible for medical transportation)  Local Police based on reserve  Local Ambulance service  Victim Assistance Programs (off-reserve and if available)

Community members are usually transported to the Emergency Department of Sault Ste. Marie Hospital however the Health Director noted that this is an ongoing challenge with limited transportation options and the responsibility regularly lies with the Local Police, particularly in crisis situations.

Access to Indian Residential School: Resolution Health Support Program (IRS: RHSP) Garden River First Nation does not provide or have access to the IRS: RHSP however does have funding to undertake activities that align to the IRS program. This funding is for activities only and not for a full time dedicated position. These include activities for elders and survivors and facilitated onsite at the Dan Pine Healing lodge. The original intention was to establish a peer support group for survivors but there was no available resources to implement this according to the Health Director.

REVIEW OF THE SHORT-TERM CRISIS INTERVENTION MENTAL HEALTH COUNSELLING (STCIMHC) BENEFIT

Awareness and Use of the STCIMHC Benefit The review team interviewed the Health Director, the Mental Health & Addictions worker, the Clinical & Nursing Manager, the NIHB Clerk and the Cultural worker. All staff interviewed were aware of the benefit however all commented that they were concerned by the limited availability of information pertaining to STCIMHC. One noting that it is ‘Health Canada’s best kept secret’. The Health Director is not aware of any claims being made to the STCIMHC and believed that this is largely as a result of the limited information that is being provided to them both at a regional and local level. “STCIMHC should be shared with Health Directors so that we are able to incorporate such information into our planning processes”. The North Shore Tribal Council (NSTC) Mental Health Manager also believed that there was very limited knowledge of the STCIMHC within any of the First Nation communities within NSTC’s coverage area. The Mental Health & Addictions worker is aware of a few of the clinicians that work in the community and who utilize their offices on the odd occasion however unsure of how well the benefit is being accessed and utilized by them. The Clinical & Health Services Supervisor also commented that the benefit is not well known and concerned on how regularly the clinicians list was being updated. The NIHB Clerk was aware of the STCIMHC benefit however has been unable to access any information relating to this benefit including numerous requests for a copy of the Health Canada enrolled clinicians list. “We need to know who the clinicians are”. According to the NIHB Clerk, the NIHB policies appear very vague and therefore it is difficult for clients to really understand the criteria of STCIMHC and how it works in simple language. The NIHB Clerk recalls supporting a client with a STCIMHC claim but this was a very long time ago. It was assumed by the NIHB Clerk that this benefit has a much quicker response time as her involvement with STCIMHC help has been limited.

The Director of Mental Health & Addictions, Ministry of Health and the Aboriginal lead / Officer from North East LHIN are aware of NIHB but not specifically of STCIMHC and therefore were unable to provide commentary specific to this benefit.

Perspectives on the STCIMHC Benefit

STCIMHC Enrolled Counsellors

Stakeholders were made aware that to access the STCIMHC benefit, the counsellor being used had to be enrolled with Health Canada and on their enrolment list. Two staff participants were not aware of any of the clinicians on the enrolment list even though numerous requests have been made to obtain this information. The Health Director commented that the clinicians are contracted directly by FNIHB and staff of the Garden River Wellness Centre are not involved in any part of the process. The Mental Health and Addictions worker commented that one of the enrolled clinicians has utilized the facilities and offices of the Garden River Wellness Centre but was unable to comment specifically on how effective these services are. Of the few clients that have accessed the services of Health Canada clinicians, the Mental Health and Addictions worker felt that there was a pretty quick response ranging from 2 hours to 2 days for clients to access the service. However, there are no follow up processes back to the Garden River Wellness Centre, which was assumed to be due to client confidentiality. It was also noted that clients will usually access the services off reserve as there was a feeling of stigmatization and fear of community members recognising that clients may have mental health issues. The Health Director and Aboriginal Lead / Officer for North East LHIN felt that there should be mandatory cultural safety training for the enrolled clinicians however was unsure if this already existed. This could also include enhancing the enrolled clinician list to include traditional healers as an alternative form of therapy. The current psychologist who visits the Garden River Wellness Centre once a week has worked in the community for 12 years and this local knowledge is seen as a significant benefit to the community. Importantly, it was seen that locally based workers were better able to build trust and strong relationships in the community therefore increasing their effectiveness in supporting those dealing with mental health challenges. While all participants agreed that many people could use access to STCIMHC, they felt that completing paperwork for pre-approving counsellors and then waiting for an assessment and approval of the STCIMHC sessions – would deter people from accessing the STCIMHC benefit. One participant commenting that the pre-approval process was seen to be arduous and challenging particularly when clients are in crisis. “It’s supposed to be available in a crisis….maybe a rostered on-call list would be better”. The NIHB Clerk made comment that large amounts of administrative processes and numerous paperwork for community members can be a barrier and is very burdensome.

Accessing Help in a Crisis

The Health Director identified that their community had a strong community infrastructure with supports available from local police, ambulance and family matriarchs on reserve. Although these supports were available, there was insufficient funding and resources to research, plan and implement a coordinated approach towards a crisis response system as noted by the Health Director. A number of proposals had been submitted to secure funding but with no success. As a consequence the current process is to refer Garden River First Nation Community Members in crisis to services off- reserve, including Sault Ste. Marie hospital. The current process was seen as not allowing First Nation communities to determine how best to use local resources and supports and to develop their own integrated and holistic model. Transportation was noted as a key challenge for the Garden River First Nation community. This is not only pertinent to transporting clients to Sault Ste. Marie who are in crisis but also when they are discharged from hospital with no public transport solutions when they are wishing to return back to Garden River. It was also identified that the description of the STCIMHC (15 sessions over 20 weeks) did not seem to align with a mental health crisis which was often immediate and dealt with as an emergency response – but counselling and healing from the crisis was often managed over time through counselling by the clinicians. The Clinical & Health Services Supervisor felt that ‘Mental Health’ and ‘Crisis’ required two different needs and therefore the criteria of STCIMHC needed to be more defined to differentiate these requirements. “People in crisis cannot be expected to know about the details of the benefit”. The NIHB Clerk recommended re-scoping the STCIMHC benefit to incorporate ongoing supports after a crisis situation has occurred. While the 15 counselling sessions could easily be utilized, there is a concern as to where people would go after these have ceased. The Manager of Mental Health & Addictions also concurred with this

comment and suggested the need for after care service provision once clients have received clinical services. “We need to move away from just putting out fires in the moment and nothing to support afterwards”. The Manager of Mental Health & Addictions felt that more investment is required in addressing mental health issues earlier, rather than waiting for crisis situations to occur. ”The benefit doesn’t apply to crisis it’s about counselling sessions after the fact”. Devoting more resources through promotion, early identification and the implementation of wellness programs was considered a better utilization of funds to prevent future crisis situations.

General NIHB

As a general NIHB comment, the NIHB clerk commented that there are extensive delays with responses, approvals and follow up from Health Canada which has become a lengthy exercise since the change from an online system. It appears that this comment is primarily relating to Medical Transportation approvals. The reduction in funding for medical is also a concern with only two increases in 25 years. “We hear a lot of …..Sorry that’s our policy”. Additionally there is a concern with communication between Health Canada / FNIHB and First Nation people whereby changes that occur within NIHB are not communicated to the communities. “We need to have better communication with FNIHB about health benefits in general”. It is very irregular and often put in a language that is not user friendly.

Suggested Improvements to the STCIMHC Benefit

Provide Crisis Intervention Funding direct to community

It was considered that funding for mental health crisis intervention should be provided direct to the community within the Contribution Agreement mental health funding, enabling the community to decide how best to structure crisis intervention, and who they want to provide it. There is a perception that First Nation communities are often not included in Mental Health provincial planning and therefore services are fragmented and uncoordinated. The Health Director believed that developing a locally based program / services that are linked to external services would be a more sustainable approach. This would enable the set-up of a formal system, integrate the approach within current mental health services and use the resources in a tailored way for community members’ specific needs. Additionally, the Garden River Wellness Centre advises that they do not have intensive Mental Health Support program’s on reserve and therefore nothing to offer people when they are discharged from hospital. This model of practice would also address the transportation issues and challenges for the Garden River First Nation community.

Crisis Response Planning

Both the Health Director and Clinical & Health Services Supervisor suggested that communities would be better supported with the development of strong crisis response protocols or a crisis response plan that involves the Public Health Unit, Primary Health, MCFD, Local Police, Ambulance and other supports. The plan is suggested to be written by the community for the community and endorsed by Health Canada and AFN. The Garden River First Nation community is also well supported by a number of family matriarchs in the community who can provide guidance and support for those in crisis, amongst other key characteristics. These are key people who can coordinate all of the cultural supports and who have the ability to organize instant social structures to support communities. Investment would need to be made in training, information and resources to support the Matriarchs however this would enable them to take ownership in crisis events. The Dan Pine Healing Lodge would provide an appropriate venue to undertake this training and provide a gathering place for community members to plan, debrief and take part in various programs and cultural healings.

Improved awareness and description of STCIMHC

A number of participants interviewed were concerned by the limited awareness, information and criteria of STCIMHC. Upon receiving notification of the review, one interviewee had made numerous attempts to obtain information regarding STCIMHC and the enrolled clinicians list however has been unable to obtain any documentation to date. It was also identified that the description of the STCIMHC can be confusing with a ‘crisis’ often requiring immediate support and ‘mental health counselling’ being provided over time. It is recommended that policies are developed for

the benefit that clarifies the criteria, description and definition of the STCIMHC benefit and then this communicated and regularly updated to communities.

More in-depth Cultural Education for Counsellors

Participants of the review identified that better use of the STCIMHC funds would be to make these available for cultural competency education for counsellors. Suggested competencies could incorporate training around the history of Aboriginal people, the generations of trauma they have encountered, sacred traditions as well as sensitivity training. According to the comments received, this would allow counsellors to have a better understanding of community crisis situations and to relate better for community members to access the benefit. It was noted that the Ontario Works Program has adapted the British Columbia Indigenous Cultural Competency Online course to strengthen the capability of staff which early indications have been successful. Alternatively, one participant commented that enhancing the enrolled clinician list to include traditional healers would be a valuable alternative form of therapy for First Nation community members.

Investment in tele-psychiatry

Garden River Wellness Centre has recently invested in the Ontario Tele-Medicine Network (OTN), which may be a possible solution to accessing immediate crisis support through tele psychiatry. The Health Director and the NSTC Mental Health Director felt that this would work well and strengthen access for community members to specialist mental health support services, particularly for younger community members who have a stronger connection to the technology. Investment in tele-psychiatry would also help to address access barriers such as a lack of transportation, as well as making efficient use of limited mental health clinicians that could cover multiple communities using technology.

Holistic family counselling – not individualised

A few staff interviews agreed with a focus on holistic family counselling, whereby Matriarchs, family members or close relatives were involved in the healing process of the individual in crisis. One interviewee commented that individual counselling sessions may be beneficial as an initial assessment however family members would play a critical role in the long term healing pathway. The Health Director is currently investigating the option to offer Multi Systemic Therapy or more family based approaches as individual counselling only addresses small isolated issues rather than looking at the whole picture.

Improve Paperwork & Approvals

A number of participants noted that paperwork can be a barrier to accessing a benefit such as this, noting that sometimes the inability to complete extensive paperwork can produce further trauma for people already in crisis. Administrative requirements and processes should be tailored to the needs of the target population of the benefit – clients in crisis. The requirements should avoid being so complex, time-consuming or burdensome for clients that they feel disempowered and ultimately disengage from the process. Reducing as many barriers as possible to support those who are reaching out for help is a key priority.

Re-scope and fund local health promotion or early intervention programs

Another idea from two of the participants were to re-direct funding towards early intervention; prevention or promotion work. Another person felt that investing more resources in early identification and the implementation of wellness programs would also be beneficial to the community and a step in the right direction towards preventing future crisis events.

Client Access to Mental Health Crisis Support

Since there was limited information surrounding the claims for STCIMHC, the stakeholders were asked for information on how Mental Health Crisis Support was currently provided; and how/whether the STCIMHC benefit could be a useful part of that continuum. They were also asked if they had ideas on how to improve access to the benefit. The Health Director, Clinical & Health Services Manager, the Mental Health & Addictions worker, the Director of Mental Health & Addictions and the Aboriginal Lead / Officer all commented that there is very limited funding for Crisis Support and Mental Health counselling in the region, despite the need. The STCIMHC benefit would fill some of this service provision gap if it was more accessible and there was stronger awareness available at a community level according to most interviewees. The Health Director noted that due to the demand in the region for such services, there should be stronger emphasis in sharing more information regarding the STCIMHC benefit. It is deemed that there is no real linking process between the enrolled clinicians and health centres of the services that are and have been provided to clients. Furthermore, the STCIMHC process only allows the Garden River Wellness Centre to make referrals after a needs assessment and to make clients aware, but no further communication once clients are actually accessing the services. “The process only involves us letting people know of the benefit however STCIMHC is not considered an effective sustainable service”. One staff member commenting that it is a dead-end program with no long term service provision solutions.

Strengthening alignment with Provincial Health services

According to both the Health Director of Garden River Wellness Centre and the Director of Mental Health & Addictions Manager, Sault Ste. Marie - the challenges that regularly presents itself is upon discharge. There appear to be issues with limited follow up care of supports in place for members returning home, when sending people home either when they are still in crisis based on their risk assessment, or finding suitable solutions with the Garden River Wellness Centre to transport clients home. The Health Director noted that often workers from the provincial system assumed that Garden River Wellness Centre offered a range of intensive mental health support program’s on reserve. As Garden River are not funded to provide these types of mental health services, it often meant community members suffering from serious mental health conditions were being sent home without proper support services available to them.

On the other hand, the Garden River Wellness Centre Mental Health & Addictions worker found that the discharge process works well and communication is received from the hospital. “It works well but there is room for improvement with networking and communication”. The Aboriginal Lead / Office of North East LHIN advised that they have discharge counsellors as part of the AHAC program however this service is primarily accessed and provided to the senior community. The Health Director and the Aboriginal Lead / Officer for the North East LHIN felt there is limited funding allocation for Mental Health counselling in Sault Ste. Marie and currently funds are restricted to the Aboriginal Health Access Centre (AHAC) through the North Shore Tribal Council. The Health Director also noted that First Nation communities are often not included in Mental Health provincial planning and has found services to be fragmented and uncoordinated. It is also perceived that the provincial system allocates a high level of funding to administration which results in the reduction of frontline resources and services available in community. Nevertheless, the Health Director noted that communication and collaboration with provincial partners has strengthened in recent years leading to incremental improvements in coordination of services with First Nation communities.

The Aboriginal Lead / Officer North East LHIN also noted that it would be beneficial to invest in more culturally appropriate service provision although the Mental Health and Addictions Worker did find the crisis intervention workers to be culturally competent. The intention of this investments is to place a stronger emphasis with clinicians and community workers to become familiar with the history of First Nation peoples and the generations of trauma that have encountered. “In order to move forward we must first acknowledge and recognise that people need time to heal”. It was noted that the Ontario Works Program has adapted the British Columbia Indigenous Cultural Competency Online course to strengthen the capability of staff but this is yet to reach this region of Ontario.

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ALBERTA REGION: STONEY BEARSPAW FIRST NATION

JOINT REVIEW OF NON-INSURED HEALTH BENEFITS

SHORT-TERM CRISIS INTERVENTION MENTAL HEALTH COUNSELLING (STCIMHC) BENEFIT Operational Benefit Review

ALBERTA REGION

SITE: BEARSPAW STONEY FIRST NATION, Calgary, Alberta

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COMMUNITY DESCRIPTION

Bearspaw Nakoda First Nation is one of three bands that make up the Stoney Nation along with the Chiniki (population approximately 1662) and Wesley (population approximately 1555) bands presenting the Nakoda people in Alberta. Stoney First Nation make up an Indian reserve in the Southwest of Alberta and by land area, it is the third largest Indian Reserve in Canada. Historically the Stoney Nakoda was known as ‘Assiniboine’ – a name that literally means “Stone people’ or “People who cook with Stones’. The main Stoney reserve is located along the Highway 1, midway between Calgary and Banff. It is also known as a key location for filming well known movies.

View of Bearspaw on the shore of the lake

Bearspaw Nakoda First Nation is located in the Morley town site situated beside Bow River approximately 30 minutes northwest of Calgary and east of the town of Cochrane on Highway 1A.

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According to the AANDC24 May 2015 data, the total Bearspaw First Nation registered population is 1897.

Bearspaw First Nation is located in the small town of Morley that consists of the Stoney Health Centre (including Pharmacy), an Elders Lodge, Youth Centre, Community Centre and an Adult Education Centre. The gas bar opened in December 2013 and most recently the community celebrated the opening of a Subway restaurant franchise in April 2015.

STONEY TRIBAL COUNCIL

There are three Chiefs and 12 counsellors of the lyane Nakoda that comprise the Stoney Tribal Council. They are the primary decision-makers and policy-makers on behalf of the registered membership and are elected to represent and service their communities. They must also address internal social and economic concerns impacting the communities at a local level including corrections/justice, economic development and land use, education, emergency and security services, employment, family services, housing, infrastructure, recreation wellness and health care. The Stoney Nakoda First Nation has developed a number of projects designed to assist the flood victims of the Alberta Flood in 2013.

STONEY HEALTH CENTRE

Stoney Health Centre (SHC) provides a range of services to all Stoney First Nation citizens, which includes those from Bearspaw Nation. SHC has around 40 staff who provide a range of services including primary care, public health, mental health, home care, transportation and community services, as well as a suite of visiting specialist services including onsite pharmacy, x-ray, optometry, dental, occupational therapy, endocrinology, internal medicine, rheumatology as well as psychiatry. SHC is governed by an independent Board of Directors who report and are accountable to the Stoney Tribal Administration. SHC is currently in the process of negotiating a Full Transfer Agreement with Health Canada, and was recently accredited with commendation by Accreditation Canada.

