Brian's Law (Mental
Health Legislative Reform), 2000, Bill 68, Mrs
Witmer / Loi Brian de 2000 sur la réforme
législative concernant la santé mentale,
projet de loi 68, Mme Witmer
Schizophrenia Society
of Ontario
Mr Ted Fielding
Ms Janice Wiggins
Ontario Medical
Association
Dr Albert Schumacher
Dr Stephen Connell
Dr Brian Hoffman
Ms Barb LeBlanc
Community advisory
committee of the St Joseph's mental health
programs
Mr Terry Burrell
Ms Margaret Van Dijk
Ontario Homes for
Special Care Association
Mr Brad Rye
Mr Mike Dowdall
STANDING COMMITTEE ON
GENERAL GOVERNMENT
Chair /
Président
Mr Steve Gilchrist (Scarborough East / -Est PC)
Vice-Chair / Vice-Présidente
Mrs Julia Munro (York North / -Nord PC)
Mr Toby Barrett (Norfolk PC)
Mrs Marie Bountrogianni (Hamilton Mountain L)
Mr Ted Chudleigh (Halton PC)
Mr Garfield Dunlop (Simcoe North / -Nord PC)
Mr Steve Gilchrist (Scarborough East / -Est PC)
Mr Dave Levac (Brant L)
Mr Rosario Marchese (Trinity-Spadina ND)
Mrs Julia Munro (York North / -Nord PC)
Substitutions / Membres remplaçants
Mr Brad Clark (Stoney Creek PC)
Ms Frances Lankin (Beaches-East York ND)
Mr Richard Patten (Ottawa Centre / -Centre L)
Mr Joseph Spina (Brampton Centre / -Centre PC)
Also taking part / Autres participants et
participantes
Mrs Lyn McLeod (Thunder Bay-Atikokan L)
Clerk / Greffier
Mr Viktor Kaczkowski
Staff /Personnel
Ms Lorraine Luski, research officer, Research and Information
Services
The committee met at 1616 in committee room
1.
SUBCOMMITTEE REPORT
The Vice-Chair (Mrs
Julia Munro): I'd like to welcome all of you to the
standing committee on general government. We are going to begin
this afternoon's proceedings. I must apologize for the lateness
of our start, but we are of course under the rule of the House in
terms of when we are able to start. We're going to begin this
afternoon with the report of the subcommittee. I'd ask Mr Clark
to do that for us.
Mr Brad Clark (Stoney
Creek): Your subcommittee met on Thursday, May 4, 2000,
and Monday, May 8, 2000, to consider the method of proceeding on
Bill 68, An Act, in memory of Brian Smith, to amend the Mental
Health Act and the Health Care Consent Act, 1996, and agreed to
recommend the following:
(1) That the committee meet
in Toronto at its regularly scheduled meeting times on the
following dates: Wednesday, May 10, Monday, May 15, Wednesday,
May 17, Monday, May 29, and Wednesday, May 31; that the committee
meet in Toronto on the evening of May 15, and that the committee
meet in Hamilton on Friday, May 12, Thunder Bay on Tuesday, May
23, and Ottawa on Wednesday, May 24, 2000.
(2) That the Chair of the
committee write to the House leaders to request authorization for
the committee to meet beyond its regularly scheduled meeting
times in accordance with the schedule set out in paragraph
(1).
(3) That the committee invite
the Minister of Health to make a statement to the committee on
the final day of committee hearings. The time allocated for
caucus statements and questions will be determined at a later
date.
(4) That the clerk of the
committee be provided with the names and contact information of
any expert witnesses that each of the three caucuses would like
to invite to make presentations to the committee.
(5) That an advertisement be
placed in the largest circulation daily paper in each of the
following cities: Toronto, Hamilton, Ottawa and Thunder Bay, as
well as in the Ottawa French-language daily, and local papers in
the communities of Fort Frances, Kenora, Dryden and Marathon.
Notice of hearings is also to be placed on the Ontario
Parliamentary Channel and the committee's Internet Web page.
(6) That the deadline for the
receipt of requests for those wishing to make an oral
presentation be no later than 48 hours (two business days) prior
to the commencement of the hearing on a given day.
(7) That time for those
requesting to make oral presentations be allocated on the
following basis: 30 minutes for expert witnesses, 20 minutes for
groups and organizations and 10 minutes for individuals.
(8) That the Chair and clerk
of the committee be authorized to schedule witnesses and to make
whatever logistical arrangements that are necessary to facilitate
the committee's proceedings.
(9) That the deadline for the
receipt of written submissions be 5 pm on Monday, May 29,
2000.
(10) The witness expenses be
paid subject to approval by the subcommittee.
(11) That the legislative
research officer provide a summary of the oral presentations to
the committee upon the completion of public hearings and to
undertake any other research that may be requested.
(12) That the clerk of the
committee be authorized, prior to the passage of the report of
the subcommittee, to commence making any preliminary arrangements
necessary to facilitate the committee's proceedings.
The
Vice-Chair: Any discussion, any debate? Moved for the
acceptance of the report of the subcommittee?
Mr Garfield Dunlop
(Simcoe North): So moved.
The
Vice-Chair: All those in favour? Agreed.
BRIAN'S LAW (MENTAL HEALTH LEGISLATIVE REFORM), 2000
/ LOI BRIAN DE 2000 SUR LA RÉFORME LÉGISLATIVE
CONCERNANT LA SANTÉ MENTALE
Consideration of Bill 68, An
Act, in memory of Brian Smith, to amend the Mental Health Act and
the Health Care Consent Act, 1996 / Projet de loi 68, Loi à
la mémoire de Brian Smith modifiant la Loi sur la santé
mentale et la Loi de 1996 sur le consentement aux soins de
santé.
SCHIZOPHRENIA SOCIETY OF ONTARIO
The
Vice-Chair: We are now able then to proceed with the
presentations. I'd like to ask for the Schizophrenia Society of
Ontario, the provincial office, if those making a submission on their behalf would come
forward to the front.
Welcome. If I could ask you,
for the purposes of Hansard, to introduce yourselves and then you
may begin your presentation.
Mr Ted
Fielding: My name is Ted Fielding. I'm president of the
Schizophrenia Society of Ontario.
Ms Janice
Wiggins: My name is Janice Wiggins. I'm the executive
director of the Schizophrenia Society of Ontario.
Mr Fielding:
Thank you for allowing us the opportunity to appear here this
afternoon. I'm pleased to say that quite a few members of our
society are here supporting us and it's nice to see such a good
turnout on such short notice.
I'd like to start by just
giving you a thumbnail sketch of the Schizophrenia Society of
Ontario. It was founded in 1979 and its mandate includes
educating the public on schizophrenia, supporting people with
schizophrenia and their families, and advocating for better
treatment, care and services for people with schizophrenia. The
society has 34 chapters that cover the entire province, from
Toronto to Thunder Bay and Windsor to Cornwall.
The Schizophrenia Society of
Ontario has been working for over 20 years to alleviate the
suffering caused by this complex brain disease, and we are
convinced that Brian's Law represents a large step towards the
creation of a more flexible mental health system that can better
answer individual needs.
Just a brief comment on what
schizophrenia is. Schizophrenia is a brain disease that, at
worst, deprives its victims of contact with reality. The positive
symptoms of the disease include hallucinations, delusions and
paranoia. The negative symptoms include difficulty in organizing
thought or speech and in initiating goal-directed behaviour. The
positive symptoms of the disease can usually be controlled
through medication, which is a fundamental component in treating
schizophrenia. Unfortunately, the disease deprives some people of
the ability to recognize that they are ill and so leads to
treatment refusals and much suffering and harm. We covered some
of this in a paper that we presented to the government in May
1999 with the title Enough is Enough.