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SHC has built a number of strong partnerships with other health partners to enhance their community based services, which has resulted in a number of visiting medical specialists to the community. SHC currently receive on-site services in Endocrinology, Occupational Therapy, Internal Medicine, Infectious Disease, Rheumatology, Psychiatry and various specialty services from Alberta Children’s Hospital Child Development Services. Stoney Health Services continue to build community partnerships that are ever so important to improving the delivery of health care. Stoney Health Centre Entrance

Health Department Staff

Stoney Health Centre is a department of the Stoney First Nation administration and the Health Director reports to the CEO. Staffing includes:

SERVICE GROUP POSITIONS Management /  1 Executive Director of Health Services Administration  1 Finance Manager (contracted part-time)  1 Receptionist

Mental Wellness and . 2 Adult Mental Health Therapists (based in the Chiniki Community Substance Use College up the road from the Health Centre) . 1 Youth Mental Health Therapist (working out of both the Chiniki Community College and the Morley Community School)

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SERVICE GROUP POSITIONS

. 2 Psychiatrists (contracted – bi-weekly visits = 1 day per week) Primary Care  5 Physicians (each working 1 day per week)  Registered Nurse  1 Radiographer  1 Pharmacist (full-time) working in on-site pharmacy  2 Occupational Therapists (part-time)  1 Dental Therapist (part-time)  1 Optometrist (part-time)  Ambulance Services (based in community and available 24/7) Community Health  Maternal Child Health Program  School Health Program  Communicable Disease Control  Nutrition Education  Home and Community Care

Stoney Health Services provides the ‘Turning Point’ program, a community based mental health service which consists of 3 therapists offering mental health support services including crisis management for all Stoney members. Funding for the program is provided through Health Canada, Non-Insured Health Benefits, First Nations and Inuit Health Branch. Referrals to Turning point come primarily from programs within the Stoney Health Centre and self-referrals, but also through referrals from RCMP and the local schools.

Location of Chiniki Community College – Delivery of Turning Point Program

The program has recently moved from a temporary trailer unit based within Morley to the refurbished basement facility at the Chiniki Community College. Services provided include: treatment plan discussion and goal setting, service provision and follow-up services for emotional and mental health disorders. Specific services include individual psychotherapy with adults and children, marital therapy and family therapy. A wide range of mental health challenges are addressed from individuals suffering from anxiety and depression, to clients requiring grief and critical incident stress management, to relationship and family conflict management. There is a qualified psychiatrist that visits the community one day per month, as well as 2 psychologists that visit the community bi-weekly, which is for clients referred by the Turning Point therapists or other primary care specialists. The Stoney Nation has experienced very high rates of suicides over recent years, typically in clusters. Over the 12 months to July 2015, there were 14 individuals who committed suicide, across the age ranges. When these clusters of suicides have occurred, much attention has been garnered from judicial, law enforcement, social and

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health sector stakeholders, and have served as opportunities for broader engagement. This engagement, however, has typically been short lived, with little sustained partnership or commitment from broader system stakeholders. The approach taken by Stoney through the Turning Point program has therefore been to localize mental health and social supports within the community to facilitate greater access to these much needed resources, better enable community members to build trusting and sustained relationships with therapists, and better integrate these supports across all services offered by the Stoney Health Centre and Band. In general, community members do not like accessing services from the local hospitals, so the Stoney Health Centre has ‘brought services closer to home’ through building up a network of health specialists who visit the community regularly. The Stoney Health Centre has also established a strong relationship with Alberta Health Services around the sharing of important health data to inform community health planning and program design processes. The Health Centre receives monthly health data and information regarding Stoney members across a range of health indicators, which includes information relating to the use of prescription medication as well as the prevalence of anxiety, depression and drug abuse. While the therapists at Turning Point are often able to provide the necessary support to manage mental health crises within the community, in some cases the level of crisis is so severe that clients will be transported by the local EMS or the RCMP to the nearest hospital. There is currently no formalized mental health crisis intervention program run by the Stoney Health Centre, and no mental health capacity on weekday evenings or weekends. The Stoney Health Centre are keen to establish a volunteer crisis team within the community, and have looked at models from other neighbouring First Nation communities. The Health Centre is also looking to create a crisis telephone line, however there is currently no budget for this. Elders Lodge (located next to the Chiniki Community College)

Access to Provincial Services

The closest hospital with Mental Health and Addictions Services is located 30 minutes west of the community at the Canmore General Hospital in Canmore. Three of the physicians that provide service at the Stoney Health Centre also work at Canmore Hospital, which assists in facilitating relationships and engagement with Stoney clients and their families. The Canmore Hospital provides mental health urgent care which includes crisis assessment and psychosocial interventions. The service is available from 2pm – 9pm Monday through Sunday. There is also a Social Worker service based at the Hospital that is available each day from 2pm – 10pm that is able to support patients and their families. There is an Aboriginal Hospital Liaison position based at Canmore Hospital to support Aboriginal clients and their families to access to navigate services provided by the Hospital. These services are available during weekdays 8.00am- 4.15pm, with clients able to access a hospital-based social worker outside of these hours.

Those assessed as experiencing a severe level of mental health crisis are transported directly to Calgary, about an hour east of Canmore, which has a much wider range of specialist mental health services, including all of the

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inpatient psychiatric beds (approximately 40 beds) for the area which are located across the 4 Calgary hospitals. There is also a Crisis Response Team which is part of the Urgent Care Centre based at the Sheldon M. Chumir Health Centre, which includes crisis intervention and urgent psychiatric assessments.

The Stoney Health Centre has established a good working relationship with the Foothills Medical Centre based in Calgary, which includes an inpatient psychiatric unit and is often the first point of call for community members suffering an acute mental health crisis. The Health Centre is able to ring in advance, and community members usually don’t have to wait any longer than an hour to be seen. There are however issues around discharge planning as the Health Centre is often not informed when the client is released and usually not involved with care planning and follow up.

According to the Alberta Health Services (AHS) Mental Health Manager, there are a high proportion of Aboriginal clients who present to the emergency departments with acute mental health issues, who are then assessed by a psychiatrist and either admitted to one of the in-patient psychiatric units, or are discharged back to the community and referred to other mental health services, usually with the support of a social worker. If the AHS Adult Aboriginal Mental Health Program (based at the Sheldon M. Chumir Health Centre in central Calgary) is notified at either the intake or discharge planning stages, one of the Aboriginal Outreach Workers will go and meet with the client, and if they are from one of the reserve communities, will try to link the client back in with any community based mental health support services. The Aboriginal Health Program also provides culturally based counselling services and support programs to Aboriginal clients with mental health challenges.

One of the major challenges identified is the lack of transportation for on-reserve members suffering with mental health crises. Some clients in crisis have ended up in Calgary and been discharged with no way of getting home back to their communities. Also the lack of transportation is a barrier in accessing many of the community based mental health support programs that are largely located in Calgary. Stigma around mental health as well as discrimination felt by First Nations clients were also issues identified as being barriers to accessing mental health services.

Family rooms at Alberta Health Services

Access to Indian Residential School: Resolution Health Support Program (IRS: RHSP)

The Health Director was aware of the IRS: RHSP but did not believe many clients were currently accessing this service. The Health Centre had in the past assisted clients with filling out the necessary application forms to access this service, however that was the extent to which the Health Centre was involved with this service. The Health Director was reluctant to promote this program within the community as he had been advised by Health Canada representative and other community health directors that the program was fraught with issues and largely ineffective in assisting residential school survivors and their families.

The Turning Point therapists were aware of the IRS: RHSP as there were a number of residential school survivors within the community. The Turning Point program was not specifically connected with this program, but had run community workshops for survivors and undertaken some work specifically with residential school survivors and their families.

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View of Bearspaw on the shore of the lake

REVIEW OF THE SHORT-TERM CRISIS INTERVENTION MENTAL HEALTH COUNSELLING (STCIMHC) BENEFIT

Awareness and Use of the STCIMHC Benefit The Health Director and one of the Turning Point therapists was aware of the STCIMHC benefit and had provided information about the program to clients in the past. The therapist knew of the program through personally knowing some of the enrolled counsellors. Two of the therapists were not aware of the STCIMHC benefit program prior to our visit. All community group participants were not aware of the availability of this benefit or had awareness of the Health Canada enrolled counsellors that were available. Two members suggested that more information be provided to the community to better understand what is available. Staff at the Alberta Health Services, Aboriginal Health Program (AHP), were aware of the Non-Insured Health Benefits programs, including the STCIMHC Benefit. The AHP has access to the list of FNIHB enrolled counsellors which they promote to clients if applicable. An AHP Outreach Worker will regularly ring the FNIHB enrolled counsellors to make sure they are currently practicing and their contact details are up to date as there are constant changes. A FNIHB enrolled counsellor recently came to meet with the Adult Aboriginal Mental Health Program team to introduce herself and discuss closer collaboration.

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Perspectives on the STCIMHC Benefit

STCIMHC Enrolled Counsellors Many of the stakeholders believed that the STCIMHC Benefit program was an ‘overly bureaucratic system that was self-serving towards Health Canada’s interests’ but made little difference in addressing the needs of First Nation communities. There was limited to no connection or communication between Health Canada, the enrolled counsellors and the Stoney Health Centre. All community group participants were not aware of the professionals who provided the service. The Health Director was aware of a private psychiatrist, who was assumed to be a Health Canada enrolled counsellor, who goes to see clients in one of the Stoney communities, however he was unaware of the details of their work and had no link to this practitioner. KTCL was notified that most of the clients who accessed private practitioners either through STCIMHC or some other program, were referrals from probation or court services. Overall, the Health Director and therapists had very limited connection to the work of STCIMHC funded counsellors and saw this as limiting the impact of the service on the Stoney community. There was also a feeling that the counsellors were not culturally sensitive or responsive and by and large lacked the necessary training and understanding to be effective in dealing with intergenerational First Nations trauma. In the past, there was a perception that the enrolment list for the STCIMHC program was filled by newly graduated counsellors looking to establish themselves and their careers, but often lacked the necessary experience and knowledge to deal with the complexity of the crisis situations being experienced by First Nation members. Two community group members encouraged cultural advisor participation to support the counsellors including members who can speak the local Stoney language. Other counsellors were seen as taking advantage of First Nation communities, with some seen as ‘travelling around communities getting well paid to provide intermittent crisis services that had limited impact or effectiveness’, and were not often available or responsive in times when communities needed their services the most. In some cases counsellors would not travel to the community or do home visits, requiring the client to travel to receive service which created barriers for those most in need. There was a perception that the STCIMHC program was more geared towards the interests of the counsellors than in serving the needs of the client. There was a need for Health Canada to provide clearer expectations to those on the enrolment list around standards of care and the responsibilities that they have for their clients. There should also be more explicit direction set by Health Canada that counsellors collaborate more closely with the communities they serve and align with local services where appropriate. Staff at the AHP found that there was a constant turnover of counsellors which made it difficult to build relationships and collaboration with both clients and other service providers. They felt this was due to counsellors not liking the high level of paperwork required with the STCIMHC program, as well as the inequity of funding provided by Health Canada compared to those being funded through the provincial system.

Accessing Help in a Crisis The current STCIMHC program was largely seen as lacking responsiveness to clients who find themselves in crisis. By the time clients are able to get access to an enrolled counsellor, if they can persist with the Health Canada approval process, they are often no longer in crisis. The investment would be better made in programs such as Turning Point where mental health supports are located within the community, and where counsellors and therapists are able to get to know and become a part of the community, thus building the necessary confidence and trust of the people which are critical in moments of crisis.

Suggested Improvements to the STCIMHC Benefit / Short Term Crisis Mental Health Counselling

More local mental health capacity The Health Director as well as the Turning Point therapists suggested that in order to make a sustainable long term impact on addressing the complex and deep rooted mental health issues within First Nations communities, there was a need to invest in First Nations to provide their own local mental health capacity. There was a further need to more closely align funding for STCIMHC and other Health Canada funded First

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Nations mental health and addictions programs such as NNADAP. Currently these programs were seen to be disconnected and not working in alignment.

Traditional Healers and Elders The Health Director suggested that the criteria for those eligible to provide service under the STCIMHC program be expanded to include traditional healers, Elders and cultural practitioners who have a history of working with people within the community. The community needs to be a part of the process of determining appropriate people within the community to fulfil these roles. AHP suggested that traditional healers and cultural practitioners be included on the FNIHB enrolment list as clients often preferred to access these types of services when suffering from a mental health crisis.

Investment in cultural capacity The Health Centre stated that there is a lot of cultural strength that can be found within the community that is key to addressing many of the mental health challenges currently found within the community. There was a need to invest more in preventative measures that build off and strengthen the cultural capacity within the community. “This is a community that cares a lot but don’t always know how to express that care. When we use the strengths that exist within the culture that care and compassion comes through in a very natural way.” The language was seen as being particularly strong within the community and an area that with further investment, would have a significantly positive long term influence on health outcomes.

Expanding the scope of the current program Given the extent and intergenerational nature of the mental health issues within First Nations communities, there was a need to extend provision of counselling services beyond 15 one hour sessions. A longer term counselling support program was needed for First Nations communities, which enabled clients to build trust and rapport with their counsellor, establish a care plan and then slowly begin to address often complex mental health issues. “For the many years have they suffered, 15 sessions is not enough”. There was need to broaden the scope of the program to address clients with both mental health and addiction issues. The level of addictions and substance misuse within First Nations communities was significantly high in comparison to non- First Nations communities, and in many cases First Nation clients suffered with concurrent disorders. Yet the STCIMHC only addressed mental health disorders and did not address the often present addiction issues. Enrolled counsellors also needed to be trained in dealing with concurrent disorders and addictions, in order to effectively respond to all the challenges faced by clients.

Using family–based approaches The Turning Point program has experienced a lot of success in promoting family-based approaches to counselling and healing. In a number of cases, the therapists found that they were working one on one with multiple clients from the same family, where many of the presenting issues stemmed from family-related issues. Turning Point had a deliberate strategy of promoting family-based approaches to counselling, however it often required some time to work with clients individually first in order to prepare and support them, and to ensure that family-based approaches were appropriate and effective. Also, involving the whole family in the process of addressing some of the root causes of the issues, was found to have a greater impact over the long term and a higher chance of preventing relapse and reoccurring crises.

Transportation Transportation was identified by all stakeholders as being a significant barrier to clients accessing mental health services, particularly in times of crisis. Many clients felt that they had no choice but to suffer in silence because there were limited transportation options available, many did not have the resources for their own private transportation, and the NIHB program excluded clients from being able to access transportation support to access mental health services. Even in cases where transportation support was eligible within the NIHB program, the approval process was often cumbersome and lengthy and was not seen as being responsive to the needs of clients.

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QUEBEC REGION: CONSEIL DES ATIKAMEKW DE WEMOTACI FIRST NATION

JOINT REVIEW OF NON-INSURED HEALTH BENEFITS

SHORT-TERM CRISIS INTERVENTION MENTAL HEALTH COUNSELLING (STCIMHC) BENEFIT Operational Benefit Review

QUEBEC REGION

SITE: CONSEIL DES ATIKAMEKW DE WEMOTACI FIRST NATION, Quebec

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COMMUNITY DESCRIPTION Conseil des Atikamekw de Wemotaci First Nation is a community based north of Montreal in the region of Mauricie accessible by gravel road from La Tuque. Wemotaci is 115km on a gravel road from La Tuque the nearest town – and a total of 277km from Trois-Rivières the larger city with more extensive hospital facilities and psychiatric unit. Conseil Des Atikamekw de Wemotaci – health center sign

There is a total of around 1,435 registered members living on-reserve and 439 members living off-reserve.

Registered Population as of June, 2015 (AANDC, June 2015)

Residency # of People Registered Males On Own Reserve 736 Registered Females On Own Reserve 699 Registered Males On Other Reserves 14 Registered Females On Other Reserves 12 Registered Males On Own Crown Land 0 Registered Females On Own Crown Land 0 Registered Males On Other Band Crown Land 0 Registered Females On Other Band Crown Land 0 Registered Males On No Band Crown Land 0 Registered Females On No Band Crown Land 0 Registered Males Off Reserve 208 Registered Females Off Reserve 205 Total Registered Population 1,874

The Wemotaci First Nation has a secondary school (Ecole Nikanik) and is currently building a new elementary school (Ecole Seskitin). There is also a fairly new Band Office building (in which social development and mental health are located), supermarket, restaurant, large children’s playground and gas station (Wemogaz). Wemotaci

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also has their own police officers (public safety) who assist the community and health centre with clients as needed.

The health centre on-reserve has recently been renovated and includes rooms for medical / nursing appointments; dental services; ambulance and emergency room; and several other offices for home care, maternal child health and other programming. Conseil Des Atikamekw de Wemotaci – view of community from hill above

Wemotaci Police (Public Safety) Nikanik High School

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CONSEIL DES ATIKAMEKW DE WEMOTACI HEALTH CENTRE AND SERVICES The Health Centre provides a range of services and programs in health promotion, maternal child health and mental health & addictions services as well as Nursing / Medical, dental and ambulance/emergency.

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Wemotaci ambulance in the tailored ambulance bay – adjacent to emergency room

Ambulance Bay from exterior

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Health Department Staff Conseil Des Atikamekw de Wemotaci Health Centre is a department of the Nation administration and the Health Director reports to the Band Manager. Staffing includes:

SERVICE GROUP POSITIONS

Management / . 1 Health Director Administration . 1 Program Manager . Receptionists . Drivers / patient travel staff Mental Wellness and Employed by Wemotaci Substance Use . 1 Clinical supervisor / counsellor

. 3 counsellors NB: This team is not based in . 1 NNADAP Worker the Wemotaci health centre. Staff funded from Brighter Futures; NASYPS; NNADAP and Building They are located separately in Healthy Communities programs the Band office building Time paid by Health Canada (STCIMHC funds & IRS funds)  1 Clinical Psychologist (8 days per month (4 days every 2 weeks)

Medical and Nursing . Doctor comes once per week (Groupe de Medecine Familiale de La Tuque) Aboriginal focused, family doctor that has come more regularly for the past two years. There is a good link with these doctors. The visiting doctor makes referrals to the psychologist. In some cases of sexual abuse, the doctor has referred externally for clients who did not want to see a man. . Nursing team: one male, one female nurse - both coordinators of the doctors at home program, and work in mental health. Work 12 days, then 16 days off. . Two chair dental clinic Community Health Social services is funded by AANDC and managed by the Atikamekw Tribal Council. Front line services are also partially funded with Ministry of Social Services (provincial), for prevention. The child protection services are funded by AANDC.