We congratulate the
government on the thorough job it has done in consulting with
interested parties and for its careful effort to provide balanced
and fair amendments to the Mental Health Act. Brian's Law will
make treatment available more quickly and reliably to severely
ill people and will allow the community and hospital systems to
better coordinate their efforts.
The bill's critics have
alleged that it is an attempt to use coercion as a substitute for
adequate community resources. We categorically reject this claim.
The better use we make of our community resources, the fewer
people we allow to deteriorate to the point of severe illness
before intervening to assist them, the more resources will be
available to provide better social supports for people with
mental illness.
We have two specific
recommendations regarding the proposed amendment. The first one:
We recommend speedy crisis intervention. We recommend that the
government further amend subsection 15(1) and related provisions
of the Mental Health Act, so that clause l5(1)(c) of the act,
"lack of competence to care for self," will include a new and
distinct criteria, which reads "or has shown or is showing an
apparent lack of capacity to make a decision with respect to
admission to a psychiatric facility for treatment," and so that
clause l5(1)(f) of the act, "serious physical impairment of the
person" will include a new and distinct criteria "or serious
disruption of ordinary mental functioning."
Families, and people with
severe mental illness, have experienced first-hand the suffering
that occurs when a person is allowed to deteriorate to such an
extent that they are no longer able to make decisions for
themselves. Mental deterioration must be recognized as a symptom
of severe and persistent mental illness and included as a
criterion for involuntary assessment.
This is a quote from a family
member from northern Ontario in a letter to Minister Witmer,
dated April 10 of this year:
"More representative of a
person suffering from a severe mental illness is the person who
is no threat to anyone, but suffers constantly. Typically, they
are malnourished, lonely, living in constant anxiety or fear and
unable to maintain a residency. They are sometimes taken
advantage of or mistreated by others. They would benefit from
treatment but will not agree to treatment. They have been
hospitalized numerous times but relapse upon release....
"While never a threat to
anyone else and only a threat to himself by neglect"-and this is
a man in particular-"(this man) lived in constant suffering."
The second change or
amendment we'd like to see is greater protection from liability
for the substitute decision-maker who consents to a plan and for
family members who participate in the plan.
The issue of liability is of
great concern for the members of the Schizophrenia Society of
Ontario. The proposed legislation will expose the substitute
deciders who consent to a treatment plan as part of an outpatient
committal order, and the family members who participate in the
treatment plan, to the risk of civil lawsuits. It is unfair to
saddle family members, who already carry unusually heavy burdens,
with the fear that a treatment plan gone awry could expose them
to financial ruin. The legislation should make it easier, not
harder, for relatives and friends of people with mental disorders
to participate in their care.
I have another quote, this
one from a mother of a son with schizophrenia living in the
Golden Horseshoe. This letter was addressed to Minister Witmer on
March 28 of this year:
"My son has never been
hospitalized. I have taken care of him at home by myself. My son
has never displayed violent behaviour toward others. He has
always been self-destructive. I cannot describe the trauma of
finding your loved one
ablaze in fire, or any one of the other terrifying events that
finally result in the diagnosis of schizophrenia. I cannot
describe the grief experienced by families who have a child,
sister, brother etc diagnosed with schizophrenia.... Once we,
their families, are gone, these invisible mentally ill will then
become the very visible mentally ill as we are their
lifelines."
I'd like to turn the
presentation over to Janice.
Ms Wiggins:
Does Brian's Law stigmatize or stereotype people with mental
disorders? The existing law limits hospitalization to those who
are dangerous to themselves or others. The new law permits
intervention when a person is experiencing substantial mental or
physical deterioration, that is, the old law fosters the
stereotype that mental illness is linked to dangerousness. The
new law counters the old stereotype by recognizing that people
with serious mental illness are exposed to suffering and
deterioration from which they can and should be spared. Untreated
serious mental illness can sometimes lead to violence towards
others, but more often it leads to horrible suffering in the
person afflicted by the disorder. We need to ensure that people
who are in need of medical treatment get it. SSO emphasizes that
the community must look after the many, many more people with
mental illness who are not dangerous, but who are ill and
suffering.
The existing law requires
that people be taken out of the community, that is, hospitalized,
for treatment. The new law allows people to be treated in the
community in the least intrusive environment. This will mean
people with mental illness need no longer be excluded from the
community merely because they require treatment, but will instead
remain and function in the community, where they belong.
Often catastrophic events
make headlines. Last December, a 47-year-old man with
schizophrenia was set on fire near his Toronto apartment
building. While police said the motive for the attack was
robbery, neighbours said the man's condition had been
deteriorating before the incident.
In a letter published in the
Globe and Mail, our president, Ted Fielding, wrote, "This hate
crime might not have happened if we had a Mental Health Act that
recognized more than just bodily harm as a criteria for
involuntary committal." SSO members, many of whom are with us
today, ask how many more people have to commit suicide, how many
more people have to be put in jail, how many more people have to
suffer on the streets of Ontario or die, before laws designed to
protect all people come into place? There have been many
coroners' inquests that have dealt with these questions and
solutions that must be implemented to prevent such tragedies from
happening again.
1630
The fact is that some people
with severe mental illness, when not taking medication, are more
dangerous than other people. Most often they are a danger to
themselves, not others; 10% commit suicide. Every time an
untreated mentally ill person commits a crime like killing a
sportscaster, pushing someone in front of a subway train or
attacking their next-door neighbour, that reinforces the public
perception and the myths that spread to the majority who are not
dangerous.
I'd also like to address the
question of resources. Additional social resources, for example
housing, income supports and so on, will not benefit people who
are too sick to take advantage of them. A significant fact of
schizophrenia is that people lack insight into their illness.
Hence, people believe that they are not sick while at the same
time suffering from awful consequences of this debilitating
illness, including homelessness and suicide.
This law requires
psychiatrists, hospitals and the community care sector to
coordinate their efforts, which the current Mental Health Act
does not do. Accountability for the provision of service to the
severely mentally ill must be built into the system. It is
unconscionable that any responsible community agency could or
would refuse to provide access to treatment and supports for
those who are severely mentally ill. Service providers must face
an obligation to serve those people who may require more
intensive care for longer-term response. It is not enough to only
look after the worried well.
This law will allow us to
open existing social resources-for example, supported housing-to
people who are otherwise too sick to be safely admitted to them.
Some of the mentally ill who are now homeless have been evicted
from supported housing because of their psychotic behaviour.
Provisions in the law will now ensure that people can live in the
community.
This law will allow
psychiatrists and hospitals to provide assistance to families,
who are now the main resource in the community for serious mental
illness. All too often, caregivers are family members who are
aging and stricken by the effects of caring for someone who is
mentally ill.
As we said earlier, we have
brothers, mothers, wives, sisters and friends of persons who are
ill in the audience today and they can tell you first-hand what
it's like.
Caregivers are often left
with nowhere else to turn in a crisis. Many of our volunteers
across the province have experienced untold trauma in their
homes. Many of them have informed us that they have sought help
repeatedly but were unable to get it under the inadequacies of
the current legislation. We often hear anguished parents asking
who will care for their loved one when they are no longer able to
do so. Siblings share concern for their brother or sister and
look to the mental health system to provide some reassurance.
I'm quoting from a letter,
from the mother of a man with schizophrenia who lives in the
greater Toronto area, dated April 10, 2000. She says: "No home
was meant to be a mental institution, but many are. If you have a
son or daughter, sister or brother, mother or father with a
severe mental illness your life is forever changed. You
constantly worry when they are not with you and are in constant
turmoil when they are at home. The pain of watching someone you love living in a world of
voices-you cannot explain it."