Other community health programs: . Maternal / infant / child health . Youth health . Communicable disease control . Chronic Disease Management / Diabetes (including retinal scanning and footcare) Home Care First Nations Home and Community Care program – home care nurse and home support workers

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Current Mental Health / Addiction Services and Crisis Intervention Arrangements Conseil des Atikamekw de Wemotaci (‘Wemotaci’) is a fully transferred community (Block Flexible) and manages all of its own programs. Wemotaci already has a system in place for responding to mental health needs (including crises) and they have mental health specialists both in community as well as a visiting psychologist. Wemotaci has a mental health team which includes 3 counsellors and 1 NNADAP worker who work together. One of the team members is a nurse who splits his time between the Home Care team and the mental health team. Another nurse shares time with this nurse and between them they make up a 1FTE nursing position. The team has set protocols for suicidal cases, or violence, or if there are children involved then the social services team is called. There is a visiting Clinical Psychologist who comes to Wemotaci 4 days every 2 weeks. As a private practitioner he submits claims to Health Canada for either NIHB STCIMHC funding or IRS; HSP funding reimbursements. Around 20- 25% of his claims are for IRS: RHSP consultations and the balance for STCIMHC claims. This psychologist always has a full caseload of visits when he is in the community where he usually sees 16 – 20 on average although in some busy weeks he can see as many as 24 people in the 4 days he is there. Currently the psychologist has a wait-list of 8 people. It is understood that community members prefer to see this psychologist in the community as the provincial system has a long waiting list (6 – 8 months) to see psychologists for counselling. In cases of crisis, the nurse in the mental health team can be called. If necessary that nurse will spend time with the doctor when they are in community every Tuesday to discuss a case. This ensures that both the Doctor and the nurse in the mental health team are ‘on the same page’ with shared clients. Between the mental health team, Doctor and nurses they are usually able to stabilize someone in crisis and make a referral to the Doctor who comes every Tuesday or the Clinical Psychologist for their next visit. If the person wants to see the psychologist quickly then room will be made for that person in the schedule when the psychologist is on site even if other less urgent cases have to be moved. If the psychologist is in the community at the time of the crisis then priority is given to that person.

Access to Provincial Services: Center for Health and Social Services of Upper Saint-Maurice, La Tuque Wemotaci has existing links established with mental health specialists, addictions counsellors outside of the community including the Domrémy therapy centre which is a provincial body and focuses on addictions. Domrémy has a service centre at La Tuque as well as Trois-Rivières. The closest hospital with Mental Health and Addictions Services and a psychiatric unit is located 1.5 hours’ south of the community at the La Tuque Hospital. The Centre for Health and Social Services of Upper Saint-Maurice is the regional health authority at La Tuque (the nearest service centre) the Mental Health & Addiction Services provides inpatient, transitional day treatment and follow-up outpatient mental health care for children, youth and adults, in both urban and rural settings. The psychologist noted that he had good relationships with the Psychiatrist and other staff at La Tuque and they have never had problems working together and discussing cases if needed. He also noted that transfers out to La Tuque are quite rare since in the majority of circumstances, the mental health team, police, Doctor and nurses have usually been able to stabilize people in crisis in the community. If needed those clients can be referred to the visiting Doctor or Psychologist but more often than not the mental health team is able to cope with supporting the clients. If the 5 psychiatric beds are full, the Wemotaci health team advised that the province might keep someone for a few days in another unit until one of the beds is free if the person absolutely needs to be hospitalized. This is however a rare situation. More often, La Tuque hospital gives the patient medications, and the person is sent home. There are two psychiatrists in La Tuque that do regular follow up, and who have relationships with the nurses in Wemotaci. The nurses in mental health and the psychiatrists work together directly and this appears to work well as the psychiatrists will speak directly with the counsellors. From the provincial perspective, the La Tuque service is aware that in case of a mental health crisis at Wemotaci, the mental health team in Wemotaci conducts the first assessment. If needed, the team connects with the centre in La Tuque for further support and advice and this has been done from time to time. With regards to P-38 cases: when a person who has been designated as a P-38 case comes to La Tuque, the staff in the health centre in La Tuque conduct the follow-up of that client. Police officers bring the patient into the centre, and the protocols for working with a P-38 case are followed.

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With regards to individuals who have not been designated as P-38: there are no differences in the intervention or services that the La Tuque service provides either for Wemotaci community members or the local non-Aboriginal community. The mental health staff members in La Tuque follow the appropriate protocol based on the mental health condition of the client. After the person has been brought home, the Center in La Tuque follows up with the community by phone. The follow-up depends on the needs of the client. In many cases of referred crises, the La Tuque centre will call Wemotaci to make sure that the necessary linkages are made. The La Tuque Centre also has an interpreter in Atikamekw language to assist with translation needs, as necessary. La Tuque does not have psychologists or mental health professionals who travel from La Tuque to Wemotaci since Wemotaci already has services in the community for mental health interventions.

Mental Health and Addictions Services available from La Tuque In the provincial system there is a crisis line (Info-Social service that is available by dialing 811). Qualified psychosocial workers are available 24 hours every day of the year to answer calls. They can support persons in crisis and refer them to a range of appropriate aid resources in the region. It is not known how many Wemotaci community members may be using this service. Mental Health and Addictions services offered at La Tuque are: . individualized intervention plans incorporating the family or significant other . a gateway to the wider program (the team of current psychosocial services) for clients in need . an organizational model of services in the community, intensive monitoring and non-intensive monitoring; . activities of promotion and prevention; . psychosocial services (including preventive services, curative intervention and support for clients struggling with mental health issues). Regular psychosocial services are the main entrance of the Mental Health and Addictions team. Anyone who requires the services of this program are hosted by a psychosocial worker conducting an assessment of needs and directing clients to the most suitable resource. Other services at La Tuque are: . Outpatient mental health: Services are available through the front line mental health team or the variable intensity support program. The services are aimed at the adult with severe and persistent mental illness, as well as clients facing transient disturbances leading to psychological distress. Professionals work closely with community organizations and territorial partners by conducting assessments, monitoring and treatment. . Psychiatric Outpatient Clinic: Services are available through the outpatient psychiatry or non-intensive community monitoring. They cater to both adults with severe and persistent mental illness to clients struggling with transitional problems leading to psychological distress. Professionals who work there work closely with community organizations and territorial partners. . Acute psychiatric care unit: This service is for adults hospitalized for acute phases of illness and instability of their condition. The hospital stay is used to control the immediate danger and the person's functional limitations, hence the importance of a safe environment. Formal agreements allow the service to refer clients who require a highly secure environment, particularly in the context of forensic criminal or residential care, to health and social services . Variable intensity support (SIV): The Center for Health and Social Services of Upper Saint-Maurice provides various mental health services, including variable intensity support (SIV) in the community. This service is for people with serious mental health problem. It aims to support the development of individual skills; keep members in the community and improve the quality of life for those with needs that vary and change over time.

Access to Indian Residential School: Resolution Health Support Program (IRS: RHSP) The Clinical Psychologist as a Health Canada enrolled psychologist, can access the IRS: RHSP benefit if he sees someone who is eligible for this. He stated that around 20 – 25% of his clients are eligible for IRS: RHSP support. The psychologist stated that he has been informed that funding for the IRS: RHSP is sun-setting in March 2016 and they do not know what will happen after that in terms of supporting clients who are IRS survivors.

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Wemotaci previously had a sexual abuse project called MERUSKAMIN that was funded through the Aboriginal Healing Foundation from Federal government IRS funding. The funding ran out and Wemotaci asked Health Canada for additional funding to keep the initiative going. They received funding for evaluation only but not to keep the program going. The evaluation was done by the University du Quebec and University de Chicoutimi. They gave lectures, and went to conferences on how successful this project had been. They shared the successes with other counsellors, and trained other community health specialists.

There are ongoing requests from community members for this program where participants attended five-ten day sessions which aimed at getting IRS survivors and their families to reveal their abuse stories. Team members stated that it was very hard and difficult work and often extremely challenging, sometimes ‘triggering’ for some community members. Staff members were heavily impacted as part of the process due to the emotion, hurt and trauma that was shared – but they also knew it was a necessary healing process.

This project was developed by a sexologist who trained the Wemotaci counsellors, and they converted the program for Atikamekw populations. They ran the program in their language; they had massage therapists to have people be touched – heads, hands, feet, for support. This project started after 5 young girls had killed themselves and the community prioritized sexual abuse and suicide to prevent this in their schools. They trained police, teachers, and went into schools to do prevention. They expected the suicide crisis to explode. While the Meruskamin project was not funded by IRS – the participant group were IRS survivors and their families.

Key Partner: Domremy-de-la-Mauricie (specialized addictions agency) Domremy agency under the Quebec Ministry of Health and Social Services serves the Mauricie region in which Wemotaci is located. The first service centres run by Domrémy focused on external interventions in Trois-Rivières and Victoriaville. Later service centres were opened in Shawinigan which is 246km from Wemotaci and La Tuque (1996) among others. Since 1992, young people under 18 have accessed services for addictions including drugs, alcohol and gambling. The university Integrated Centre for Health and Social Services (CIUSSS) Mauricie-et-Centre- du-Québec is responsible for providing care and services to the entire population of the region. Wemotaci has very good relationships with Domrémy-de-la-Mauricie who focus on addictions – for alcohol drugs and gambling. Domrémy comes once per week to Wemotaci because many clients are referred to this service. Domrémy found that they had to do services in community to do proper follow up. Medical Transport authorizes travel for only one treatment travel per year so it is easier and cheaper to bring Domrémy into the community than send anyone out of community. All access procedures remain the same for the population, for example the coordinates of the points of service, the appointment made, how to consult a health professional or social worker. Addiction, alcohol, drugs, medication, gambling (including lottery) of any kind are addressed by Domrémy. As a public institution of the Health and Social Services Network services are free. Services include: External / Outreach Services: The vast majority of people who receive services from Domrémy benefit from external services provided as outreach rather than in a residential or inpatient setting. Young adults programs are distinct and each person receives services tailored to their own condition. External services can be group or individual. Support for the family: Spouses or significant others for the addict or dependent person can also receive services. They can then share their experiences and be better equipped to deal with the problem in their own home. It is not necessary that the addict receives services in order for families to receive support. Meetings are open to parents of adolescents experiencing psychotropic drug problems. They aim to better equip parents to help their teen and better protect themselves against this problem. It is not necessary that the young person receives services for access by parents. Adult Residential: The services with accommodation Centre in Trois-Rivières Pointe-du-Lac area places 30 men or women. The rehabilitation program and its activities extend over a period of 21 days - the duration is tailored to the needs of each person. Almost all activities are conducted in groups. However, each resident receives individual meetings to assess the path travelled and to adjust the content offered. Whichever services are provided, particular attention is paid to the specific needs of those who seek help. The service is intended primarily for clients with physical stability and psychosocial needs that have an addiction to alcohol, drugs, drugs or gambling.

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Youth residential: Since October 2000, the Centre Le Grand Chemin offers services with accommodation for young people who have abuse problems. The Centre Le Grand Chemin located in Saint-Célestin and Quebec City and Montreal can accommodate 12 teenagers. Access to these services is coordinated by Domrémy supported by a committee of partners. The approach is multidisciplinary and consider the totality of the adolescent. Drug and alcohol problems and other issues that are manifested in various spheres of life of the young are affected by the interventions. The length of stay is eight weeks. Detoxification: Detoxification can be achieved in alternative methods such as services with accommodation of Trois- Rivières Pointe-du-Lac area or Hospital. According to the product consumed and the particular situation of the person, it may be appropriate to proceed with a gradual reduction in consumption or pharmacological substitution. Depending on the degree of risk presented, each person is rigorously assessed and appropriate services are available. Mental Health and Addictions Concurrent Disorders: Several studies have highlighted a number of higher and more severe symptoms in people with psychotropic drugs problem and a mental disorder. For these people there is a greater instability in the accommodation, increased suicide risk and violent behavior, a higher rate of detention, homelessness and spread of HIV or other infections. Consumer problems of these people also tend to persist long- term. In many cases, they have greater and more varied needs.

REVIEW OF THE SHORT-TERM CRISIS INTERVENTION MENTAL HEALTH COUNSELLING (STCIMHC) BENEFIT

Awareness and Use of the STCIMHC Benefit The review team interviewed the Health Director, the Clinical Psychologist, 3 mental health counsellors, the NNADAP Worker as well as a Wemotaci police (public safety) representative The health management team advised that the Clinical Psychologist is funded by the STCIMHC funding and therefore individual claims are made to the NIHB STCIMHC benefit for specific short term crisis cases. The psychologist sends an invoice for his regular visits to Health Canada as a private practitioner and Health Canada processes the claims directly to him. The STCIMHC claims and the IRS: RHSP claims provide sufficient work for the psychologist to be in the community for the “4 days every 2 weeks” service model. The psychologist confirmed that he uses the 15 visits per 20 weeks claiming model for STCIMHC clients (or less if needed) and can extend to a further 5 sessions if the person requires further counselling. He also does the same for the 22 sessions per year allowed under the IRS: RHSP for those clients who are IRS survivors. Other front-line staff members were not aware of the availability of this specific benefit but knew that the Clinical Psychologist was paid directly by Health Canada. The psychologist did state however that he was on the Health Canada list for counselling and sometimes provided IRS: RHSP counselling as a result. Medical transport funding (from the Wemotaci Contribution Agreement) pays for the psychologist’s travel and accommodation is provided by the health centre in their own housing for visiting health professionals.

Client Access to Mental Health Crisis Support Since there were no individual claims made by clients for specific crises, the stakeholders (workers and community representatives) were asked for information on how short term mental health crisis intervention was currently provided and whether the process worked well. Clients access mental health services through various means including self or family referrals, referrals from Elders, health team, social services team, doctor or nurses and from community members who know the mental health counsellors. The process often depends on who received the call first related to the crisis – whether someone is in danger of harming themselves or others, whether there is a domestic situation; whether there is potential for harm of workers who intervene; whether there is violence involved in the situation or whether there is a potential suicide that has been flagged. If there is a danger the initial responder will send the Police with a mental health counsellor. They might send the police ahead of time before the counsellor to ensure the environment is safe.

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One year, police had declared a state of emergency, because of suicide pacts. The mental health team back then had the green light to send anyone to therapy. They once put 104 people in therapy in one year. This was after a wave of suicides that happened over about 4 years. In a crisis, the staff member`s security is also a primary goal as well as the safety of the community member. The mental health team have a protocol in place where the Wemotaci police will accompany the mental health staff member with any person in crisis. The security of the counsellor is a key priority especially if the community member is in a volatile or violent state. The Police can change their radio channels to speak directly to the mental health team and have a direct link. Communication works well. They have been doing this for about 3-4 years. Before this, they could only connect over the phone. Now it’s easier to reach each other over the radio, and it works with social services and the health centre. There are channels for the nursing team too. The social services also have a red button on their end that can create an immediate teleconference between police, MH support, and nursing, if ever there is a crisis. If the Wemotaci Police cannot do a transfer to the city, then they call the Surete du Quebec (SQ = provincial police) to pick up someone in crisis, and they bring an ambulance from La Tuque. Sometimes the local police might go half way and meet the SQ there and handover the client. For major crises, there are usually two support workers who will travel with the person to La Tuque. Police find they are quite advanced in terms of interventions. They have protocols in place, one for crisis intervention, another for post-vention, and another for emergency measures/emergency response, in case of fire. On Monday mornings there is a case study meeting, to prevent and reduce risks, and detect people at risk, and increase surveillance. The Police might also dispatch cases and use a triage system. The collective teams are discussing putting in place a space for men in crisis, but there are currently not enough resources. The teams are trying to work more towards prevention, not just response. In case of crisis there is a good teamwork between the teams. Wemotaci has developed a good team over the years despite staff turnover and everyone understands their roles in the situation of a crisis. They have built good teamwork and a solid process for responding. As soon as there is a crisis, or a suicide, “everyone will be talking about it”. The family might ask to see the body, “even if someone shot themselves in the head” and the counsellor will coordinate these requests depending on the situation. The clinical supervisor / counsellor is also known to have the respect of everyone in the community with her 30 years’ experience, so it makes working with the community easier. She is known to be a “pillar in the community and no one complains about her”. One worker said “she keeps the village together. She brings people together at the time and is highly respected and this makes a huge difference in crisis intervention”. If the counsellor was there at the time of death, or discovered the death, this person will be supported by the entire team to assist with the grief and debriefing. There is an intervention protocol in place for critical incident debriefing. They have challenges with follow up with difficult cases. They try not to abandon the case, but the clinical supervisor will go to see the person to convince the person that they need help now. “When people want to see the team, they need to see them straight away especially men because when they need help, it`s now - not in 2 minutes”. For suicide-related cases, often it is a family member that will ask for help from the mental health team. They put a ‘safety net all around the person to try and save the life’. They will contact everyone possible to try and protect the person and follow up at hourly intervals. The person may be encouraged to get out into the forest for a while ‘to get healthier’ and one of the team will support them if they wish. This approach is known to put the person in less danger and to help calm them. If someone is in a family encampment, trying to get healthy, the counsellors are available to go out to check on them. Police and mental health staff that were interviewed identified that the Quebec ‘P-38’ law (copy of summary in appendix) can be applied by a police officer that forces a person to be treated for mental health e.g. someone who is violent and/or has attempted suicide. If a person brings violence against themselves then Police apply this law. If the person is suicidal they can force that person to be treated through application of this law. The police accompany the client (often handcuffed) and transport them with health staff in an ambulance. Between the police, mental health staff, and/or health staff they decide whether they need to apply this law. If that happens, the mental health team escorts the person. The nurse also coordinates medical transport, and emergency transportation. In emergency cases, they use the local ambulance, or the ambulance from La Tuque. 121

Once the community manages the immediate crisis, they may elect to drive down to La Tuque (1.5 hours’ drive) to have the person evaluated. The hospital either determines that the person is no longer in crisis and may prescribe medication and/or send them home to the community. Alternatively they may elect to admit the person to the psychiatric unit. Staff noted that often - by the time they are in La Tuque or Trois-Rivières - the person may no longer be suicidal and are feeling strong enough to return home. Sometimes it was noted that the health staff at La Tuque did not trust the Wemotaci staff’s assessment of the situation or disagreed that the person was in crisis. The effect of this is that sometimes the mental health staff felt they lost credibility with the La Tuque mental health staff and the client in these cases. Key personnel in the Wemotaci mental health team have built contacts in the provincial psychiatry team and they have come to know which psychiatric nurses have good judgment and work well with their community members. Some nurses will share client information back with the community to ensure continuity of care while others will not. When information is not being shared with the community, the mental health team have no idea what happened to the person while they were in treatment and what the follow up should be. Wemotaci mental health staff members are also concerned about levels of literacy and in particular health literacy. For instance many young people were known to have low literacy rates and often did not understand diagnoses or next steps when being seen by provincial mental health staff. On occasion the Wemotaci mental health staff might call the Doctor to get an emergency prescription and in extreme cases, they call the La Tuque 911 ambulance for application of the P-38 law. They have found that sometimes the ambulance is reluctant to come all the way to Wemotaci. If they do arrive, along with the provincial police, they can apply the P-38 procedure. If they decide to escort the person away the Police will travel in the ambulance with the community member. Once the P-38 law is applied the person’s rights are removed so that they can be mandatorily evaluated by a psychiatrist. Another example of a crisis is that sometimes someone may be in crisis or behaving irrationally because they are under the influence of a substance that has impacted their behaviour in the community. As a result, this person may be transported by Police and the mental health team to La Tuque. However once a person has ‘come down’ from being on any substance, they may sign a treatment refusal form just so that they can return home. In this case they are let go to return to the community and there is often no feedback, instruction or guidance given by the La Tuque services to the Wemotaci mental health team to ensure the person is followed up appropriately. The NNADAP program funds the same mental health support staff, who can give support for NNADAP, and can assess the level of substance use consumption, and refer to treatment centres. One of the treatment centres is called Wapan in La Tuque. They also have an agreement with the provincial service called Domrémy. There are 5 or 6 treatment centres in Quebec.