Brian's Law, a natural step
in the development of Ontario's mental health law: Ontario's
Mental Health Act, the Consent to Treatment Act, 1992, and the
current Health Care Consent Act, 1996, have allowed people to be
found incapable of consenting to their own treatment. Such people
may, after having an opportunity to exercise their legal rights
to resist the finding of mental incapacity, be treated on another
person's consent, and it's usually the relative's consent.
Brian's Law is not about
forcing treatment but rather about keeping people out of
hospital. The issue raised by Brian's Law, especially the new
provisions of community treatment orders, is not about whether
you treat but about where you treat.
I have another quote from a
letter, dated March 29 this year, from the mother of a son with
schizophrenia in Markham. She says: "The proposed legislation
provides a ray of hope to families who are struggling to cope
with a loved one stricken by this insidious disease, and I hope
that our elected representatives will have the courage,
compassion and determination to carry it through."
Another individual in
Scarborough, who is a wife and mother of persons with
schizophrenia, wrote: "The heart-wrenching experiences families
have had to go through because the act has been structured to
allow people with schizophrenia to escape treatment when it is so
obviously needed are no longer tenable in this day and age. I
have experienced these hardships through my husband and my son
who have been affected by this disorder. In both cases, they
refused to take their medication and found themselves in a crisis
situation involving the law and spending time in jail. This was
totally inappropriate. Schizophrenia is a medical condition and
must be recognized as such. Often it is necessary to remove such
a person from society, but when this is the case, provisions must
be found in the medical setting-a hospital, not a jail. These
were very trying times for all the family who love them and were
so powerless to effect treatment."
A very simply put statement
from a woman whose brother suffers from schizophrenia is, "Please
help to open up the way to earlier interventions by changing the
current legislation."
In summary, SSO believes that
the recent development of more effective medications with lower
side effects, and new government initiatives such as the
assertive community treatment teams, are improving life for many
people disabled with schizophrenia. The passage of Brian's Law
will make these opportunities available to more sick people and
increase the hope we see for the thousands of lives that have
been affected by severe and persistent mental illness.
I want to thank the committee
for their attention to our deputation today. Certainly, we're
available for questions.
The
Vice-Chair: Thank you very much. We have about four
minutes per caucus for questions. We'll begin with the official
opposition.
Mrs Lyn McLeod
(Thunder Bay-Atikokan): Thank you. I very much
appreciated your presentation. I know how important it is to you
to be here today and to make this presentation to the
committee.
I just want to ask you a
question specifically about the first amendment you proposed,
because that's an area where there are already significant
amendments proposed to the current act. Can you explain to me
what you think is missing from the proposed amendment in Brian's
Law and how your amendment would make a significant
difference?
Mr Fielding:
The proposed amendment, which I presume is section 15(1), talks
primarily of bodily harm as one of the criteria for involuntary
commitment, and is also one of the three items in that section
that talks of lack of competence to care for self. We find that
is a bit too narrow. There are a lot of people who are extremely
ill and are not a danger to themselves or anyone else and
obviously need treatment. What we would like to do is expand that
lack of competence to care for self to include "or has shown or
is showing an apparent lack of capacity to make a decision with
respect to admission to a psychiatric facility for
treatment."
We get many calls from
parents who are desperate to get their loved ones into treatment
but can't because they don't meet the "dangerous" criteria or
just the "lack of competence" one.
Mrs McLeod:
That's where my question comes in. Obviously, removing "from
imminent harm," which is in my colleague's original bill, is an
important part of that. But it does go on to say, in addition to
the bodily harm, "or substantial mental or physical deterioration
of the person." I just thought that was fairly similar to what
you were proposing as an amendment. That's why I was trying to
get a sense, because it does suggest in the government's bill
that it would be mental deterioration, not just physical
harm.
Mr Fielding:
Yes, but that's after the first episode, the way the amendment to
the bill is currently written. What we're talking about is a
situation where you have a first episode in the illness, which is
this subsection (1). The new subsection that the government has
added is (1.1), which is, if previously treated, this is what you
look for.
Mrs McLeod:
A last thing: You make a point in your very well organized brief
of saying that this is not about coercion and it's not about
force. The images that are put forward are often of somebody
being physically forced to take their medication. What response
would you give to that?
Mr Fielding:
We have a Health Care Consent Act that says that treatment can
only be offered to someone who will accept the treatment. If that
person does not have the capacity to understand what is involved
with the treatment, then the law provides for a substitute
decision-maker who can make that decision. If the decision is to
treat that person, that person still has the right to appeal
to the Consent and
Capacity Review Board if they don't like that particular
decision. We support that; we always have. People have a right to
oppose that if they wish.
1640
The
Vice-Chair: One quick question, Mr Patten.
Mr Richard Patten
(Ottawa Centre): Actually I just want to make a comment.
I know that for many years you've worked diligently, patiently
and with great vigour representing a lot of families in this
province who truly have gone through very difficult times and
people who have not been able to receive treatment. I just want
to personally congratulate you on that and I am pleased to see
you here today. Thank you.
Ms Frances Lankin
(Beaches-East York): Let me add my words of welcome to
you and also to Ruth Molloy and a number of people from the East
York Schizophrenia Society who are all here in the row. I welcome
them. I had the opportunity to meet with them and it was very
helpful to me as a member of the Legislature in dealing with this
bill.
I have a quick comment and
then a couple of questions. I wanted to indicate that I really
support the point you made about family liability and protection
from liability. I have a bit of concern about the breadth of
protection from liability that already exists in the act, that
there is no one who has any responsibility, and yet under current
law there are professional responsibility and accountability
mechanisms. So I want to understand from experts how those
provisions interact with that. But I completely agree that it is
wrong that the family be left with the liability. We need to have
the families involved without that threat.
One of the points that I
think a lot of people have made is that for this bill to be
successful the access to the treatment facilities and resources
in the community have got to be there. There was a previous law
in this province, the Long-Term Care Act, which is no longer in
effect because we've gone a different route in terms of how we
organize those services, but contained in that was a list of
minimum mandatory services that had to be made available in all
regions of the province. I've been talking to people, proposing
to bring forward an amendment of that sort to this bill, because
for the community treatment order, which has a provision that
says it will only happen if those services are available in the
community, to be successful and to have a positive intervention
in people's lives, we need to ensure the services. I'm wondering
if you could comment on whether that's something you might, in
general terms, be supportive of as an organization.
Mr Fielding:
Definitely. Obviously we need the services to make this law work.
I'm not a lawyer so I don't know whether this can be done through
regulations after this law is proclaimed. We recognize that this
thing won't work unless you have those supports and we would
certainly advocate for that if it doesn't happen, you can rest
assured.
Ms Lankin:
Stay tuned for my amendment then.
The other thing that I would
like to propose to you, in some jurisdictions governments have
created an office called a mental health advocate's office. Here
in Ontario we have a child advocate's office, we have an
Environmental Commissioner, an Ombudsman and a number of things.
The mandate of such an office would be to review what's happening
in this field, the way in which there is coordination or lack of
coordination between psychiatric facility-based,
institutional-based services, community-based services and law
services dealing with persons with mental disorders.
I again have talked to some
people and am interested in proposing the creation of such an
advocate's office, because one of the things we need to do is
monitor the implementation of this legislation and ensure that it
is reaching the collective goals that have been expressed by
people who even have opposing views about the details. Is that
something in general that you have ever looked at or that you
might be supportive of?
Ms Wiggins:
That is something we have considered but maybe not under that
specific title of advocate's office. But I think you raise a very
good point in recognizing that there are many components to
mental health and many components to the law that need to be
implemented. To have a quasi-independent body available to all of
us, in the community in particular and speaking on behalf of the
families, yes, if there is a number that you can call or there's
an office that is going to be able to respond is up for
discussion. I can't comment on specifics of it because we haven't
seen the proposal, but certainly on the general side.
Ms Lankin:
The last thing I want to put forward is the concept of requiring
a reporting mechanism. a community treatment order can't be
implemented because services are not available in the community
or people are unwilling to provide the services-you referenced
that-that there is triggered a reporting mechanism back to the
ministry and the Legislature so we can keep track of that and it
allows us to examine what we need to do as government to
implement greater resources. That's another general idea I'm
interested in if you think that might be useful.
Ms Wiggins:
I would suggest that, yes, that would be a useful mechanism to
ensure that the accountability is there in the system. I think
what we're emphasizing is that the system must be held
accountable.
Mr Toby Barrett
(Haldimand-Norfolk-Brant): I want to thank Ms Wiggins
and Mr Fielding for testifying. You can appreciate that this
standing committee is going to hear some divergent perspectives
on this issue with respect to very serious mental health issues.
There are different opinions as far as the causes and certainly
different opinions with respect to solutions.
Earlier we had a question
making reference to your statement that Brian's Law is not about
forcing treatment but rather about keeping people out of the
hospital. As I understand it, a community treatment order defines
conditions under which a person with a serious mental illness may
live in the community and, failing to follow an order, is returned to a psychiatric
facility. But the return, as I understand it, is for assessment,
not hospitalization. That's my understanding of these community
treatment orders.
I wished to ask you a
question. In much of your presentation you present evidence of
support for community treatment orders, specifically in this case
for people with schizophrenia. I wondered if you could be more
specific. Could you give us some specific examples of ways in
which community treatment orders can benefit people with
schizophrenia?
Mr Fielding:
The whole concept of community treatment orders is to prevent
this revolving-door situation that occurs with people who are the
most severely ill. If you can keep people in the community on
community treatment orders, it then frees up beds that now are
being occupied by those people on a repeat basis. It's a much
more efficient use of the services available for mental
health.
Mr Clark: I
want to thank you again for coming out and participating in the
consultations.
During the first round of
the consultations we heard from a number of different parties
that they believed the Mental Health Act was fine as it was
written and that it was simply a question of education; if we
educated the public, if we educated health care providers, the
Mental Health Act was sufficient as it is currently written.
Would you care to comment on that position?
Mr
Fielding: Actually, we've said in our paper that we just
presented that the current Mental Health Act, which is centred
very much around bodily harm, really perpetuates the stigma
attached to mental illness that all people with mental illness
are potentially dangerous. We know very well that they aren't.
The majority are not dangerous. That is one thing we don't like
about the current Mental Health Act.
The second is that it waits
for you to descend to a level of illness where you might be
dangerous or you might be dangerous to yourself, and we don't
believe that people should be allowed to reach that level of
suffering. We don't do that for people who are suffering from
cancer, for example. We start treatment as soon as we discover
that they have cancer. This act allows people to just keep
sliding down until the inevitable happens.
We're faced with that all
the time at the schizophrenia society, where I get a call from a
mother saying, "My son is very ill," and I say, "Does he meet
these criteria in the act?" She says, "No, but he's very ill,"
and I say, "I'm sorry, but there's nothing we can do; you're
going to have to wait till he does something."
Mr Clark:
That being said, if we're successful in amending the act, what
would your position be about public education at that point?
Mr
Fielding: I think it's very important, and it should
continue. Only with education can you deal with the perception of
the stigma attached to mental illness. It's time we recognized it
for what it is: just an illness.
The
Vice-Chair: Thank you very much for being here today and
providing us with this presentation. We're ready to move on to
our next presenters.
1650
ONTARIO MEDICAL ASSOCIATION
The Chair (Mr Steve
Gilchrist): Good afternoon. I wonder if we could get you
to introduce yourselves for the record, please.
Dr Albert
Schumacher: I am Albert Schumacher, a family physician
and president-elect of the Ontario Medical Association.
Dr Stephen
Connell: I am Stephen Connell, a psychiatrist and chair
of the Ontario Medical Association section on psychiatry.
Dr Brian
Hoffman: I am Dr Brian Hoffman, chief of psychiatry at
North York General Hospital.
Ms Barb
LeBlanc: Barb LeBlanc, staff at the Ontario Medical
Association.
The Chair:
As you know, you have 30 minutes for your presentation. Please
proceed.
Dr
Schumacher: Thank you to the committee for allowing the
Ontario Medical Association to present our views on Brian's Law
before you today.
As a family physician in
Windsor, which is underserved for psychiatry, family physicians
like me are the primary providers of mental health services for
many patients. We need the legislative changes that will help us
provide better care for people with serious mental disorders. It
is positive to see that there will be an enhanced ability for
psychiatrists to work with family physicians and others in the
community to tailor comprehensive treatment plans for each
patient who is deemed to be suitable for either early release
from hospital or hospital diversion entirely through community
treatment orders.
In addition to our oral
presentation, we have provided more detailed comments on each of
the subject areas we intend to cover in our remarks. We hope this
allows us to keep our presentation succinct and provide time for
dialogue in areas that require further exploration. We also want
to give you the proposals and the rationale behind them.
We plan to address four
main issues with you this afternoon: first, the criteria for
involuntary assessment and admission; second, community treatment
orders; third, leaves of absence; and finally, accountability and
liability.
I'll now turn the
presentation over to my psychiatrist colleagues, who have been
more closely involved than I with the legislative amendment
process thus far. But before doing so, I would like to thank the
government for adopting a number of the recommendations from our
report in December 1999 and subsequent consultations.
Dr
Connell: The Ontario Medical Association section on
psychiatry has been working closely with the Ontario Psychiatric
Association for about a year in order to press for amendments to
the Mental Health Act that would help bring our legislative
infrastructure in line with mental health reform, provincial psychiatric hospital
divestment and patients' treatment needs. We are pleased to see
that the legislation moves to decriminalize persons with mental
illness by moving away from a strict "dangerousness" criterion
for involuntary admission and care, at least in the case of
patients with a lengthy psychiatric history. We believe the
introduction of the new assessment and admission criterion, which
acknowledges physical or mental deterioration, is an important
step forward in ensuring that people get help before they reach a
crisis point. This, in turn, will help to destigmatize mental
illness.
We feel it would be
clinically useful for the act to extend these non-bodily harms
beyond the chronic population described in subsection 15(1). We
recommend that clause 15(1)(f) of Brian's Law be amended to refer
to serious physical or mental impairment of the person.
Dr
Hoffman: As a psychiatrist in a hospital setting, I am
constantly challenged to use the shrinking number of in-patient
psychiatric beds more efficiently and to explore ways of
facilitating outpatient treatment and ongoing community living.
This is especially important with the downsizing of Queen Street
and Whitby, where we now expect patients with chronic and
cyclical illnesses to live in the community. I believe the
introduction of community treatment orders will help us
accomplish both of these goals, and I thank the government for
including them in Brian's Law. As always, though, the devil is in
the details, and I have some practical concerns about how I as a
physician would implement CTOs.
Since we prepared our
original brief in December 1999, we have spent a significant
amount of time refining our model based on information obtained
from other jurisdictions and extensive discussions around
clinical need. No doubt, community treatment orders are useful
for revolving-door and chronic patients. However, we now want to
put forward the argument that CTOs could be effectively used for
a more acute clinical population than we previously estimated. We
continue to recognize that community treatment orders will be
appropriate for a relatively limited number of people. Most
people will continue their outpatient treatment voluntarily. But
we believe their use should be actively encouraged as a least
restrictive treatment option for patients who meet the
involuntary hospital criteria, regardless of previous psychiatric
history.