Case Reviews Each Monday morning the mental health team reviews the cases in protection and they discuss what the next steps are, and develop a plan for the clients. They decide which of the mental health professionals will meet with the community member so that there is an appropriate match. The mental health team can offer a secondary entrance for clients to access them if they want more confidentiality (especially since the team is based in the Band office).

Professional Support for Wemotaci Mental Health Staff Wemotaci is part of the social services centre network at La Tuque and is part of the team of managers and coordinators. There are trainings available in La Tuque for mental health staff although they would prefer training in the community so that all the staff do not have to leave the village. In the agreement with Domrémy there have been trainings in substance use and other addictions. They also have some training with the CSSSPNQL, more in substance use. With Domrémy, the health care team has received training in methadone maintenance. The visiting psychologist has also provided training in personality disorders to the entire team at Wemotaci.

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One comment from a mental health team member was that “Every staff member here also has PTSD25, from having seen horrors in our community”. For cases where the P-38 law is not applied the mental health team is left to support the person and their family as best as possible. One example was given of a man who wanted to kill himself but who refused treatment, but the family were desperate for support. The team had to let the person go home and could not intervene due to the non-consent to provide care, and sometimes the mental health team would be criticised by the family and community for not helping more. There is very real concern for the employees in mental health and the need for some kind of employee assistance program that helps counsellors deal with problems. Often in a remote community such as this they are left to deal with things on their own. Regular team meetings provide an opportunity for a check-in every Tuesday, however more support is needed in the form of clinical and cultural supervision to help them manage and process the kinds of issues they are dealing with each day. The mental, spiritual and cultural well-being of the mental health workers is also a concern as sometimes workers are dealing with family members or friends who are in mental crisis. They might need to step into a family crisis of their own family and have to act as mental health professionals trying to remove emotion and be objective in their dealings. If the case concerns incest and involvement of a family member, this can add considerable pressure on the workers. All of the team members acknowledge that there is often a conflict of interest, but with Atikamekw counsellors there is always a risk that they will have some form of relationship with other Atikamekw community members. Sometimes workers themselves have been a victim of abuse in their own family and are undergoing their own healing journey. There may be examples of “arresting their own parent or finding a sibling hanging” and these were noted as very real considerations for the mental health workers. The challenge is that on the one hand, having Atikamekw / Wemotaci Police, mental health and social workers is seen as a benefit as workers are more familiar with the community; acceptable culturally and socially; and can speak the language. This makes them an appropriate workforce for the community. On the other hand – there is a risk that there will be familial relationships or associations that may make decision-making and treatment approaches challenging.

Use of Elders and Traditional Healers within Mental Health & Addictions The mental health team leaves it to the community member’s personal decision as to whether they want to access Elder support. There are some traditional services, and in exceptional cases the crisis person might request their grandparent or someone. These are all alternative arrangements and not prescribed by the team but left for community members to make their own choices. Two of the counsellors have on occasion done sweat ceremonies.

Perspectives on the STCIMHC Benefit

STCIMHC Enrolled Counsellors and Claims Process The current Clinical Psychologist is on the Health Canada enrolment list and is paid directly by Health Canada for his monthly visits. He is known and trusted in the community. Since the psychologist claims directly there is no paperwork to be done by Wemotaci health team and this appears to make the process less bureaucratic. The health team simply manages the travel and accommodation side of the psychologist’s visits and the system appears to work well. The advantage of having the service in the community is that there is greater retention, and patients will stay with the psychologist longer, as opposed to using program funding for one off crises. The health management sees a risk with accepting the funding to manage themselves as it might limit the amount they could receive and services they can offer. They generally have no reimbursement issues for the psychologist, but he has to justify every funding request and report on each case he is managing. Refusals have happened where there had been several important social crises, e.g. multiple suicides, so the entire community was affected. The network of treatment centres was not sufficient to meet the need. Those centres could take NNADAP cases, but they had to send community members to other centres, private centres that had been pre-

25 Post-Traumatic Stress Disorder (PTSD) 123

approved by Health Canada. They had to justify why they were asking for one person to go to an urgent mental health centre, for therapy. They still rarely do this, but they get refused more often.

Potential Areas or Opportunities for Improvement

Travel Challenges The gravel road outside the community down to La Tuque is a barrier. If someone has to leave the community - in terms of not only mental health but all health needs – it can be challenging if people do not have appropriate vehicles or no licence. The cost of travelling 115km to La Tuque is also a barrier as there is no routine public transport. There is a vehicle for semi-urgent cases which covers appointments for elders and for handicapped. This will take people to Montreal and Trois-Rivieres for specialist appointments. Often elders and others are known to be uncomfortable if asked to travel with someone with a mental health condition where they cannot predict behaviour. Sometimes the health team would like to make two separate trips to keep the person with a mental health crisis (or someone who is suicidal) separate from others going to see specialists for a physical ailment – but Health Canada “makes it difficult as they won’t approve two trips or make us really justify to do this”. The health team is often concerned for the privacy and confidentiality of the person with the mental health crisis and so prefers to give them privacy in the vehicle on their own with the counsellor and/or support person.

More Clinical Psychology Time Wemotaci management noted that having a second visiting psychologist would be helpful. There are some clients that the current psychologist cannot see - maybe because he is already seeing one family member and cannot see another, or because he is male. Management considers that in cases when the client would need to see a different psychologist, they could still access the STCIMHC funds. Also if a health staff member had to see a psychologist, they would have to refer to a private psychologist elsewhere. The staff person would have to leave the community in this case as it would not be appropriate for them to see the psychologist in the community.

Lack of Atikamekw-speaking Psychologist With most people in the community speaking Atikamekw as a first language (French 2nd) there is a desire for a clinical psychologist who can speak the language and provide a more appropriate service for community members. While the community recognizes the challenge to achieve this they do believe this would make the current service much more accessible.

Gaps in services for Men and Homeless People It was stated that for men in crises there are no safe places to put them in the community if they have suicidal ideations. The neediest men often do not have a Care Card and may have no fixed address and this presents challenges for them to receive provincial services. There is a shortage of around 100 houses in Wemotaci so in cases of homeless people, there is nowhere for them to go. These folks may go to La Tuque but often do not have any personal ID cards or money and are left unsupported. In judicial cases, the NNADAP worker has occasionally housed people personally at his home in La Tuque (cottage). Resources for male community members is an issue for the community as there are no safe houses or specific programs for them that are tailored to men’s needs. Discussions and plans had been put in place for a safe house for men in crisis, but there wasn’t a suitable facility that met the requirements. The mental health team noted that it was often hard to approach men in crisis, and it appeared that only those in the most extreme circumstances asked for help. In some cases, men would simply go into the woods to “resource” themselves, because they know how to heal themselves there, or reduce their suffering. Men might be too proud to ask for help. The team is considering bringing men together to discuss in group, and to establish their collective needs and supports. The collaboration with Domrémy helps as well as linkages with the Friendship Centres in La Tuque and Trois-Rivières (Centre d’Amitie Autochtone).

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Employee Assistance Management is concerned about the lack of programs for employee assistance and support. If a staff member is having a challenging personal situation, they are not going to see one of their colleagues for assistance, say to avoid burnout. More support for staff would be a very useful. Council would recommend that staff go to their own insurance company to get this cost covered, but not all employees have insurance. Long wait lists with provincial services also make it difficult. The services in La Tuque are not anonymous enough for Wemotaci employees and likely the staff members would need to go to Montreal or Trois-Rivières.

Lack of Housing adds to mental health burden There is a lack of recognition of the trauma lived by community members and staff because of the shortage of housing. With over 100 on the housing wait-list people are not living in ideal situations and often become very frustrated, Housing staff too are affected by the frustration targeted at them by community members.

Crisis Centre The health team proposed a crisis centre for community members. The hospital in La Tuque is not considered to be adequate for crisis situations and they would prefer a separate facility to stabilize someone and keep them safe. They had submitted a proposal to Health Canada for a crisis health space, but Health Canada said the designated space in their current building was not legal, and that it didn’t meet the required standards. The need is still there, and the issues with La Tuque still exist. Sending people directly to the hospital is not the ideal solution – “it would be better to keep people in the community. Before, they used to put people in cells, but this wasn’t legal. Before that, they would see the patient here in the health centre, gave him a coffee, to get his mind to calm down. They also used to have a large tent for this purpose”. Management stated that in cases of conjugal violence, it was easier for women and children to find services in a home or elsewhere in La Tuque as there were safe houses there. This does not exist for men. Medical transport does not pay for travel for women and children to attend a safe house but men have even less support when in situations of abuse. Mental health services should be extended to include family violence, so that they could access medical transportation for these cases.

Self-Managing the Funds While management saw the benefit of managing their own STCIMHC funds, medical transportation, and mental health funding (so that they didn’t have to justify everything with Health Canada in Montreal) they were also concerned about the risk of deficits due to the high needs in the community. At present they manage to get approvals by phone fairly quickly as they have a good relationship with the staff member at Health Canada, but if that person changes, Wemotaci would be worried that the next person may not treat them the same way.

Confidentiality and Privacy with co-location of Mental Health Team in Band Office With the co-location of the mental health team with the other Band Office services (rather than the health service building), this can be an issue for some people accessing services. The finance, social services, housing and education departments are all in the same building as well as the political level staff who support Chief and Council. The social services have their own entrance to the building, but mental health does not have their own entrance. Clients for mental health have to go through the main entrance. When someone is very uncomfortable and does not want to go to the band office, they have to find temporary space in the health building. If someone goes to the mental health service, they will be identified by other staff since most community members know each other. As one interviewee stated “While staff members try to keep it confidential, the community still knows who is selling drugs, who might not be walking straight, who might be in there for counselling. It’s a small community”.

A Case Study the community wanted to share: Mental Health crisis event in the community . Psychosis symptoms case; several weeks of consuming ‘speed’; the person became violent . Public safety (Police) were the first to intervene to arrest the person (any counsellors who go to a home are now systematically assisted by the police) . Police drive the person to the health centre for a medical assessment

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. The mental health counsellor will intervene at different times, not necessarily at the start when the police show up . Mental health team will do an evaluation of the patient. The medical portion will be taken care of by the nursing team. . When the evaluation is done, the next steps and follow up are established . In the case of psychosis or hallucination, they would likely apply the p-38 protocol, because the person might be a risk to themselves or others . The nursing team would send a medical consult via fax, and then the doctors at the hospital in La Tuque would recommend next steps, especially in terms of medication . The nursing team would contact the ambulance to come and get the person in crisis . Public safety (Wemotaci police) would contact the provincial police to get a police escort. Often, these people are under the influence of substances, and by the time they arrive in La Tuque the crisis is over. The problem isn’t solved, but they are no longer in the same crisis. . If the person comes back quickly to the community, they don’t always have the information about what happened at the emergency room in La Tuque. Wemotaci does not have a formal agreement between the emergency services in La Tuque and the Wemotaci mental health team . Often because of confidentiality, the teams in La Tuque do not inform Wemotaci to support continuity of care or follow up . When the patient is followed by one of the psychiatrists in La Tuque then the follow up is much better, even If there is no official agreement in place. The nursing team receives the follow up from the psychiatrist . In Quebec, the agreement that Wemotaci have with the psychologist and Health Canada is not unique to Wemotaci. The goal is to be as autonomous as possible. Mostly works well, but access is sometimes difficult.

Case Study: Community Crisis

The Wemotaci community was severely affected by a nearby forest fire in early 2010. There were some people who didn’t want to leave the community. The fire was “right there, but some people didn’t want to leave” according to the mental health workers. The community was evacuated and stayed at the school in La Tuque. Fortunately there were no deaths from the fire. People were concerned about their pets that had stayed behind.

“People could see the fire arriving quickly and there were huge burning pieces of wood dropping into people’s backyards”

“The police did a good job of organizing people to leave, but many people didn’t have enough gas in the cars. There were cars that weren’t insured or no license plates that were driving out. There were buses and taxis driving into La Tuque. One police officer in La Tuque was giving tickets to people without plates. The community picked up all the tickets and brought them to city hall, and they were cancelled”

“After that, the community equipped itself better and is now better prepared for an emergency like this. There were a number of people” frustrated and affected by the fire, especially because they wanted to return home and weren’t allowed”.

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“The evacuation lasted more than 10 days. The Ministry had to inspect all the homes, to check air quality, and the community’s impatience was exploding. They had to manage the crisis of anxiety and frustration. This was a collective crisis”.

“They had some trouble communicating with the fire teams. They only had 5 radios for the entire team, and had to make it up as they went along. They had to feed the teams, and equip them too. Some people were going out with hockey sticks to fight the fire. They had to use hoses from homes to fight the fire. They were emptying pools. They would just grab any gardening hose and put holes in it, and connect it to whoever’s house, just to keep everything wet”.

After the fire, the mental health worked with other teams in the community such as public safety, social services and the nurses to ensure a good system was put in place for responding to community crises like this; improving communications; and being able to support people in vulnerable situations.

CBC NEWS ARTICLE MAY 2010

The more than 1,400 people forced from their homes because of forest fires near the Wemotaci First Nation in central Quebec have been told it is unlikely they will be able to return home any time soon. Four forest fires burn out of control on the Wemotaci reserve, about 300 kilometres north of Trois-Rivières on Thursday.Four forest fires are burning out of control on the territory, located about 300 kilometres north of Trois-Rivières. Smoke and burning sparks were starting to affect the village, according to Quebec's forest fire protection agency.

On Thursday, Native Affairs Minister Pierre Corbeil and the minister responsible for the Mauricie Region, Julie Boulet, visited La Tuque to meet with officials and evacuees. "There will be no talk of returning to the community until it is possible to do so safely," Corbeil told reporters.Electricity has been cut off to the community, which is also without drinking water, Corbeil said. "The situation is evolving from hour to hour," he said. "They are calling for hot weather and there is not much rain on the horizon. I think [the situation] are something that will unfortunately last for some time."

Provincial police said the fires had been started by lightning storms on Tuesday night. Corbeil warned people to stay out of the forest in the area. He said the province could issue an order restricting access to the forest because of the danger. "I am reminding people to exercise extreme prudence and extreme vigilance and to avoid all open fires," he said.

More than 1,400 residents are being helped by the Red Cross, including more than 200 who are being given shelter in a school in La Tuque, said Boulet. "We have advised them that their homes have not been touched by the fire," she said. "They are anxious to return home, which is normal and what we have said is that we will do everything we can and hope that Mother Nature co-operates."

Fires close to homes The fire is so hot that firefighters have been forced to battle the blaze indirectly using water bombers and machinery, the CBC's Marika Wheeler reported from La Tuque, where many residents are staying at an emergency shelter set up at a school. Quebec Native Affairs Minister Pierre Corbeil reiterates the importance of the ban open fires which is in effect in much of the province. On Wednesday, the fire came so close to the community that one home was damaged and several sheds burned to the ground, she said

"We were already ready to go. When we saw there was smoke, we knew we would be evacuated," said one woman at the shelter. Some residents refused to leave the village, and early Thursday morning several men who had gone to the emergency shelter decided to return home to help battle the blazes. "It's our village. We have to protect our village," said Wemotaci resident Denis Chilton. The villagers who stayed were able to save dozens of houses from the fire, he added.

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NORTHWEST TERRITORY: LUTSEL K’E DENE BAND

JOINT REVIEW OF NON-INSURED HEALTH BENEFITS

SHORT-TERM CRISIS INTERVENTION MENTAL HEALTH COUNSELLING (STCIMHC) BENEFIT Operational Benefit Review

NORTHERN REGION – Northwest Territories

SITE: LUTSEL K’E DENE FIRST NATION, Northwest Territories

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BACKGROUND CONTEXT

Short Term Crisis Intervention Mental Health Counselling (STCIMHC) is not available as a benefit under the NIHB Program in Northwest Territories (NWT). However, this is not to say short term crisis intervention mental health counselling is not available to First Nations communities in the NWT. This service is provided by the Territorial Government through regional health and social service authorities – rather than by way of a ‘benefit’ accessed through the Non-Insured Health Benefits (NIHB) program.