Dr
Connell: Many people don't realize that our existing
legislation already has a provision in it for a time-limited
leave of absence from hospital, with a planned return. The OMA
has examined this provision closely and believes it would be much
more effective if it were modified to remove the existing
requirement for a planned return, thus allowing a step-down
system from in-patient treatment to supervised outpatient
treatment prior to full discharge from the hospital. So we're
talking about a transitional phase.
The OMA recommends that
subsection 27(1) of the Mental Health Act be amended to remove
the requirement that the patient be expected to return to the
hospital. This is consistent with our encouraging moves to
treatment based in the community.
Dr
Hoffman: The final major area we would like to talk
about today is accountability and liability. I want to go back to
Stephen's point about community treatment orders. There is a pet
peeve in that legislation why it will not be used in a general
hospital under existing legislation, and that's because it
requires the signature of the officer in charge of the
psychiatric facility. That is not a doctor or a psychiatrist;
it's the president and CEO of the hospital. You might get that
person in a psychiatric hospital to sign, but in a general
hospital-North York General is close to a $200-million operation.
Throughout Brian's Law those duties assigned to the CEO are not
delegable, and a lawyer will point that out. So I would ask for
the repeated amendment that wherever you have "officer in charge
of a psychiatric facility," you put "officer in charge of a
psychiatric facility or delegate." The CEO would delegate that to
me, and I could then implement things. The accountability would
still go back to the officer in charge. It's a very simple thing,
but it's one of the reasons why leaves of absence are rarely used
in a general hospital.
As Dr Connell noted, the
existing Mental Health Act has a leave-of-absence provision which
allows a patient to live for a period of time in the community as
long as he or she adheres to the conditions of the leave.
Unfortunately, some of my colleagues in community hospitals are
wary of using those leaves because of concerns about legal
liability. It is interesting to note that many of my colleagues
in the provincial psychiatric hospitals are less worried about
this, and I suspect the reason lies in the fact that the act
indemnifies hospitals and their employees from liability for any
torts committed by their patients. Psychiatric hospital
psychiatrists are employed directly by the provincial government,
and therefore are also protected from liability in this
regard.
Community hospital
psychiatrists are not employees of the hospital in which they
work, and therefore do not enjoy the same protection. In order to
support community-based, team-oriented care, government should
provide a medical-legal climate that encourages the use of
leaves, community treatment orders and other least-restrictive
alternatives to involuntary, in-patient hospitalization.
The OMA also believes that
the accountability and liability provisions in the community
treatment order section of Brian's Law are incomplete, as they
only talk about physicians and other regulated health
professionals but do not extend to community-based care
providers. The OMA suggests that the provisions be expanded to
include all persons who are involved in the treatment, care or
supervision provided to a patient under a community treatment
plan.
1700
Dr
Schumacher: The OMA sees great potential for the
amendments introduced by the government to the Mental Health Act
to significantly improve our ability to provide more timely care
and better follow-up care to persons with serious mental disorders. We
support the major thrust of the government's amendments but have
some specific suggestions for changes that will make the
legislation more practicable in the field.
We hope you will read our
detailed suggestions and give them your active attention.
Thank you for your
attention to our presentation. We'll be pleased to use the
remaining time to answer any questions you may have.
The Chair:
Thank you, Dr Schumacher. I appreciate your comments and the
specific suggestions that are attached.
We have approximately five
minutes per caucus for questioning. This time the rotation will
start with the NDP, Ms Lankin.
Ms Lankin:
I appreciate your presentation, and it's a pleasure to see all of
you again.
I have three areas that I
would like to explore with you, and anyone can respond. But the
first, perhaps, is directed to Dr Hoffman.
I have spoken to heads of
psychiatry departments in a number of general hospitals. One of
the concerns I hear, entirely off the record-and I didn't hear it
presented here today, so I want to see if this is a concern we
can put on the record-is the broadening of criteria for
involuntary committal. If we experience, as we have in other
jurisdictions, that CTOs are applied to a relatively small
proportion of the patient population, with the scaling back of
provincial psychiatric hospitals, I've heard a concern about what
is going to be happening in our emergency rooms and the ability
and capacity of our institutional psychiatric resources to meet
the need and the demands that will be created.
In particular, I note that
we have a number of recommendations from the hospital
restructuring commission that were based on number crunching done
at a time when the law was different than it will be, and that we
may see a very different effect as a result of these amendments.
Has the OMA given thought to this? Do you have any comments on
that, Dr Hoffman or Dr Connell?
Dr
Connell: There is a lot of concern with change at many
different levels with legislation in this area.
In terms of resources, what
we do know, and I think it was pointed out by the Schizophrenia
Society, is that bed usage is going to drop down. So you are
going to have those beds, which are already shrunk in the system,
available for other patients, because these revolving-door
patients will hopefully be maintained in the community.
In a study in Iowa which we
have the use of in-patient beds was reduced by 86%, and visits to
the emergency department for the chronic community treatment
order population were reduced by half. This has been replicated
elsewhere. This sort of legislation is present in 40 US states,
as well as in other jurisdictions in Canada, so we have quite a
body of literature that is building to show that it is quite
effective in reducing the demand on the bed system and on the
emergency department.
If you have a treatment
plan, the legislation and treatment resources in the community,
that treatment team is going to be on top of that patient, making
sure that if there is any deterioration they're not going to have
to go to the emergency department. If a GP or a family member is
concerned about that patient, they will be in touch with a
designated member of a treatment team. So it really puts a system
of care, a hospital without walls, in the community, which I
think is a humane and progressive way of treating this
population, who until now have been at the mercy of shrinking
resources. I think it ensures that a treatment plan is going to
be available.
Ms Lankin:
So you actually think there won't be a requirement to add
additional institutional beds at this point in time?
Dr
Connell: Not institutional beds, but I think what we may
have with other aspects of the act is the ability to capture a
population that hitherto did not receive treatment. These are
people who were deteriorating and don't go to doctors' offices
but whose family members were powerless to take anywhere. If
those patients are deteriorating at home or are students at a
university and going downhill, manic and deteriorating, those
individuals could now be taken to an emergency department.
I think this is where some
of these chiefs of psychiatry may fear they are suddenly going to
get all these previously undiagnosed and untreated patients
deluging the emergency department. We'll have to wait and see
whether that is going to be the case. But working with the
government on the next phase, which is the regulations, we can
try to anticipate areas of resourcing, based on the literature,
that might be needed.
Ms Lankin:
I have two questions, but I'll go to the more important one that
I want to address.
In the rationale for your
amendments to community treatment orders, you talk about the fact
that after considerable study from the consultation period, you
have determined that CTOs, which are for persons who meet the
involuntary admission criteria-in fact, you are looking at
broadening this in some ways, because it is a less restrictive
alternative.
One thing I am concerned
about, and I'm not sure if this is a legitimate concern, but when
I read that section, the individual has to meet the criteria for
an assessment for involuntary committal, not involuntary
committal criteria. In order for me to get my head around this,
to see a CTO as a less restrictive option, I feel like the
individual should at the very least meet the criteria for having
been assessed for involuntary committal. That seems to be what
you say the law does. But when I read it, it does something
slightly different. Did you give any consideration to the form 1
versus the form 3 criteria in the way this section is
written?