Transfer North of the 60th Parallel26 A 1954 Cabinet decision gave First Nations and Inuit Health Branch (FNIHB) responsibility for the delivery of health services to all residents of the Yukon and Northwest Territories. The Cabinet decision stated that once territorial governments showed a desire, and had developed the necessary expertise, responsibility for health care delivery would be transferred to them. Generally, the approach was to transfer responsibility in stages, starting with the transfer of hospitals. Early in the 1980s discussions were held with the Government of the Northwest Territories and the Inuit Tapiriit Kanatami with the aim of developing an arrangement for the transfer of service responsibilities to the Government of the Northwest Territories. Several universal health programs and services were transferred to the government of the Northwest Territories during the 1980s. The transfer of the remainder of universal federal health services in the territories to the Government of the Northwest Territories was completed by March, 1988, and became effective on April 1, 1988. While the federal government retained responsibility for the NIHB Program after the 1988 transfer, the GNWT administers certain portions of the NIHB Program under contribution agreement with Health Canada. Health and social services are fully integrated for all territorial residents. This includes all aspects of health service delivery such as primary care, acute care, mental health and addictions (including crisis counselling) and medical transport. There is no direct interaction between First Nations community members and NIHB in the NWT, as NIHB is delivered and administered in a seamless fashion with all aspects of care coordination remaining a responsibility of the GNWT. The arrangement between the NIHB program and the GNWT would be considered more of a ‘back-office’ function where the GNWT can claim payments from NIHB if the claim meets the NIHB criteria - and is outside what is already covered by the territorial government.

Government of Northwest Territories (GNWT)27

The Government of the Northwest Territories operates several Departments much like the Provinces south of 60th parallel such as (list not exhaustive):  Aboriginal Affairs and Intergovernmental Relations  Education, Culture and Employment  Environment and Natural Resources  Health and Social Services  Industry, Tourism and Investment  Municipal and Community Affairs

The Health and Social Services Department is primarily responsible for the delivery of high quality, patient- centered care to residents of the NWT. The Department invests across a wide spectrum of programs and services aligned with the Department’s mandate to provide high quality health and social services that support our vision, mission and goals. In 2013/14, the Department spent approximately $391 million on ambulatory care, community health programs, community social programs, diagnostic and therapeutic services, nursing and inpatient services, supplementary health programs, and administration and support services. Over $254.1

26 Extract from http://www.hc-sc.gc.ca/fniah-spnia/pubs/finance/_agree-accord/10_years_ans_trans/index-eng.php 27 Adapted from information acquired from www.gov.nt.ca and www.hss.gov.nt.ca/social_services 129

million (65%) went directly to Health and Social Services Authorities under Core Funding Contribution Agreements.

Health and Social Services Authorities The Hospital Insurance and Health and Social Services Administration Act provides the Minister of Health and Social Services the authority to establish Boards of Management for health and social services facilities. The Boards of Management are responsible for managing, controlling and operating the health and social services facilities in their region. Along with the Health and Social Services Department, 7 regional health and social services authorities plan, manage and provide health and social services for the Northwest Territories: 1. Beaufort-Delta Health & Social Services Authority 2. Deh Cho Health & Social Services Authority 3. Fort Smith Health & Social Services Authority 4. Hay River Health & Social Services Authority 5. Sahtu Health & Social Services Authority 6. Stanton Territorial Health Authority 7. Yellowknife Health & Social Services Authority The Lutsel K’e community falls within the boundaries of the Yellowknife Health and Social Services Authority (YHSSA) however access to the Psychiatric Unit is through the Stanton Territorial Hospital in Yellowknife operated by the Stanton Territorial Health Authority (STHA).

Yellowknife Health and Social Services Authority (YHSSA)28

Yellowknife Health and Social Services Authority (YHSSA) provides community-based health and social services programs to 20,000+ residents of Dettah, Fort Resolution, Lutsel K’e, NDilo and Yellowknife. YHSSA employs a Health and Social Services System Navigator to help people with questions and concerns about how to access services provided by the NWT health and social services system.

YHSSA Health Centre @ Lutsel K’e

YHSSA has a health centre based in the Lutsel K’e community that provides primary care services as well as mental health and addictions counselling services at the Wellness Centre also located in the community. In addition to community-based services, YHSSA also provides Mental Health and Addictions services at Yellowknife including Central Intake, community Counsellors (who can make referrals to Treatment Centres and the Psychiatric Unit at Stanton Hospital in Yellowknife) and a 24 hour 7 day a week 1-800 NWT Help Line.

28 www.yhssa.hss.nt.gov.ca 130

Stanton Territorial Health Authority (Yellowknife Hospital)29

The Stanton Territorial Health Authority is at the centre of the acute care delivery system in the Northwest Territories. STHA is also an important part of the Government of the Northwest Territories’ territorial integrated approach to healthcare. Through Stanton Territorial Hospital and the related clinics, the STHA offers a full spectrum of health care services for patients from Yellowknife, as well as every other region of the NWT and the Kitikmeot Region of Nunavut. Stanton Territorial Health Authority provides acute inpatient and ambulatory care to the 43,459 residents of the Northwest Territories and the 5,500 residents of the Kitikmeot region of Nunavut. These services are offered at Stanton Territorial Hospital and various other sites such as the Stanton Eye Clinic, the Stanton Medical Clinic and the Stanton Medical Centre, as well as a variety of travel clinics throughout the Northwest Territories and Nunavut. In addition to its territorial responsibilities in acute and ambulatory care, STHA is responsible for territorial health programs such as Medical Travel and Med-Response. The Stanton Hospital Psychiatry Unit is a secure, 10 bed unit, accepting both voluntary and involuntary (certified/formed) patients from the Northwest Territories and the Kitikmeot Region of Nunavut. While learning about their illness, symptoms and treatment options, patients on the Psychiatry Unit, in collaboration with their health care team, develop a personalized care plan incorporating the patient's treatment goals and transition back into the community upon discharge. STHA has an Aboriginal Wellness program supported by an Elders’ Council consisting of representatives across the NWT. The Aboriginal Wellness Program includes language services, patient supports, healing practices, northern foods and traditional medicine. Also - in accordance with the Official Languages Act of the Northwest Territories and its guidelines for implementation – there are language services available seven days a week, 24 hours a day to ensure on-going interpreting services in all the official languages of the NWT. The STHA website is also available in Dene languages and Inuktitut languages for instance.

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Representation of the Structure:

NIHB’s role is to cover GOVERNMENT OF NORTHWEST the Medical Travel co- payment to ensure TERRITORIES (GNWT) access to services

HEALTH & SOCIAL SERVICES Other Departments (HSS) (Territory-wide mandate)

Five other Health & Social Yellowknife Health and Stanton Territorial Health Service (HSS) Authorities in NWT Social Services Authority Authority (STHA) (YHSSA) Hospital @ Yellowknife Community services including Psychiatric Unit

Community health centre Community Health Centres Community Health Centres in based at Lutsel K'e other First Nations Commuities in YELLOWKNIFE city Staff employed / contracted (Fort Resolution, Dettah and community / primary care by YHSSA Ndilo)

The Lutsel K’e First Nation does not deliver any health services or programs itself or employ any health staff like Provinces south of the 60th parallel or the Yukon. All services that community members need are provided by the GNWT through YHSSA and STHA. This includes Mental Health Crisis community counselling, and if needed, inpatient psychiatric care.

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COMMUNITY DESCRIPTION – Lutsel K’e In the Northwest Territories, Nunavut and the Yukon, where few reserves have been established, the bands have been gathered into communities known as settlements, which are generally on Crown land, but these bands and settlements do not have reserve status. The majority of First Nations in Lutsel K’e reside on Crown land (see AANDC data below). Lutsel K’e Dene First Nation is a community based east of Yellowknife on the eastern border of Slave Lake, accessible by plane (airstrip) or floatplane in the summer, and by ice road road over Slave Lake in winter. Yellowknife is the nearest main center for access to health services beyond what is provided in the community through the local YHSSA Health Centre. Housing is available for visiting health professionals. The airstrip, health centre and housing are very much part of the community and physically accessible to community members by car or by foot – see photo below:

Airport

Housing for visiting YHSSA professionals Health Centre

Photo Credit: GWNT Department of Municipal and Community Affairs

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There are a total of around 520 registered members living in the community.

Registered Population as of June, 2015 (AANDC, June 2015)

Residency # of People Registered Males On Own Reserve 2 Registered Females On Own Reserve 7 Registered Males On Other Reserves 3 Registered Females On Other Reserves 2 Registered Males On Own Crown Land (Lutsel K’e Dene village) 264 Registered Females On Own Crown Land (Lutsel K’e Dene village) 231 Registered Males On Other Band Crown Land 2 Registered Females On Other Band Crown Land 4 Registered Males On No Band Crown Land 0 Registered Females On No Band Crown Land 0 Registered Males Off Reserve 111 Registered Females Off Reserve 142 Total Registered Population 768

The Lutsel K’e Dene First Nation community has a school, arena, Band office, Elders Lodge, Coop supermarket, airstrip and RCMP office – as well as the YHSSA Health Center.

The YHSSA health center includes rooms for medical / nursing appointments; dental services (2 chairs) and several other offices for home care, maternal child health and other programming. Unlike the Provinces south of 60th parallel, there are no band-employed health staff members since health and social service delivery is the responsibility of the territorial government.

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YHSSA Health Centre Staff Staffing includes:

SERVICE GROUP POSITIONS Management / . CEO (based in Yellowknife) Administration for YHSSA . Manager Health Centres (based in Yellowknife) . Nurse-in-Charge (based at Lutsel K’e Dene health centre) – also a practicing nurse on site Mental Wellness and Employed by YHSSA Substance Use . 1 Clinical counsellor – visits for 3 days every two weeks and is rostered between one male and one female counsellor (extended support available from YHSSA in Yellowknife if needed. The whole team includes only 6 counsellors to serve the entire coverage area of YHSSA) . 2 Social Workers (based in the Wellness centre just down the road from the health centre) Yellowknife  Central Intake for mental health and adult services (YHSSA)  6 counsellors in team – 2 for child and youth and 4 for adults (YHSSA)  Psychiatric unit (STHA) Medical and Nursing . Doctor comes from Yellowknife 2 days every 2 weeks . 2 nurses currently (one Nurse-in-charge and 1 other) and a 3rd nurse is being employed shortly. They run sick clinics in mornings and emergency in afternoon - as well as public health clinics . Clerk for reception . Two chair dental clinic (visiting dental) Community Health . CHR (Maternal / infant / child health; Chronic Disease Management / Diabetes . Administration . Housekeeper

Current Crisis Intervention Mental Health Counselling Arrangements30

Health and Social services (including mental health and addictions) are provided and managed by YHSSA for the Lutsel K’e community. There is a visiting Clinical Psychologist position (YHSSA employee) that comes to Lutsel K’e Dene 3 days every 2 weeks – the role is split between a male and female counsellor who rotate. YHSSA advised that their vision is for a consistent mental health and addiction service that people can rely on and build trust in. Sometimes the ability to achieve this has been hampered by recruitment challenges for psychiatrists and psychologists, and lack of available funding to hire more mental health staff for the coverage area. The general consensus among interviewees is that having someone independent come in helps protect peoples’ privacy and confidentiality – and even though ideally the community could have locally grown, Dene-speaking counsellors – many confirm that likely most community members would not use them for fear of losing confidentiality.

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In cases of crisis, people would usually let the health centre know and the Nurse-in-Charge would contact RCMP who have 2 officers based in the community. Sometimes RCMP may be called in directly and they would often contact one of the Social Workers in the mental health team. If necessary that nurse will contact the doctor to discuss a case or refer the person to the Doctor or counsellor when they are in community y to discuss a case. This ensures that both the Doctor and the nurse in the mental health team are ‘on the same page’ with shared clients. Between the RCMP, social workers, doctor and nurses they are usually able to stabilize someone in crisis and make a referral to the Doctor or psychologist when they visit. If the case is serious then the person would be escorted out on the next plane to the psychiatric unit Yellowknife.

REVIEW OF THE SHORT-TERM CRISIS INTERVENTION MENTAL HEALTH COUNSELLING (STCIMHC) BENEFIT

Awareness and Use of the STCIMHC Benefit The review team interviewed a number of key stakeholders during the visit to Lutsel K’e in the NWT. While all were aware of the NIHB Program, none of those interviewed had heard of the STCIMHC benefit. They knew about medical transport, dental and pharmacy but had not heard of this benefit before. YHSSA acknowledged that they received some funding for mental health and addictions from the NWT Government but were unaware whether some of this included the STCIMHC. They did not manage or specifically handle STCIMHC claims or services. They did not know whether Health Canada (through FNIHB) were directly managing the STCIMHC benefit and were perhaps paying clinical psychologists directly. Community members in the focus group were also not aware of this benefit but knew that the visiting Clinical Psychologist was paid by YHSSA. It was not until after the visit and contact with FNIHB Headquarters, that the reviewers learned that the Northwest Territories does not offer the STCIMHC benefit – and has not done so since 1988. This is due to the 1988 transfer of health and social service responsibilities from Health Canada to the Government of the NWT. As a result of this finding after the site visit, this report has been adapted to align findings with the specific service delivery model in the Northwest Territories.

Client Access to Mental Health Crisis Intervention Support & alignment with Mental Health Continuum The purpose of this part of the review is not to review territorial services which are the jurisdiction of the GNWT – but to describe how the current crisis intervention mental health counselling model aligns with the (AFN) Mental Health Continuum. Clients access mental health services through various means including self or family referrals, referrals from Elders, the YHSSA Health team, the YHSSA Wellness services team (Social Workers), the visiting Doctor and from community members who know the visiting mental health counsellor. In speaking with staff and community members – many discussed the high need for trauma-informed care and counselling citing cases of suicide; murder-suicide; deaths on frozen lakes; vehicular accidents from intoxication; alcohol-related domestic violence; depression; bipolar disorders; schizophrenia; psychosis; marijuana use; alcohol (legal and home brew / bootleg) and long term trauma as the types of mental health and addictions needs (that often lead to crises) that they have dealt with in the community. Some also felt that although the Dene people often turned to their culture (e.g. pilgrimage) for healing and revitalisation (which included getting away to healing camps), the challenge was often how to build this cultural strength into daily life once community members returned from those experiences. The review team were informed that the process for accessing crisis support often depends on who received the call first related to the crisis – whether someone was in danger of harming themselves or others, whether there was a domestic violence situation; whether there was potential for harm of workers who intervened; whether there was physical violence involved in the situation or whether there was a potential suicide that was flagged. If there was a danger the initial responder would invariably send the RCMP (located at Lutsel K’e) and often the RCMP will take one of the Social Workers. It was stated that often the RCMP would go ahead before the Social Worker to ensure the environment was safe. In a crisis, the staff person`s security was a primary goal as well as the safety of the community member and those around them. It was stated that if the community member or family connected directly with the Nurse-in-Charge at the YHSSA Health Centre, there was already a good linkage with RCMP and the local Social Workers. The counsellors at Yellowknife could also

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be reached by phone if necessary for advice on a specific case. The YHSSA health and social service staff at Lutsel K’e can also connect directly with the territorial psychiatry team at Stanton Hospital to determine if the person should be transferred to Yellowknife for support based on the facts of the case.

Potential Opportunities for Improvement Although the NWT does not offer the STCIMHC – there was one suggestion offered by the community focus group; the community member of the YHSSA Board and Chief and Council members that may be useful in contributing to ongoing quality improvement of the crisis intervention mental health counselling service. With most people in the community speaking Dene as a first language (English 2nd) there was a desire for a clinical psychologist who could speak the Dene language. While the community recognized the challenge in achieving this - they did all agree that this would make the current service much more culturally appropriate. In the interim the CHR was usually called upon to help translate for the counsellor and other YHSSA staff if someone was not confident or comfortable speaking English. Whilst not directly related to the STCIMHC review - the Chief and Council members also stated that there is a broader aspiration by the Dene Nation to assume control of their own programs (including health) from the Government as part of moving to self-governance. They offered this comment on the basis that this ‘bigger picture’ was important to Dene people and needed to be considered within the context of the National NIHB review. They noted that there was some work being done by Dene leaders looking at the feasibility of a Dene health centre (similar to the South Central Foundation model in Anchorage Alaska) which was self-governing and also incorporated cultural healing alongside western medicine. One recommendation associated with this ‘bigger picture’ was a desire by Chief and Council for the GNWT and Federal Governments to invest more in training and encouraging more Dene people into management, governance and front line service delivery to support the community moving to a self-governing model.

Access to Indian Residential School: Health Support Program (IRS: HSP) Some participants that were interviewed knew about this benefit but were not sure how to access it. There was a concern raised from one interviewee that this program was sun-setting in March 2016 and that the impact of this may put pressure on current services. Government staff (NWT and YHSSA) believed it was being delivered by one or more NGOs in Yellowknife but were not sure who as there had been some organizational changes. Community members did not know about the IRS counselling program and guessed that perhaps IRS counselling was absorbed into the visiting counselling service. They were not sure who was providing the service in the region if it wasn’t the YHSSA counsellor. There was a desire by all to know more about how to access this program in the NWT.

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MANITOBA REGION – PAUINGASSI FIRST NATION

JOINT REVIEW OF NON-INSURED HEALTH BENEFITS

SHORT-TERM CRISIS INTERVENTION MENTAL HEALTH COUNSELLING (STCIMHC) BENEFIT Operational Benefit Review

MANITOBA REGION

SITE: PAUINGASSI FIRST NATION, Pauingassi, Winnipeg

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COMMUNITY DESCRIPTION Pauingassi First Nation is commonly defined as a “fly-in” community located on a peninsula approximately 280 kilometers northeast of Winnipeg and 24 kilometers north of Little Grand Rapids. The community is isolated and remote with access to the community via Floatplane or boat – there is no permanent road access in summer. During winter, the Floatplane can land on an ice airstrip although roads are also constructed over ice either from Pine Dock or Little Grand Rapids. The floatplane duration is approximately 2 hours from Winnipeg or Selkirk being the closest city to provide hospital services and psychiatric services. The first language in Pauingassi is Ojibway and according to AANDC, the total registered population is 634, with over 95% living on reserve.