Dr
Hoffman: Yes. I want to make the argument that by
opening the front door, CTOs open the back door, so there should
not be any need for increased beds. The form 3 criteria are
actually quite different in that you do not need current
evidence. It's simply the opinion that the person will run into
harm. The form 1 requires evidence, A, B, or C-has threatened or
is behaving in a way that's dangerous. So I think it's important
for CTOs that you have
an evidentiary-based opinion. The form 3 does not require that,
because once the person is in hospital, they're no longer
threatening their father or starving themselves, because the
nurses are feeding them.
Ms Lankin:
But they are receiving a psychiatric assessment as to whether or
not they're a candidate. Presumably some people are assessed, and
it is determined that they're not candidates for involuntary
committal. So for a CTO to be left restrictive, I'm having a
problem making a circle around that square.
The Chair:
I'm afraid we are going to have to move on. We have about seven
minutes.
Mr Clark:
I'm interested in your comments about liability for physicians
and psychiatrists. In section 33.6 of the proposed act, there are
three subsections. The first deals specifically with physicians
who issue community treatment orders, and it states pretty
clearly "the physician is not liable for any default or neglect
by those persons in providing treatment."
The next subsection deals
specifically with the people who are involved with the community
treatment order themselves, the other health care providers. It
seems to me, in reading the three subsections, that the act
pretty well indemnifies psychiatrists and physicians, as well as
health care providers, if they are providing treatment based on
the requirements set out by the physician or psychiatrist who
issued the community treatment order. So I'm a little confused in
terms of where you are coming from in stating that we're not
providing enough indemnification.
1710
Ms
LeBlanc: Specifically, we're looking at the word
"treatment," because not everyone who is involved in the care
plan will be actually providing treatment. Some will be providing
supervision; some will be providing care. Treatment, when you
start to look at it, can only be provided by regulated health
care professionals. It's a bit of a picky question, but it's
really just for the sake of completeness. We want everyone to be
in. We want everyone who is part of the community care team to be
indemnified.
Mr Clark:
Arguably the line states "If a person who is responsible for
providing an aspect of treatment under a community treatment
plan." You don't feel comfortable that it states "an aspect of
treatment under a community treatment plan"? I view that as
covering it off, but I don't know. I'm not a lawyer.
Ms
LeBlanc: The definition of "treatment" under the Health
Care Consent Act is quite broad, but we just want to make sure
that it is crystal clear that all aspects, including the
supervision-because that isn't in there necessarily-and the
ancillary care are captured.
The Chair:
Mr Barrett, fairly quickly.
Mr
Barrett: A quick question. You raise the issue of
concern of an administrator releasing a psychiatric patient from
a hospital. My understanding is that much of the thrust of these
orders, which are issued by medical practitioners, is to keep
people out of the hospitals. This is something we heard in the
previous presentation. How realistic is that statement? How
realistic are these community treatment orders, to be designed to
assist people to remain in the community, and failing that, they
go to the hospital for assessment? How realistic is that approach
in the real world?
Dr
Connell: I can only refer back to the response I gave to
Francis Lankin, and that is, the studies we have, for example, in
New York showed that the people on the orders had 44 days of
hospitalization over an 11-month period; people without the
orders were I think 101 days. So you're getting dramatic
differences in the use of the hospital and the need for
hospitalization. In fact, that's the one clear, resounding piece
of research outcome on the community treatment orders as they've
been applied elsewhere. We're encouraged by that.
The only other proviso
about the treatment orders is that they must be combined with
treatment in the community. You can't just put a person on an
order without treatment. It's not enough just for housing or
vocational rehabilitation-as some of the critics have said, "We
don't need CTOs; we just need housing." That's not what the
research is showing us. The research is showing us that you must
have the person getting their faculties together so then they can
determine what the best for them is in their rehabilitation. The
only way you can do that is have intensive outpatient treatment
services available to them.
The cost of outpatient
treatment services is a fraction of in-patient services. If it's
$600 or $1,000 a day for in-patient services, it's only going to
be $10,000 a year for the outpatient, so you just need 10 days of
hospitalization to pay for that person's entire year of
outpatient services. In the Iowa study, if you had 2,000 people
on CTOs for a year, you would save $34 million. That's taking
into account the cost of the medication and the cost of the
outpatient services. If they use 26 days less hospitalization per
year, when you don't have that being spent, you're saving $34
million a year for 2,000 people on CTOs. So just from a cost
basis, in terms of better using our health dollars, it makes a
lot of sense.
Mr Patten:
Very quickly, Dr Connell, I wonder if you might share with the
committee a synthesis of some of these studies that you've
referred to, especially the Iowa case.
Dr
Connell: Fortunately, there is a foundation in the
States called the Stanley Foundation. This is a family-I don't
know if it's Stanley Tools-who have a lot of money and they put
$400 million into this foundation. They have a Web site. I
believe a lot of these studies are on the Web site. John Stanley
sent these up to me by courier yesterday. He sent me up a number
of them and we'll pass that on to you.
Mr Patten:
Thank you. One other point, and it had to do also with the
liability question. I would take that almost as a friendly
amendment, Barb, when you talked about the aspect of treatment.
As I read the legislation, the intent is that there will be a
treatment plan that may have a number of players in it, and some
of those players may not be "treating" the individual-they may be
supporting in other
fashions-but they do have a role and they have a responsibility.
I think that was the intent. However, a friendly amendment might
be able to clarify that, because it is a good point. Go
ahead.
Mrs
McLeod: In previous briefs that the OMA has made on the
issue of changes to the Mental Health Act, one of the suggestions
you'd made quite strongly was that there be a redefinition of
"mental disorder" from the current act, wherein the current act
it says "`mental disorder' means any disease or disability of the
mind."
I don't have your proposed
redefinition in front of me, but it seemed to me to be an
important qualification that what we're talking about here is
mental illness and not something as broadly defined as the
current act is. Is that still a recommendation that you would
make for amendment?
Ms
LeBlanc: It's certainly one that we still believe in. We
haven't pushed it forward today. We really did want to focus on
what's in Brian's Law as opposed to bringing too many new
concepts to the table.
Mrs
McLeod: I appreciate that, although after many, many
years we may not often be looking at changes to the Mental Health
Act.
Ms
LeBlanc: Understood.
Mrs
McLeod: I guess my basic question is, given the current
status of community treatment resources and the fact that Dr
Musgrave has said that we need three times the number of ACTT
teams that we currently have to be able to make community
treatment orders work, I'm wondering practically whether you
think these are going to be frequently used. I recognize that in
the bill it's very clear that you cannot have a community
treatment order without being able to provide the community
treatment.
Dr
Hoffman: Could I tackle that from a general hospital
point of view? I am concerned about resources, not about beds.
We're not used, at this point in time, to dealing with families
and community resources on an in-patient unit to the degree that
these acts imply. So I'm short on two kinds of staff on an
in-patient unit to implement community treatment orders, one a
psychiatrist-only 40% are attached to a hospital-and the second
is social workers. I have 1.4 social workers on a 30-bed ward and
it wouldn't take very many seriously ill people where I need a
community treatment order to gobble up all the time. These are
costly professionals. So that will have to be solved.
The community services:
We've never been so rich-some of the changes that have come in in
the last two years in this province-ACTT teams; not just ACTT
teams, but ACTT teams attached to general hospitals under the
authority of general hospitals. ACTT teams were designed in the
States not attached to hospitals, and this gives us a tremendous
right to access their resources and to coordinate care. As well,
crisis teams, court diversion workers, and this week's
announcements about increased sessional fees on psychiatric wards
and increased on-call fees will help us to attract psychiatrists
to work in these areas. In addition, the government has allocated
significant millions of dollars to housing for these groups.