Registered Population as of June, 2015 (AANDC, June 2015)

The community has the Omishosh Memorial School (up to Grade 9 with a current roll of 80 pupils), Band office, Daycare Centre, Teachers residence, Youth residence (6 houses with rotating foster parents), Fire Station, Northern Store, Dojo shop, Church, Helicopter pad, Docks (2), Nursing Station with connecting residence and former NDL building. The Band Office consists of a Chief, councilors (each with portfolios), Band constables, finance, receptionist, Janitor and water treatment workers who provide some community services. The community does not have local RCMP officers based on-reserve. The nearest RCMP station is located at Little Grand Rapids, another community approximately 30 minutes boat ride away and therefore immediate response is limited. Community perspectives indicated that the RCMP only responds to community issues depending on the seriousness or severity of the situation. One community member noted that ‘the response times to domestic violence can be 3 or 4 days’. The SERDC Health Advisor did make comment that the RCMP does provide good education sessions when they are visiting the community. The two Band Constables essentially act as peacekeepers but have no authority to deal with criminal matters. They provide support to community members, respond to domestic situations, act as safety wardens and will also support patients being transported out of community. Although the community [focus group] identified that they had a high prevalence of alcohol related concerns, the Nursing station interviewee said she had noticed a change over the past 3 years with a reduced number of patients presenting themselves with alcohol-

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related issues. Additionally, the current Chief stated that he has recently disseminated a memo ‘cracking down’ on the distribution and use of alcohol especially amongst staff working for Band. According to the Health Director, there are limited activities for youth in the community with no recreation center. There are 2 pieces of gym equipment (located in the same building as the Band’s health staff), a baseball field, skating rink, basketball court and the school gym - however there is limited utilization of these facilities by the community or sports groups. The community also receives sporadic radio reception and cellphone coverage - as well as limited internet coverage. The majority of internal community communications are via a 2-way CB radio. View of Pauingassi on the shore of fishing lake from the air

SOUTHEAST RESOURCE DEVELOPMENT GROUP (SERDC) – TRIBAL COUNCIL Pauingassi First Nation is one of 8 member First Nations in the southeastern portion of Manitoba that belongs to the Southeast Resource Development Council (SERDC) – commonly referred to as the Tribal Council. The Tribal Council is accountable to approximately 12,000 members under the leadership of its 8 First Nation members. Located in Winnipeg, SERDC is governed by the Chiefs of its member communities and was incorporated in 1978.

SERDC oversees an estimated annual budget of $32 million to facilitate the development of local control and responsibility of programs and services with a focus on capacity development to member First Nations including Pauingassi First Nation. SERDC finance and administer advisory services in the areas of:  Band Financial Management  Capital  Technical Services  Housing Advisory  Maintenance  Social Services Advisory  Economic Development  Community Planning

Specific Health Programs and Services include:  National Native Alcohol and Drug Abuse Program (NNADAP)  Canada Prenatal Nutrition Program (CPNP)  Success Through Advocacy & Role Modeling (STAR)  Fetal Alcohol Spectrum Disorder (FASD)

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 Home and Community Care ( H&CC)  Aboriginal Diabetes Initiative (ADI)  Brighter Futures & Building Healthier Communities (BF/BHC)  National Aboriginal Youth Suicide Prevention Strategy (NAYSPS)  SERDC was also awarded the contract for the construction of an 80-bed Personal Care Home for Aboriginal residents in the City of Winnipeg.

PAUINGASSI HEALTH PROGRAM The Pauingassi Health programs are operated from two sites located opposite the road from each other. Some of the Pauingassi Health Program staff are located at the FNIHB Nursing Station while others are located in the former NDL building as there is insufficient space in the main nursing Station. The Band’s Health team provides a range of services and programs in health promotion, maternal child health, nutrition and mental health & addictions services. The Health team’s site is also one of the venues used to hold community gatherings and has a kitchen. The gym equipment for young adults is located in the same space. The FNIHB Nursing station includes rooms for nursing appointments, laboratory, dental services (1 chair), x-rays and several other offices. The nurse’s residence (made up of 5-6 fully independent units) is adjoined by an access ‘tunnel’ to the Nursing Station and houses the nurses and visiting medical staff when they are in the community. Pauingassi has a Block Flexible Agreement through FNIHB and manages all of its own programs excluding the Community Health Representative’s, Medical Clerk and Security Workers services which are under a Set Contribution Agreement. NDL building housing the Pauingassi health team

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FNIHB Nursing Station at Pauingassi

Health Staff The Pauingassi Health team is a department of the Nation’s administration and the Health Director reports to the Chief and Council through the Band Manager. Staffing includes:

SERVICE GROUP POSITIONS Management / . 1 Health Director (since January 2013) – who is also the Administration Brighter Futures Initiative (BFI) alternate worker when the usual BFI worker is absent

The following personnel are not based in the Pauingassi Health team offices. They are located separately in the community or at the Nursing Station.

. 2 full time Medical Transport Drivers plus 1 additional driver who works 16 hours per week . 3 Security workers for the FNIHB Nursing Station . 1 Medical Clerk . 3 maintenance workers . 1 Housekeeper / cleaner

The two Band Constables also support the health team but have broader roles in the community. Mental Wellness and Employed by Pauingassi Substance Use . 1 Building Healthy Communities (BHC) Worker . 1 NNADAP Worker (on bereavement leave) . 1 Brighter Future Initiatives (BFI) Worker (currently under suspension) . 1 CHR contributes to the work – and works within the FNIHB Nursing Station

Contracted by Health Canada  1 Clinical Therapist (2 days twice per month) Medical and Nursing . The Doctor / General Practitioner (Northern Medical Unit) visits as part of the University of Manitoba’s remote network and comes bi-weekly for 1 day from Wednesday

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SERVICE GROUP POSITIONS

afternoon to Thursday afternoon. The visiting doctor works closely with, and can make referrals to, the clinical therapist.

Employed by Health Canada . Nurse in Charge who works 2 weeks on / 2 weeks off rotation (since 2012) . One Clinic Registered Nurse . One dentist (twice a year) contracted Community Health Employed by Pauingassi . 1 Community Health Representative . 1 ADI / CPNP Worker Home Care First Nations Home and Community Care program – home care nurse and health care aid

There are currently no qualified clinical staff specifically employed by the Pauingassi Health team to deliver mental health services to the Pauingassi community. Due to the limited mental health resources within the community, the CHR appears to take on a broader role including advocacy / translation for clients speaking in their indigenous language. The NNADAP worker currently provides mental health awareness and education through promotional and prevention activities. This includes post treatment sessions and the 12 step program (including AA groups) however does not provide formal counselling services. In 2013, the Health Director established a voluntary resource committee that includes band leadership, RCMP, Ministry of Child Family Development (MCFD) and community members. The objective of establishing the resource committee was to provide an avenue for key partners to work together with ‘families’ offering frontline support in the event of a community or individual crisis. The committee members were seen as additional supports for the 2 FNIHB nurses, visiting doctors and Grand Rapids RCMP - to look after individuals in crisis until they could help with the crisis response. Given the voluntary nature of this committee, members are not always available to meet regularly to prioritize the implementation of this resource committee activities however early indications are positive. The first two workshop meetings saw the appointment and training of 4 local community members consisting of a Band Constable, BFI worker, BHC worker and MCFD worker in crisis response. Alternate members were also appointed, in the event of any absentees. The training focused on increasing the capability of the group through crisis intervention workshops and response training (provided by SERDC). The next stage will include working with the band leadership to in order to move to the next phase. While a positive approach - resourcing has delayed implementation. There is a visiting Clinical Therapist funded through Health Canada who comes to Pauingassi 2 days every 2 weeks and therefore community access to this service is limited. Clients can access services from the Clinical Therapist through self-referrals or referrals from the nurses and/or visiting doctor. According to the Health Director and the community group members, there is a view that this relationship works well and clients can easily access services. Three participants did however comment that community members do not utilize this service due to her female gender (no male counsellor for male community members); inability to speak the local indigenous language (while Aboriginal her dialect is different); and a perception from some that “there were sometimes ineffective discussions that did not address the client’s issues”. Therefore it was difficult to assess how effective the clinical therapist was and whether she had a full caseload when she visited the community. The SERDC representative also noted that there were no processes for the Clinical Therapist or clients to provide feedback on how client sessions were being managed to identify areas for improvement. Basically some felt it was a ’take it or leave it’ service. Selkirk Psychiatric Hospital is the closest hospital with a psychiatric unit located over 200kms away from Pauingassi and only accessible by flight from Pauingassi. Should an assessment identify that a client requires psychiatric services, the nurses and security guards organize transport. This is quite a lengthy exercise with

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transport being provided by boat to Little Grand Rapids and then Medivac is organized from Little Grand Rapids to Selkirk (or Thomson if there are no beds available in Selkirk). The Northern Patient Transportation Program (NPTP) manages the triage for all Medivac services. Little Grand Rapids

Access to Provincial Services: Interlake-Eastern Regional Health Authority (IERHA) IERHA is responsible for the delivery of health services in the Interlake and Eastern regions of Manitoba (pictured). The IERHA is the recent result of a merger in 2012 of the former Interlake and North Eastern Regional Health Authorities. There are over 124,000 people living in the region with Aboriginal populations comprising over 25 percent of the region’s residents of 17 First Nation communities including Pauingassi First Nation. IERHA region comprises of 10 hospitals, 16 Long Term Care sites, 6 Primary Care Centres, 18 EMS stations, 1 Quick Care Clinic and 6 dialysis sites. Although the closest hospital to Pauingassi is Pine Falls Hospital, all participants of the review commented that clients primarily utilize the services of Selkirk & District General Hospital. Selkirk is located approximately 30 minutes outside of Winnipeg and is an approximate 2 hour flight from Pauingassi. Selkirk provides mental health services, including 51 acute care beds, inpatient, outpatient, emergency and community services. Selkirk also operates the Government of Manitoba - Selkirk Mental Health Centre which comprises a 252 bed facility that provides specialized inpatient mental health treatment and rehabilitation services to residents of Manitoba whose needs cannot be met elsewhere in the provincial health care system. Within the provincial system there is a Crisis Stabilization Unit (CSU), Mobile Crisis Services and the Mental Health Program available for residents of the IERHA region. The CSU operates an 8-bed nurse managed facility in Selkirk for individuals 15 years and older, who are voluntary and in apparent psycho-social crisis. CSU provides assessment, short-term crisis intervention, treatment and linkage/referrals to needed supports. The CSU works with a high number of fly-in community members, as noted by the IERHA Clinical Team Manager. The Mobile Crisis Service is an outreach program for individuals of all ages who are experiencing a mental health/psychosocial crisis. The Mobile Crisis program operates an adult service from 2pm to 2am 7 days a week. The regional team consists of a Community Health Representative Worker, a Social Worker, Clinical therapists and intake staff who are available 7 days a week for Adult Mental Health Services. According to the IERHA Clinical Team Manager there is a high number of First Nation individuals accessing the Mobile Crisis Service. The Mobile Crisis program also operates a child and adolescent service from 1.30pm to 9.30pm Monday to Friday. This is a relatively new Youth Mental Health Services team consisting of 8 staff for the region however early indications of the service/program demonstrates a real need for youth mental health services with a current wait time for appointments of 3-8 days via way of triage. To add further context, there are currently no youth beds available in the region. The Adult Mental Health Program consists of a regional team of 20 staff who receive approximately 200 referrals per month with a further 8 staff who cater to the needs of Elders through personal home care. There is also a 24 hour 7 day a week crisis line available for all individuals to access mental health support when

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required. They can support persons in crisis and refer them to a range of appropriate aid resources in the region. It is not known how many Pauingassi community members may be using this service. The emergency department psychiatric unit takes most of the crisis clients and includes a physician or nurse assessment, diagnosis and referral to the mental health crisis services. Typically the referral would go to a psychiatric nurse. Depending on the assessment, if someone needed to be admitted they would be referred to one of the psychiatric units which are available 24/7. If the client is not admitted to a psychiatric unit from the Emergency Department they are discharged and a follow up process is implemented back to the nursing station in Pauingassi. As noted by the nurse in charge, there is a good follow up process whereby any clients flown by Medivac includes a check box which determines if the discharge notes have been received. Additionally, telehealth will also be used to further discuss the client’s assessment and discharge. The FNIHB Nurse-in-Charge at Pauingassi noted that they have never had problems working together with Selkirk Hospital and discussing cases if needed. The Pauingassi Health Director on the other hand however commented that they are not aware of or are not involved in any part of this process with Selkirk or any psychiatric service referrals. These occur directly between hospitals and the FNIHB nurses and visiting doctors. The Health Director noted that the relationship with the provincial system could be enhanced significantly. In 2013, the Regional Health Authorities in Manitoba established the ‘Partnerships Committee’ which involves representatives from all regional health authorities and community providers. According to the Health Director, the committee is very client focused and is a forum for collecting community input. Key discussions include 3 key questions - What is working ? - What improvements can be made ? - Whats not working ?

The Health Director forms part of the ‘fly-in’ subcomittee group and has participated in 2 meetings over the past year. These meetings were originally undertaken by conference call only as physical attendance at the meetings involved high travel costs from Pauingassi. The committee meetings have since been put on hold however SERDC are advocating for a budget to continue with particpation at such meetings due to the value it adds for community members. The Regional Manager First Nations and Metis Health, IERHA commented that she also sees value in this partnership committee and has been advocating for such collaborations and meetings to occur in order to ensure that the First Nation community voice is heard, represented and supported.

SERDC and community group members also believed that communication could be improved between the provincial system and the community. SERDC is supportive of a stronger link between NIHB, the enrolled clinicians and the provincial system. The community group noted that no provincial system staff visit the Pauingassi community with one participant recalling a visit 15-20 years ago whereby ‘Signs & Symptoms’ training was provided to Pauingassi. “Would be good if they (provincial system) visited so that they better understand our challenges and needs”.

Access to Indian Residential School: Resolution Health Support Program (IRS: RHSP) Pauingassi does not provide the IRS: RHSP as many survivors have passed on, according to the Health Director and those living with IRS-related trauma now are very minimal in number. The SERDC Health Program Advisor advised that four non-profit agencies hold the IRS: RHSP contract which is only available in urban Winnipeg - as there is a view that most IRS survivors are now deceased. It was also noted by the SERDC representative that most referrals for the IRS: RHSP primarily come through the Court system. SERDC are currently recruiting 2 positions to provide cultural support to community members, including cultural ceremonies, spiritual support and counselling. SERDC felt that a stronger emphasis was needed on promoting greater inclusiveness of Aboriginal culture and practices and that this was needed for community members, including IRS survivors.

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REVIEW OF THE SHORT-TERM CRISIS INTERVENTION MENTAL HEALTH COUNSELLING (STCIMHC) BENEFIT

Awareness and Use of the STCIMHC Benefit The review team interviewed the Health Director, Nurse-in-Charge (FNIHB Nursing Station), Community Health Representative and the SERDC Health Program Advisor. Two Pauingassi staff also attended the community focus group. All participants (excluding the SERDC Health Program Advisor) were not aware of the availability of this specific benefit or had any awareness of the Health Canada enrolled clinicians that were available. Upon observing the offices of the health team however, there was evidence of marketing material such as large posters which clearly describes and displays all of the Health Canada FNIHB programs, MCFD and other programs available. Included on this poster were mental health services available to the community including STCIMHC. It appeared that no-one had really taken notice of this information even though it was displayed in the public foyer. Health Center Poster

The SERDC Health Advisor has a long history of working in the region and was only made aware of the STCIMHC benefit 4 years ago. According to SERDC, the STCIMHC benefit is referred to as the Community Therapist Program. The respondent was also aware of the Health Canada enrolled clinicians list but identified that it was difficult to access this list. Furthermore, she was not aware the counselling sessions had increased from 12 to 15 sessions. She noted that FNIHB communication was limited when there were changes to NIHB policy. The community focus group was held and all eight participants were not aware of the STCIMHC benefit until our visit. One participant noted that they were aware of NIHB but not specifically STCIMHC. They asked for a description of the eligibility criteria and description of the benefit and this information was provided. Participants said that there is a real need in the community for such services with a very high usage of alcohol, drugs and suicide ideation in the community. One participant did note that the terminology of “Mental Health” is causing stigma and they would like to see a more resilient based name for Mental Health Counselling. Both participants from IERHA had good knowledge and awareness of the STCIMHC benefit. The Clinical Team Manager regularly receives the enrolment list from Health Canada and disseminates this to the Regional Manager First Nations and Metis Health who has often had to support community members with the

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navigation steps for accessing STCIMHC. This information is also distributed and communicated to the Crisis Stabilization Unit. The Regional Manager First Nations and Metis Health also has sound awareness of the benefit through her previous discharge/planning role. This former role provided a good platform for more effective promotion of the STCIMHC benefit through the communities across the IERHA region.

Client Access to Mental Health Crisis Support Although it appears clients are receiving the STCIMHC benefit through the visiting Clinical therapist, Health staff and community members were not aware this was the case and therefore they were asked for information on how short term mental health crisis intervention was currently provided and whether the process worked well. Clients access mental health services through various means including self referrals or referrals from the Doctor or nurses and from community members. Typically clients are referred to the Health Canada clinical therapist who visits the community twice a month for 2 days. Members of the community group commented that clients tend to avoid utilizing this service due to a range of factors including: the inability to speak the local Ojibway language; being of an opposite gender and a perceived lack of engagement. One participant noted that the clinical therapist is provided with supervision however no feedback is provided to the community or SERDC as an opportunity to enhance service provision. SERDC also noted that the clinical therapist does not provide home visits which could also be a barrier for community members accessing mental health services due to the sensitivity, privacy and nature of the circumstance. Through SERDC, the NNADAP program also funds a Pauingassi mental health support staff member, who can provide prevention and intervention education and promotion programs. A few community group participants commented that SERDC do not provide enough services to the Health Director while additional services would only benefit such a remote community. “SERDC only visits every 3 to 4 months and they should visit the community more to understand the local system and needs”. As noted by the community group, it is believed that more education and increased capability is required for the community due to the limited resources available and remoteness of the community. The types of training and education could include tools for supporting community crisis situations and a better understanding of what to do and what not to do. The signs and symptoms training provided by the provincial system 15-20 years ago was also seen as being beneficial. While there is a range of crisis intervention and mental health support services available through the provincial health system, clients face transportation barriers when accessing these services. SERDC acknowledges that there is a good relationship with the provincial system and believes that clinicians will clear their schedules to visit communities who may be in crisis however travel costs are the usually the responsibility of SERDC. Therefore this resource is not available on a day-to-day or frequent basis. Therefore community members have no choice but to utilize the services available on-reserve such as the visiting clinical therapist and Doctor unless transportation to the city is made available. In cases of crisis, the immediate availability of resources is very restricted due to the remoteness of the community, lack of RCMP presence, constraints of having only 2 nurses who cannot leave the nursing station individually leaving the other nurse alone to respond to emergencies; intermittent visits of the Clinical Therapist and lack of locally trained mental health and addiction counsellors or social workers living in the community. The nurses are typically the first point of contact or the Band Constables if the individual is suicidal and a threat to the community. If applicable, the nurse will liaise with the doctor by phone to seek advice on an immediate response or if it can wait they discuss situations with the Doctor and/or Clinical therapist when they are in the community. Between the clinical staff, Band Constable and security officers they are usually able to stabilize someone in crisis - however the Doctor will seek (make a referral) for available specialist resource or psychiatric services outside of the community should the need arise. Two participants noted that over the past year the Pauingassi community have been faced with numerous issues causing crisis situations such as suicides and alcohol abuse and while this should be recognised as an issue for the community, it has now become normalised within Pauingassi and members have become more resilient in managing these situations. As noted earlier however, there appears to be a reduction in community members presenting themselves with mental health issues over the past 3 years. The Nurse-in-Charge noted that RCMP do not tend to be involved as they are not located on reserve.