This is timely. Community
treatment orders would not work without these community resources
in play and this is an appropriate time. In fact, without
community treatment orders some of these other resources won't be
utilized, such as ACTT teams; they'll be immobilized.
Dr
Connell: Mr Chair, could I just follow up on that,
quickly? I think that's a misquote from Dr Musgrave, but he's
going to be before the committee. I know you mentioned that in
the House and we gave him a call. He's a strong advocate for the
ACTT teams but I think he'll clarify for you what his thinking is
about the two going together.
Mrs
McLeod: It's evidently in a letter to Mr Clark.
The Chair:
Thank you very much for coming forward. I don't know if it's been
said here this afternoon, but this is only the second piece of
legislation where we've gone to hearings after first reading. Mr
Patten commented about friendly amendments. In fact, the bill is
not really crystallized at all, and our hope from all three
parties is that we have an opportunity to hear presentations such
as yours and distill those down into changes to the bill, before
taking the relatively hardened positions that seem to be more the
norm in second and third readings. So we very much appreciate all
those coming forward at this time.
1720
COMMUNITY ADVISORY COMMITTEE OF THE ST JOSEPH'S
MENTAL HEALTH PROGRAMS
The Chair:
I call our next group forward, the community advisory committee
of the St Joseph's mental health programs.
Good afternoon to you both.
Thank you for your indulgence. With the House proceedings, we're
a little delayed today and we appreciate your accommodating
that.
For the purposes of
Hansard, I wonder if you would be kind enough to introduce
yourselves. We have 20 minutes for your presentation.
Mr Terry
Burrell: Thank you. My name is Terry Burrell.
Ms Margaret Van
Dijk: My name is Margaret Van Dijk.
The Chair:
Thank you. Please proceed.
Mr
Burrell: Good afternoon, members of the Legislature.
Thank you very much for permitting us to come before you to make
our presentation today.
We're members of the
community advisory committee of the mental health programs at the
St Joseph's Health Centre. St Joseph's Health Centre, which was
previously known as St Joseph's Hospital, is located at 30 The
Queensway in Toronto. It's at the corner of Sunnyside and The
Queensway in the Parkdale-High Park area in west Toronto.
Bill 68 is about mandating treatment in the stated
interests of public safety. St Joseph's Centre's mission includes
the provision of competent and compassionate care to our
community. I should just note at this stage that during my
presentation I'll be using "treatment" and "care"
interchangeably. They mean basically the same thing. I'm not
using a narrow definition for treatment and a broader one for
care.
St Joseph's mission has
also always emphasized providing care to the poor and the
disadvantaged. When our advisory committee looked at the bill, we
focused on the impact of the bill on our mandate because, in
large part, we think that if a bill like this helps an
institution like ours, then it's likely to be able to help the
community at large. We pose the question: Will the bill help us
or will it hinder us in our mandate of providing competent and
compassionate care to our community? Will it help us provide care
to the poor and the disadvantaged? Will our community be better
off and will the public be safer as a result?
There are two principal
mandated treatments in the bill which have a direct impact on St
Joseph's. The first is the community treatment order, which
mandates the kind of treatment that would otherwise have taken
place in a hospital like ours, to have that treatment take place
in the community. So we have a movement of treatment that would
otherwise have taken place in the hospital out into the
community.
The second mandated
treatment that the bill presents is by way of broadening the
criteria under which a person can be involuntarily committed to
hospital for treatment. What it does is mandate more treatment in
the hospital.
In considering the impacts
on our facility, we have to look at the context in which St Joe's
has been operating. First of all, the community itself that we
serve includes South Parkdale. South Parkdale has a large number
of people with extensive psychosocial needs and of course they
tend to proportionately make up the highest users of our hospital
services. We have in that community 17% of families living on low
income. In some areas, over half of the residents live on social
assistance. There has been an increase lately of 44% of
single-parent families, an increase in the proportion of
immigrants and a large number of people in the community who are
in need of the services that the mental health program
provides.
Parkdale neighbourhood has
been the neighbourhood of choice for many long-term previous
residents of both Queen Street Mental Health Centre and the
former Lakeshore Psychiatric Hospital, so our hospital is in the
area of Toronto that has perhaps the highest proportion of
individuals at risk and vulnerable and that require substantial,
on-going mental health care and support.
The other component of the
context in which we have to look at the bill, apart from the
nature of the community which we have traditionally served, is
the impact of the changes in the health care system over the last
period on our ability to meet the services that are demanded from
us.
The first thing I'd like to
note is that, as a result of the changes that have taken place,
the nature of the demand that has been placed on our facility has
changed markedly. The nature of the demand for mental health
services in the St Joseph's Health Centre has increased
significantly, in large part because of health care
restructuring. Health care restructuring has decreased the number
of beds that are available in Toronto as a whole for providing
psychiatric services. There has been not just a decrease in the
number of beds, but there has been a decrease in the number of
beds that are available to people in the community at large. I'm
not talking about just the St Joseph's community, but the
community of Toronto. For example, at Queen Street there are
fewer beds available, partially as a result of allocation to the
provincial mandate that facility now has and partially as a
result of the choice the broader institution has made to focus
more on research and other tasks and away from treatment. So we
have a decrease in the availability of alternative treatment
facilities to St Joseph's, therefore an increase in the demand
for our services.
St Joseph's has
traditionally been very underfunded. Prior even to the health
care restructuring, St Joseph's was identified as a facility that
had a proportionally smaller availability of resources for its
mandate than other facilities; for example, North York General.
So we've had a major increase in the demand for our services and
we've historically been underfunded. Recently we have had some
increase in our funding, for which we are very grateful, but the
increase in the funding, in our view, and just perceiving the
demands on the hospital, hasn't really brought us back to where
we should have been before restructuring and the allied impact
increased the demand for our services. We feel that we continue
to be struggling to provide the service we want to provide.
Does Bill 68 help us?
Listening to the Ontario Medical Association, I think the major
point they were making is that, in their view, a facility like St
Joe's should be helped by the bill because it should free up
hospital beds by diversion, primarily through the community
treatment arm. If that takes place, of course, we will have more
resources available in the hospital to do the kind of treatment
that we'd like to do. But at this stage we're very skeptical that
will actually take place. My reading-and I'm sure it isn't as
deep or profound as the reading the Ontario Medical Association
has done of the research-is much more ambiguous, that the results
are not nearly as clear-cut in terms of the diversion of
community treatment recipients from the hospitals and into the
community.
At the same time, while
it's not clear that there will be a clear diversion there, the
expansion of the criteria by which admissions can be made to the
hospital suggests that we will be getting admissions of people
into the hospital that we wouldn't have been getting under the
current regime, if only because the criteria are wider, broader,
more expansive.
We're deeply concerned
about the impact of the bill, were it to become law, on the
resources available to our hospital to be able to do the job
we're mandated to do.
We also have to look at the quality of care. We're
mandated to provide care. If the bill comes through, the
community treatment orders are implemented, and much more
mandatory treatment takes place than currently takes place, is
that the kind of care we would like to see? We're committed to
compassionate care which is respectful of the person and the
person's right to make decisions about their own health, as well
as the treatment considering the possible negative impacts on the
individual and others. It should be care which is respectful. It
should be least-intrusive care. We don't see this in the bill
now. We don't see any requirement that the treatment in the
treatment orders is least intrusive.
Now, listening again to the
Ontario Medical Association, it's almost by definition that if
you're treating in the community, that's less intrusive or least
intrusive. That's not necessarily true at all. In fact, it may
have more intrusive care, more medication of the sort that will
make a person tractable in the community than would be
administered in a hospital, were the person in the hospital for
care.