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If it is determined that the situation is serious and that the person needs to be transferred to the psychiatric unit for evaluation, the nurse will organize boat transportation with Medevac, the Medical Transportation driver and security officers to the Little Grand Rapids community (located 30 minutes away). In a crisis, the accompanying staff’s security is a primary goal as well as the safety of the community member and in some cases 2 security officers are sent if the community member is unstable or in a violent state. The boat trip from Pauingassi to Little Grand Rapids can involve lifting the boat in and out of the water numerous times if the rapids of the river are difficult to navigate and therefore relevant resources are required for this to occur. Upon arrival at Little Grand Rapids, Medivac will then fly the person to the closest available psychiatric unit. The arrival of the Medivac Transport usually coincides with the arrival of the boat transfer. RCMP at Little Grand Rapids can assume responsibility and take the next steps if required. Based on the known cases, Medevac has typically transported clients to Selkirk & General Hospital. The Health Director, Nurse-in-Charge and SERDC Health Program Advisor all noted that due to the logistical delays required in transporting a client from Pauingassi to the closest hospital, the crisis has usually deteriorated or been managed through those supporting the individual through the lengthy journey. The hospital either determines that the person is no longer in crisis and sends them home or alternatively may elect to admit the person to the psychiatric units that are available. If the client is discharged, there is a good relationship with the provincial system where discharge notes are provided back to the Nurse-in-Charge at Pauingassi to ensure continuity of care. The Pauingassi Nursing Station also has a secondary measure through the Medevac process that discharge notes are received and a follow up telehealth discussion can also be arranged. While this is an effective process, the Health Director is usually not privy to any of this information and is typically unaware of what happened to the community member and what additional services may be required.

Perspectives on the STCIMHC Benefit

STCIMHC Enrolled Counsellors The current visiting clinical therapist is paid directly by Health Canada for her fortnightly visits. Since the clinical therapist claims directly, most participants of the review were not aware of the paperwork or claiming process. There was a concern raised from SERDC, Community Members and Health staff that Health Canada had control of the process for approving clinicians/counsellors for enrolment when they did not have the knowledge of who could work effectively with the Pauingassi community. As an example, Pauingassi’s first language is Ojibway and therefore this results in immediate challenges for the current clinical therapist who only speaks English. At present, the community health representative is one of the staff who supports as an interpreter however this is not her primary role. Stakeholders were made aware of the STCIMHC benefit and Health Canada enrolled counsellor list. While they agreed that many people could use this service, they did not think this would be viable with the closest counsellor being located 280kms away from Pauingassi. There are no transportation costs associated with them accessing the visiting clinical therapist. SERDC also commented that the number of counselling sessions (up to 15) and the length of time (20 weeks) for the counselling to take place was inadequate, particularly for fly-in communities. The fact that the SCTIMHC program was not available for remote fly-in communities without associated travel costs meant that clients are not likely to access this service at all. The community group also noted that men in the community are not comfortable with speaking to women counsellors. One participant would also like to see more cultural awareness training for the enrolled counsellors with a recommendation that this is a Health Canada compulsory criteria to get enrolled.

Critical Incident Stress Management (CISM)31 One participant made reference to CISM which is a formal highly structured and professionally recognized psychological process that can include pre-incident preparedness to acute crisis management to post-crisis follow-up. CISM is well recognized amongst clinical therapists and is seen as an effective approach. However as noted by one participant there appears to be a difference of opinion in terms of the debriefing intervention

31 https://en.wikipedia.org/wiki/Critical_incident_stress_management 149

process. A debriefing process is normally undertaken within 72 hours of a traumatic incident and gives an individual or group the opportunity to talk about the process. It is believed that some clinical therapists in the region are being discouraged to visit communities after a crisis has occurred as it may re-traumatise individuals. However others promote community debriefing identifying it being a positive emotional process for the community. There does not appear to be a consistent approach to this among the local communities.

Suggested Improvements to the STCIMHC Benefit / Short Term Crisis Mental Health Counselling

Remote Travel Challenges Being a fly-in remote and isolated community with no permanent road access is a barrier. If someone has to leave the community - in terms of not only mental health but all health needs – it is approximately a 2 hour journey (240km) from the closest city, usually by float plane. The cost and distance of travelling to Selkirk is also a barrier and immediate service provision is not practical. For crisis situations, this is an arduous process, not only for Pauingassi staff but also for the individual. There are many parties involved, such as nursing staff, security staff, transportation driver, Band Constables and Medivac for a crisis situation to be managed. With no RCMP based on-reserve, this also results in additional challenges for the safety of staff and the individual. It should be considered that funding for mental health crisis intervention should be provided direct to fly-in communities through contribution agreements, enabling the community to decide how best to structure crisis intervention, and who they want to provide the service. This would reflect whether the specific community had other support mechanisms in place such as RCMP, Social Workers, Victim Support, community crisis teams, regular Doctor visits, security and safety personnel. This was considered a better use of resources instead of the many resources required to transport an individual from Pauingassi to the city.

Crisis Response Team The Health Director has been in the process of trying to form a crisis response team (resource committee) for community members over the past 2 years however this has lacked traction due to the time involved and voluntary nature of participating members. A crisis response team is a logical plan for such a remote community, particularly in the absence of on-reserve RCMP and other support resources. The community felt they would be better supported with the development of a crisis response plan with protocols which would provide guidance for a Crisis Response Team in a crisis situation. Investment would need to be made in training, information and resources to support the crisis response team however this would enable them to take ownership in crisis events. Sending people to Selkirk is not considered the ideal solution and it would be more conducive to devote funding to those who are already required to provide the current crisis support.

Lack of Ojibway-speaking and male counsellor With most people in the community speaking Ojibway as a first language (English 2nd) there is a desire for a counsellor who can speak the language and provide a more appropriate service for community members. While the community recognizes the challenge to achieve this they do believe this would make the current service much more accessible. An interpreter solution is not always acceptable to community members due to privacy concerns. It was also stated that for men in crises they would be more comfortable discussing their issues with a male clinical therapist and this presents a challenge for them with the current female clinical therapist. Alternatively the 2 visits per month could be split between a male and female counsellor to address this barrier. The Nurse-in-Charge, SERDC and community group members noted that having additional days would be helpful and could be incorporated as part of the male counsellor days. They could be supervised and accountable for the enhanced capacity with sound case management indicators.

Improve alignment with Continuum of care and Collaborative Service Planning The review identified that there is a strong desire for Pauingassi, SERDC and provincial services to work together better. Two participants commented that when collaborative meetings occur, the discussions are valuable with one noting that they just need someone who knows where the resources are and to understand what’s available for First Nation people. “Our people need this as there is very little awareness”. It is believed

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that planning, implementing and participating in a formalised structure with ongoing meetings would improve the effectiveness of health care processes and systems for First Nation communities and specifically be more responsive to the needs of Pauingassi. The committee / partnership meetings that have been arranged are positive however the Health Director finds it difficult to attend these due to her remote location and participation has only been possible by way of conference call. This in itself has been challenging in that her voice is heard but also due to technical difficulties. While there is a willingness to participate, there is lack of resourcing for remote community members to attend in person due to the high logistical costs. A number of participants supported the idea of having more preventative education available for staff and community members. While tele-health was proposed as a solution to this, there are technology challenges with such a remote community. While one community member also supported the idea, they also noted that Pauingassi also has a responsibility to encourage members to attend and participate in pre-organized education sessions. Education workshops and resourcing is a viable solution that would not only increase the capability of the community but also build the relationships across the various sectors.

Improved awareness and description of STCIMHC A number of participants interviewed were concerned by the limited awareness, information and criteria of STCIMHC. Health staff and community members were made aware of STCIMHC only upon receiving this information at the time of the review. One participant specifically noting that more communication should be disseminated by NIHB directly out to First Nation communities or at a minimum to Mental Health staff. It was also identified that the description of the STCIMHC can be confusing with a ‘crisis’ often requiring immediate support and ‘mental health counselling’ being provided over time. “Crisis means something different to everybody” and one participant believes there is a gap between individual and community counselling and this needs to be reviewed as an additional component to STCIMHC. It is believed that while an individual may be in crisis, their situation will more often than not involve the extended family and in some cases the entire community. Another participant noted that there is a perception that crisis is defined as a community trauma while the provincial system defines a crisis as an individual case. It is recommended that policies are developed for the benefit that clarifies the criteria, description and definition of the STCIMHC benefit and then this communicated and regularly updated to communities.

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YUKON TERRITORY: VUNTUT GWITCHIN FIRST NATION

JOINT REVIEW OF NON-INSURED HEALTH BENEFITS

SHORT-TERM CRISIS INTERVENTION MENTAL HEALTH COUNSELLING (STCIMHC) BENEFIT Operational Benefit Review

NORTHERN REGION – Yukon

SITE: VUNTUT GWITCHIN FIRST NATION, Old Crow, Yukon

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BACKGROUND CONTEXT

Transfer North of the 60th Parallel32 A 1954 Cabinet decision gave First Nations and Inuit Health Branch (FNIHB) responsibility for the delivery of health services to all residents of the Yukon and Northwest Territories. The Cabinet decision stated that once territorial governments showed a desire, and had developed the necessary expertise, responsibility for health care delivery would be transferred to them. Generally, the approach was to transfer responsibility in stages, starting with the transfer of hospitals. Tripartite negotiations were initiated in the early 1990s between FNIHB, the Council of Yukon Indians and the Yukon Territorial Government on the transfer of universal health services in the Yukon Territory. Discussions focused on the transfer of the Whitehorse General Hospital (Phase I) and the delivery of health services in the communities (Phase II). A Framework Agreement to guide the discussions was agreed on by officials representing Canada, Yukon and the Council of Yukon Indians. Phase I, the transfer of the Whitehorse General Hospital to the Government of the Yukon and the Yukon Hospital Corporation, was completed effective April 1, 1993. Phase II, the transfer of universal health services and facilities was completed on April 1, 1997. First Nation Communities in Yukon

32 Extract from http://www.hc-sc.gc.ca/fniah-spnia/pubs/finance/_agree-accord/10_years_ans_trans/index-eng.php 153

Government of Yukon33

The Yukon Territorial Government operates several Departments much like the Provinces south of 60th parallel such as (list not exhaustive):  Community Services  Economic Development  Education  Energy, Mines and Resources  Environment  Health and Social Services  Highways and Public Works  Justice  Tourism and Culture  Yukon Energy Corporation  Yukon Housing Corporation

The Yukon Health and Social Services Department is primarily responsible for the delivery of high quality, patient-centered care to residents of the Yukon. The Department invests across a wide spectrum of programs and services aligned with the Department’s mandate to provide high quality health and social services that support their vision, mission, values and strategic goals and objectives outlined in their 2014-2019 Strategic Plan.

Yukon Health and Social Services The Yukon Department of Health & Social Services (YHSS) is responsible for providing a continuum of services to all Yukoners to ensure they are cared for, protected and supported in achieving optimal mental and physical wellbeing. The Mental Health Services division is a community mental health clinic that offers assessment, individual and group therapy, supportive counselling and referral services for a wide range of emotional and behavioural problems and mental illnesses. Mental health professionals work to provide assistance in managing depression, anxiety, schizophrenia and bipolar disorders.

Yukon Hospital Corporation34

The Whitehorse General Hospital was originally owned and managed by the federal government’s National Health and Welfare, Medical Services Branch in Ottawa. In 1990 the Hospital Act was passed and the Yukon Hospital Corporation was established with the transferring of Health Services between the Yukon Territorial Government and the federal government. The Yukon Hospital Corporation, Government of Yukon and the Council of Yukon First Nations entered into an agreement to create a First Nations Health Committee of the Board of trustees to ensure health programs offered will support self- government agreements of Yukon’s First Nations. In 1993, the operation of Whitehorse General Hospital was officially transferred to the Yukon Hospital Corporation with the addition of Watson Lake Community Hospital and Dawson City Community Hospital in 2013. Whitehorse General Hospital is the Yukon’s primary health care centre, providing a full range of care including 24/7 emergency care (providing services 24 hours a day year round to approximately 32,000 visits each year), inpatient and ambulatory care, surgical services, cancer care, visiting specialists clinics, therapy, laboratory services and advanced diagnostic imaging. Dawson City Community Hospital and Watson Lake Community Hospital provide access to 24/7 emergency care, inpatient and ambulatory care. Whitehorse General Hospital Whitehorse General Hospital (WHG) is the closest hospital to Old Crow. WHG is a newly constructed 49 bed, fully accredited acute care hospital. It serves as a tertiary care facility for the entire Yukon Territory as well as northern areas of British Columbia and parts of Alaska. The Emergency Department and Outpatient Unit provides response twenty-four hours a day,

33 Adapted from information acquired from www.gov.yk.ca 34 www.yukonhospitals.ca 154

7 days a week. The hospital also has a fairly new ‘secure medical unit’ supported by a mental health team. There is the Na’Ku Healing room for family members to gather, pray or practice traditional ceremonies and also two suites with beds that are available to First Nations families for overnight stays. The multidisciplinary patient care and support teams of our hospital collaborate with 31 general practitioners, a general surgeon, an obstetrician/gynaecologist and a paediatrician to provide care, as well as various community based health related organizations, such as Home Care, Mental Health, Public Health. WHG serves as a regional referral centre for the Yukon and serves the rural nursing stations through an efficient system of ground and air ambulance as a well as consultation by various means of communication including telemedicine. WHG also provides special traditional menus, information and awareness of traditional medicines and cultural education opportunities. The First Nations Health program offers health and social liaison services primarily within the hospital, with a child life worker, traditional diet program, traditional medicine coordinator and interpretation services for patients. They also work with NIHB to support First Nation, Metis or Inuit community members including arranging transportation back home. There are 7 liaison workers at WHG as well as one at Watson Lake Community Hospital with special training in First Nations health and social work. There is a First Nations Mental Health advocate who is available to support with mental health assessments at the Emergency department or upon admission, cultural or emotional support, assistance with an inter-disciplinary team of professionals such as the psychiatrist and nurses, hospital care and discharge planning including assisting with referrals to other programs and facilities.

COUNCIL OF YUKON FIRST NATIONS The Council of Yukon First Nations (CYFN) was originally formed as the ‘Council for Yukon Indians’ in 1973 specifically to negotiate land claims. CYFN is a non-profit society working for ten of the First Nations of the Yukon, including Vuntut Gwitchin First Nation. The Health & Social Development Department of CYFN coordinates, liaises, advocates, disseminates information and facilitates the delivery of Health and Social Services on behalf of the nine First Nation communities. The establishment and facilitation of the Health & Social Development Commission is also managed by the Health & Social Services department which involves members of CYFN and all 14 Yukon First Nation Health Directors including the Vuntut Gwitchin Health Director. This group meets approximately five times a year of which their current top priority of discussion is NIHB. The CYFN Health & Social Services team employs a NIHB Navigator, instigated by Health Canada but funded by CYFN to help clients navigate NIHB challenges such as denials and appeals. This role also involves maintaining a strong relationship with NIHB and the physicians. As part of a Mental Wellness sub-committee, CYFN are looking at contribution agreements for STCIMHC however are in the early stages of planning.

COMMUNITY DESCRIPTION In the Yukon, Nunavut and the Northwest Territories, where a few reserves have been established, the bands have been gathered into communities known as settlements, which are generally on Crown land, but these bands and settlements do not have reserve status. The majority of First Nations in Old Crow reside on Crown land (see AANDC data below). Old Crow is an isolated community and home to the self-governing Vuntunt Gwitchin First Nation (People of the Lakes). Old Crow is the most northerly community in the Yukon Territory situated on the banks of the Porcupine River near Vuntut National Park. Old Crow is the only fly-in community in the Yukon and only accessible by plane (or canoe) – there is no road access however temporary winter roads are constructed. Old Crow is located 120kms north of the Arctic Circle (being the only community located within the Arctic Circle) and 100kms east of the Alaskan border. Whitehorse is the nearest main center for access to health services beyond what is provided in the community, approximately 3 hours duration by medivac.

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According to the AANDC35 June 2015 data, the total Vuntut Gwitchin First Nation registered population is 543.

The Vuntut Gwitchin First Nation signed self-government agreements in 1995 and Chief and Council are elected to govern the community. Departments within the government include Chief and Council, Human Resources, Finance, Health Social & Recreation, Government Services, Information Systems, Natural Resources and Education. Some of the services in the community include: The Sarah Abel Chitze Building which houses the Vuntut Gwitchin Government Departments (Health and Social Programs; Housing and Government Services; Finance and Human Resources; Education; Natural Resources; Information Systems; Executive, Chief and Council Offices), RCMP detachment with three officers, Nursing Station, John Tizya Heritage Centre (displaying the culture of Vuntut Gwitchin, the Porcupine Caribou herd, the landscape and oral history of Old Crow), Youth Centre offering training and work programs, Alice Frost Community Campus (satellite campus of Yukon College), Community Centre, Chief Zzeh Gittlit School with grades Kindergarten to Grade 12 (after Grade 9 students have the option to attend High School in Whitehorse), Post office, TD bank, gas services, recently opened Retail Coop, community garden, Old Crow Ski Chalet, Old Crow airport, bed & breakfast accommodations, skating arena and Anglican church. The walking time to work from the farthest houses is approximately 20 minutes. The first language of the Vuntut Gwitchin is “Gwich’in” which is still spoken among community members and taught in the local school. Elders spend a lot of time teaching pupils the ways of the past. Gwitchin culture is an essential part of school life and pupils become aware of their status as Gwitchin people. The people of Vuntut Gwitchin First Nation live a traditional life, relying heavily on the Porcupine Caribou Herd as the primary food source. Because they are so close to the land and depend on country foods such as caribou, moose, salmon and whitefish, the village has a very traditional flavour. The colonization process and the introduction of the Church have had a significant influence on Gwitchin culture. There are minimal traditional cultural activities undertaken such as smudging, sweat lodges, drumming, pow wows or ceremonies, however cultural practices such as hunting, the making of traditional clothing, beading, crafts and music are still alive and

35 Aboriginal Affairs and Northern Development Canada 156

well. One participant noted that most spiritual healing practices are undertaken by people from outside the community as there are very few people within the community who are able to pass the knowledge on. Given the remote wilderness location, its future as a wetland of international significance is secure. The climate in Old Crow reflects its location north of the Arctic Circle with temperatures ranging from an average of minus 36 degrees to plus 21 degrees. Old Crow enjoys long summer days and experiences the short days of winter, therefore the growing season is short because of the long daylight. Old Crow faces unique logistical challenges in obtaining goods and services with significantly higher costs. Old Crow is known as a close knit community with a fairly high number of young families who are closely related. Although Old Crow is a ‘dry’ community with alcohol prohibited in the community, participants commented that there are still challenges with alcohol related issues. One participant commented that there are a number of resilient individuals with a high level of trauma in their lives. Participants also commented that while there has been a recent suicide in the community, there have been fewer attempts over the past year. Vuntut Gwitchin First Nation Organization Chart

36 Health Director advised Health & Fitness Program now part of Education Department 157

SARAH ABEL CHITZE BUILDING – Location of Vuntut Gwitchin First Nation Health and Social Programs The Sarah Abel Chitze Building and the Nursing Station are located at different sites with the Nursing Station housing most of the medical staff. Health Staff Staffing includes:

SERVICE GROUP POSITIONS Yukon Territorial Yukon government’s Mental Health Worker, Alcohol & Drug Services, Social Government Staff Services, Probation Officer, Legal Aid, Victim Services, and Family Violence Program Counsellor visit Old Crow on a monthly basis to provide services to community members and to assist the Health & Social Department. Vuntut Gwitchin . 1 Health & Social Programs Director Management / . 1 Administrative Assistant Administration Mental Wellness and Employed by Vuntut Gwitchin (part funded through transfer agreements Substance Use and Health Canada) . 1 Manager Mental Health & Support Services (licenced Alcohol and Drug counsellor)

Employed by Vuntut Gwitchin (part funded by Vuntut Gwitchin and Yukon Territorial Government) . 1 Family Support Worker who provides socials services liaison services, home checks, family group conferencing, peer counselling and education support. Works closely with the Mental Health Manager when working with families. . 1 Native Court Worker who works closely with the Mental Health Manager

Employed by Department of Health & Social Services, Yukon Territorial Government  1 Community Mental Health nurse visits monthly for 2-3 days

Vuntut Gwitchin receives NNADAP and Building Healthy Communities funding which are primarily utilized for treatment travel and educational programs and support. There is also National Youth Suicide Prevention funding available for raising suicide prevention awareness activities. Medical and Nursing . 2 doctors/physicians on a 2 month rotational roster who visit Old Crow from Whitehorse 4 days a month . 1 Nurse-in-Charge and 1 nurse practitioner available 8am to 4.30pm Monday to Friday and on call 24 hours a day . Clerk for reception and house keeper . Dentist visits 4 times a year (a challenge was noted with people forgetting about their dental appointments) Community Health . 1 Home and Community Care Coordinator . 1 Foot care worker who visits 4 times a year (funded by Vuntut Gwitchin but located and administered at the Nursing Station) 158

SERVICE GROUP POSITIONS

Aboriginal diabetes and Nutrition North funding is also available which is utilized for educational programs such as the community garden activities, health eating workshops and cooking classes. This is due to the positive fact that there are no known community members who have HIV, AIDS or Hepatitis.

Prenatal nutrition and Maternal & Child Health funding (for Mums and children under 3 years) is available for education workshops and training such as FASD. However, according to the Health Director and Mental Health Manager there is limited programs available for single men in the community.

The Manager Mental Health & Support Services is a licenced Alcohol and Drug counsellor who has recently started in her role in the Old Crow community. She provides mental health counselling in areas that she is qualified. The previous role at Old Crow was originally held by a Social Worker and therefore this enhanced capacity and skillset is displaying positive signs in the initial stages of service provision. There is a visiting Community Mental Health nurse funded through the Department of Health and Social Services Yukon Government who comes to Vuntut Gwitchin, Old Crow for approximately 2-3 days every month and therefore community access to this service is limited. Clients can access services through self-referrals or referrals from the nurses and/or visiting doctors. The Community Mental Health nurse provides treatment and mental health counselling during her visits. The nursing station has a Nurse-in-Charge who has worked in the Yukon, Alaska and Northwest Territories communities for over 15 years who was originally a trained psychiatric nurse and has experience providing various nursing services. Sarah Abel Chitze Building – Location of Vuntut Gwitchin First Nation Health and Social Programs

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REVIEW OF THE SHORT-TERM CRISIS INTERVENTION MENTAL HEALTH COUNSELLING (STCIMHC) BENEFIT

Awareness and Use of the STCIMHC Benefit All 14 Yukon Health Directors, including the Vuntut Gwitchin Health Director meet every two months along with the Council of Yukon First Nations at the Yukon First Nation Health and Social Development Commission meetings. As noted by the Health Director, she was not aware of the STCIMHC benefit until she learned of this at a NIHB Health Canada presentation held at the February 2015 commission meeting. Otherwise, prior to this she had no awareness that the STCIMHC benefit was available. The review team also interviewed the Nurse-in-Charge and the Mental Health Manager in the community. While all were aware of the NIHB Program, none of those interviewed had heard of the STCIMHC benefit. “It’s not a program widely known….if I didn’t know about it, how would the community?” All community group participants were not aware of the availability of this benefit or had awareness of the Health Canada enrolled counsellors that were available. One member noted that more relevant information needs to be communicated to people to explain the benefit, of which possible ideas included more information provided to the Health and Social workers; posters; or information sessions to explain how the STCIMHC benefit works and how it is relevant to each individual. The Director First Nations Health Program Yukon Hospitals has a general awareness of NIHB programs and the Health Canada enrolled counsellors list is displayed within her division at WHB. The CYFN Health and Social Services Director was aware of the STCIMHC benefit however mentioned that it is not well utilized in the Yukon primarily due to the restrictions and criteria of the benefit and transportation barriers.

Client Access to Mental Health Crisis Support After being made aware of the STCIMHC benefit at the Yukon First Nations and Social Development Commission meeting, the Health Director attempted to access the benefit for one individual. She was aware of the Health Canada enrolled clinicians list but determined that the closest counsellor was located in Whitehorse. She found the process very difficult primarily due to the extra work required to confirm the sessions and the transportation costs associated with the individual attending the mental health counselling sessions in Whitehorse (3 hour flight away). It was noted however that the Health Canada contact who administered the funding was very prompt with the communication. Health Canada did not approve the transportation costs, however due to the immediate need of the individual, Vuntut Gwitchin agreed to pay for this and STCIMHC covered the cost of the counselling sessions. It was felt that there was no other option but to pay the transportation cost for the benefit of the individual. “We shouldn’t penalise someone because they live in a remote community, there should be equal access for all people”. Two participants commented that there are lots of hoops to jump through to access NIHB services and that it is not designed for remote communities. One participant commented that it is so much easier to access normal federal system services if you’re not Aboriginal. It is thought that there are lots of levels of bureaucracy and resources to navigate the NIHB fund. “It should be much more straight forward”. Since there was only one individual STCIMHC claim made through the Heath Director, other participants were asked for information on how short term mental health crisis intervention was currently provided and whether the process worked well. In speaking with participants, some discussed the high need for counselling citing cases of suicide; intoxication problems but particularly alcohol-related (legal and home brew / bootleg) issues that often lead to crises. Participants noted that a stronger emphasis was required in using harm reduction approaches rather than sending an individual to external services that tended to provide abstinence models of practice. “We know they will drink, but how can we reduce the potential harm that is caused by drinking”. One participant commented that mental health counselling is not just about an individual and that holistic family counselling should be involved as part of the healing process of the individual in crisis. Two community group members noted that being located in a small town can be a barrier accessing mental health services due to the sensitivity, privacy and nature of the circumstance. Additionally four community group members felt that there were geographic challenges in the Arctic and therefore the lack of access and resources for people to talk with.

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Clients access mental health services through various means including self or family referrals, health and social services team referrals or through the doctor or nurses at the nursing station. Telehealth connection appointments can also be made for Mental Health Counselling (and dietitian) workers at the health centre or nursing Station however it is currently used more for family communication rather than specialist services according to the Nurse-in-Charge. When accessing mental health crisis support, the process often depends on who received the call first related to the crisis or mental health issue – whether someone is in danger of harming themselves or others, whether there is a domestic situation; whether there is potential for harm of workers who intervene; whether there is violence involved in the situation or whether there is a potential suicide that has been flagged. If the assessment determines that someone is ‘not’ deemed in crisis, the individual will be referred to the psychiatric nurse if they are in the community or to the Vuntut Gwitchin Mental Health Manager. Between the RCMP, Mental Health Manager, doctor and nurses they are usually able to stabilize someone in crisis and make a referral to the doctor or psychiatric nurse when they visit. The psychiatric nurse and Mental Health Manager will also arrange to see community members in their own home environment or wherever is most suitable for the individual if it is requested. This process works well as an alternative option to receiving services at the Nursing Station or Health and Social Services building. In rare or extreme cases of crisis, people would usually let the nursing station know (both nurse practitioners are on call 24 hours a day) and the Nurse-in-Charge would contact RCMP who have 2 officers based in the community. Sometimes RCMP may be called in ahead of time and they would often ensure the environment is safe before nursing staff or the Mental Health Manager are involved. If the individual is unable to be stabilized, transportation is organized to Whitehorse General Hospital Secure Medical Unit (psychiatric unit). Old Crow has a home and community care transportation van which is available on call 24 hours 7 days a week to transport individuals from the community to Old Crow airport. Emergency services are provided by Air Ambulance / Medevac or escorted on scheduled Air North commercial airline flights from Old Crow to Whitehorse - approximately 3 hours flight duration. The Health Director commented that Medevac paramedics come to Old Crow immediately and will also send a Doctor if the situation requires this. Whitehorse General Hospital liaison workers (2 liaison workers are allocated to the Old Crow community) are contacted by the Health Director to support the individual upon arrival at Whitehorse General Hospital. The liaison workers can assist with coordination, planning, social work and discharge planning. It is noted however that this support is only organized if the Health Director has been notified of the situation. Feedback from the Health Director was that care and treatment at Whitehorse General Hospital was good overall and there is a good relationship with the liaison workers as well as the social worker and victims services. Upon discharge, the liaison workers will provide discharge notes and details to the Health Director via medical staff and an after care plan is completed. It is unclear if there is a reciprocal process when nurses refer clients to the hospital. The liaison workers will also provide solutions or referrals to other services within YHSS or community supports as part of the discharge process Old Crow Health Centre / Nursing Station

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Perspectives on the STCIMHC Benefit

STCIMHC Enrolled Counsellors

Community member participants were made aware that to access the STCIMHC benefit, the counsellor being used had to be enrolled with health Canada and on their list. While there was a concern from participants that these counsellors were seen as strangers to the community and trusting such a person would be difficult, the ultimate decision depends on the individual concerned. Sometimes the ability to achieve this has been hampered by recruitment challenges as noted by one participant who acknowledged that it would be difficult to employ and fund a full time local psychologist or counsellor that people can rely on and build trust in within the community as an alternative. On the other hand, one community member noted that it would be beneficial for the counsellors to spend a week in the community and work with the First Nation enabling them to build relationships with local resources. The Health Director noted that the clinicians list needs to be more accessible. After researching for it on google, there is no available Yukon list, no demographic data, no qualification details and no information on the counsellor’s specialty services. She also commented that unless you know who to call, then access to this information is inadequate and ineffective. Another interviewee was concerned also that counsellors who are enrolled by Health Canada and this raises a concern when they may not be the right fit for some communities in the Yukon. A general comment was also made that NIHB programs are just not feasible for remote communities such as Old Crow due to the timeliness and administration of accessing the NIHB programs in a timely fashion. Two participants commented that that the number of counselling sessions (up to 15) was inadequate for those individuals experiencing life-long issues. An assumption could be made that there will be a high level of mistrust and potential communication barriers which would require a number of the early sessions being utilized to break down these barriers. Another interviewee believed that the counselling sessions should not have a cap as opening up to people does take time. One participant noted that if a person is in crisis then they are probably not going to call a stranger such as the Health Canada enrolled counsellors. It would make more sense to fund someone to facilitate the process and make it more simplified for the community member. Two participants noted that it would be a good process for the enrolled counsellors to advise the community Health Director (for example) that the 15 counselling sessions have been completed with the individual. There is no need to provide any other private or confidential information about the individual sessions, but implement an additional communication step to the local community as an opportunity for the Health Director to offer after care services once the individual returns to the community. One participant also noted that there are so many more forms to access the NIHB program. There was a concern that crisis intervention is limited in its focus on managing the immediate symptoms of a mental health crisis, but does not adequately deal with the root causes of the individual’s trauma. Clients reaching out for support in a crisis situation provided a unique opportunity to engage clients in the healing process, however support services must be provided in an integrated and sustainable way. Three other participants commented that consideration should be given to traditional based counselling where traditional values and pursuits are considered as part of the counselling services or that the counsellors undergo cultural awareness training. There was a concern by one respondent that the culture and language was taken away from IRS families and therefore programs should be designed to be culturally sensitive through the help of elders and teachers in the community.

Access to Indian Residential School: Health Support Program (IRS: HSP)

The Health Director advised that IRS and Mental Health support was provided through Health Canada funding and was unsure who was providing the service in the region or how to access it. The Mental Health Manager was aware that there are a few community members who suffer from post-traumatic stress disorder who originated from IRS that she supports in her role, but this is not an area that she is qualified to manage. In any case she lends to support to these clients as there is no alternative service accessible within the Old Crow community. 162

The CYFN Health & Social Services Director was aware that there are a number of clients who have issues due to IRS. She also mentioned that Health Canada had claimed that the low utilization of the STCIMHC benefit across the Yukon was as a result of people accessing the IRS: RHSP – a claim that she refuted. The eligibility criteria of the respective programs meant that a much higher proportion of people can access STCIMHC as opposed to the IRS: HSP, where eligibility is much more limited to fewer people within the population. Therefore claims around the correlation between the two programs could be misleading if not fully explained and clarified.

Potential Areas or Opportunities for Improvement

Remote Travel Challenges and associated costs

Being a fly-in remote and isolated community with no permanent road access is a barrier. If someone has to leave the community - in terms of not only mental health but all health needs – it is approximately a 3 hour flight to Whitehorse. The cost and distance of travelling to Whitehorse is also a barrier and immediate service provision is not practical. It should be considered that funding for mental health crisis intervention should be provided direct to fly-in communities through contribution agreements, enabling the community to decide how best to structure crisis intervention, and who the community may trust or want to provide the service. This would also provide a solution to the perspective that 15 counselling sessions are not sufficient for long term trauma.

Awareness of the STCIMHC benefit

Participants interviewed were concerned by the limited awareness, information and criteria of STCIMHC. The Health Director, who only recently learnt of the STCIMHC benefit attempted to research information on the benefit and enrolled clinician information however was unable to access much information at all. Other participants, including all of the community group members were made of STCIMHC only upon receiving the information at the time of the review. One community member noted that STCIMHC information needs to be provided prior to a crisis occurring so that clients are already armed with the relevant information and whether they would use it. “This is better than informing someone about the program after the crisis has occurred”.

Incorporate Administration funding to improve access

The Health Director identified that clients would not access the STCIMHC benefit if they were in crisis and that researching the necessary clinicians and paperwork can be a barrier to accessing a benefit such as this. This process can produce further trauma for people already in crisis. She also commented that unless you know who to call or how to access the information, the administration process can be lengthy and extensive. An administration resource could allow the Health Centre to make immediate appointment bookings, complete the necessary forms and ensure that transportation was organized for the client. These processes could tend to be difficult for a client to undertake if they are in crisis and the Health Centre may be a trusted community resource who could confidently assume these administrative functions.

Holistic family counselling – not individualised

The Health Director and Mental Health Manager interviews agreed with a focus on holistic family counselling, whereby all members of the family or close relatives were involved in the healing process of the individual in crisis. One participant believes there is a gap between individual and community counselling and this area needs to be reviewed as an additional component to STCIMHC. Another two participants felt that consideration should be given to incorporating traditional based counselling as part of STCIMHC that could involve elders or traditional healers from the community.

Using the Funds more creatively Harm reduction care or Home care services

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Some of the interviewees advocated for funding to be re-directed towards providing more counselling services in the home (or private locations). There is a privacy challenge and confidentiality concerns where people tend not to access mental health services for fear that other community members will see them accessing these services. This often meant that trauma was going undetected and resulting in crises that could have been avoided. Another idea from participants was to re-direct funding towards harm reduction care. Much focus is placed on the individual once they are in crisis and attempting to identify the symptom or solution. And yet there are very little resources allocated to the source of the situation such as alcohol abuse where harm reduction strategies could play a key part in managing situations before they become a crisis.

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