1730
We have to look very
closely at two things. Does community care necessarily mean it's
less intrusive? Not necessarily, and here we get into the
resources that would be devoted to care in the community. But we
also have to look at the legislative regime and whether the
legislative regime itself mandates or requires the care and the
plan to be least intrusive.
Of course there are the
rights of the patient that are implied by the compassionate and
least-intrusive care that we're very concerned about. An
expansion of the ability to treat involuntarily is something that
all of us have to be concerned about. We're deeply skeptical that
this bill will provide care which does respect the rights of the
individual.
We're also concerned that
the bill will result in a diversion of two kinds of resources.
The first kind of diversion we're concerned about is a dollar
resource diversion into care that may well be inferior; care
that's inferior because it's care under a community treatment
order that's underfunded. In our view, that takes resources that
are inadequately provided into a form of care that may well be
inferior, resources that could have been used better in forms of
care that are better established, in a hospital setting or
elsewhere.
We're also concerned about
diversion of dollar resources by the government to protect the
legislation. This legislation is quite controversial and almost
undoubtedly will be the subject of legal challenges, charter
challenges, because of the intrusive aspect. Is that kind of
activity worth what the bill is offering us in terms of potential
impacts? We ask you to consider that. We think an enormous number
of resources may be diverted into that.
There also may be a
diversion into the kind of care-and this goes back to the first
point I was making about diversions-that is inferior because it's
devoted to the use of the new powers, because members of the
profession are under pressure to use the new authority, to use
the new pressure, even perhaps against their better judgment,
because of the pressure from families and others.
Finally, we're concerned
about the diversion of political resources. The profile of the
bill gives us the following kind of concern: If this bill becomes
law, we're concerned that passing the bill will somehow convince
the Legislative Assembly and the public at large that the mental
health agenda has been addressed and addressed adequately. We
think that is a significant diversion of political resources away
from this issue. We don't think the bill, as it stands now, does
address comprehensively the needs we feel in our community. We
don't think the bill intends to do that or purports to do that,
but by gathering the kind of attention it has and diverting
political capital in that direction, we're concerned that the
mental health agenda will be shoved to the side, left, and the
government and others will move on.
That's the substance of my
presentation. Margaret Van Dijk is going to go from the general
concerns we have to talk about our mission, our mandate, in the
context of how the bill might effect-and this is a
hypothetical-someone who is a member of our community, someone we
have the mandate to treat.
The Chair:
I should alert you that you've got about four minutes left for
your presentation.
Ms Van
Dijk: My concerns are, as we said, about the safety of
the community as well as the well-being of the mentally ill. We
have a hypothetical patient, Joe. Imagine Joe. Joe is a Canadian.
He lives in Parkdale. Joe has a history of schizophrenia. He has
paranoid delusions. He believes he's a target for Mafia hit men.
But he's not violent. He needs drugs, but he doesn't like taking
them because of their side effects. When he went off his
medications in the past, he was always hospitalized and
stabilized.
Joe has heard of community
treatment orders. His perception of them is that a CTO will
punish him for his illness. He knows he's at risk of having one
issued against him. That's why Joe now stays at home in a shared
room in a Parkdale rooming house, watching TV all day, not eating
properly, not taking care of himself, gaining weight. He never
goes out. He knows his behaviour scares people. He grunts. His
tongue clicks. His body language and disorganized speech is scary
for people who don't know him.
The current lack of beds
and resources would mean that Joe is at risk of having a
community treatment order issued against him. The mandatory
nature of this order terrifies him and so do the nauseating side
effects of the injections imposed by the order. So terrified is
Joe of having the CTO issued against him, of losing his benefits,
his drug card, his room and any semblance of freedom that he has
gone underground, that he stays in hiding in a cramped and messy
room in Parkdale.
Joe is in fact suffering
more and more. He's daily becoming more dangerous to himself and
others. As you heard, 10% of young male schizophrenics commit
suicide. What will happen to Joe? He's becoming quite detached
from reality.
What does Joe need? What's appropriate for him?
We'd like to see more support: support like specialised
residential housing; a caring institution where he can reside in
moments of crisis; a caring and trustworthy relationship with his
physician and health care providers, the ones involved in direct
clinical care-his attending physician, not just any physician.
We'd like Joe to have access to the latest medications that do
not give him disturbing side effects. We'd like assurance that in
a crisis he'll have his rights read to him within 12 hours. We'd
like him to have the right to the second opinion of a
psychiatrist. We'd like him to have assurance that he's not going
to be cut off his drug card, his benefits, his income support.
We'd like him to have confidence that his drug record will be
seen only by health professionals and with his full consent,
unlike section 16 of Bill 68. We'd like him to have confidence
that he'll get support without a CTO.
Bill 68 does not offer Joe
these supports, so what can he do and where can he go? We know
that St Joseph's hospital is stretched to the limit already. We
heard the OMA mention they have 1.4 social workers to a ward in
their hospitals. So where will Joe go?
In conclusion, on behalf of
St Joseph's mental health programs and especially on behalf of
the community St Joe's serves, we ask you to seriously consider
this bill and its implications for our community, consider more
carefully the possible misuses the bill could lead to, think
about the lack of security for the community that will still
exist due to the lack of institutions and services for the
seriously mentally ill. We'd like you to offer more support
systems to contribute to a sense of safety in the community.
As it stands, Bill 68 shows
a lack of respect for people's fundamental rights and freedoms,
and it jeopardizes the compassionate care which is so evidently
what the mentally ill need and their physicians want to provide.
We think the seriously mentally ill deserve a closer look at Bill
68, and we think our community's safety deserves a more
thoughtful approach to this issue. Thank you for your
attention.
The Chair:
Thank you very much. You've timed it perfectly. That was your 20
minutes. We very much appreciate your taking the time to come
down and share your views with the committee today.
Ms Lankin:
Mr Chair, I was just wondering if you could instruct us with
respect to the rest of the day's agenda. I'm very keen to hear
both of these presenters. In fact, I have a terrible conflict
post 6 o'clock. Have you made arrangements?
The Chair:
I'm led to believe that the folks from the Mental Health Legal
Committee have very graciously agreed to allow themselves to be
rescheduled.
Ms Lankin:
Terrific. Thank you.
The Chair:
We are in their debt and certainly we'll be very accommodating
for the rescheduling. That means we should only be a few minutes
past 6 o'clock.
1740
ONTARIO HOMES FOR SPECIAL CARE ASSOCIATION
The Chair:
The next presentation will be from the Ontario Homes for Special
Care Association. Could their representatives come forward,
please. Good afternoon. Welcome to the committee. Just a reminder
that we have about 30 minutes for your presentation, barring any
votes back in the Legislative Assembly. Perhaps for the purpose
of Hansard you could introduce yourselves.
Mr Brad
Rye: Good afternoon and thank you for this. We're from
the Ontario Homes for Special Care Association. This is our
president, Mike Dowdall. This is the secretary-treasurer, Connie
Evans, and I'm the vice-president, Brad Rye. We'd just like to go
through the first page of our handout so that you know who we
represent.
The present Ontario Homes
for Special Care Association is a non-profit organization founded
and established by the homeowners and operators throughout
Ontario in 1991. At that time all applications were accepted. As
the association evolved and matured it established for its
members a standards checklist and code of ethics which today all
members in good standing must adhere to and abide by. The
monitoring and reporting of violations of these good practices
are the responsibility of nine directors throughout the province.
This information is kept confidential and is used only by OHSCA
as we self-police our members in an effort to ensure quality
homes. The nine provincial directors and five executives have
been given the authority by the members to either accept or
refuse and, when necessary, repeal memberships.
Presently, our membership
stands at 110 members, or approximately 73%. These homes
represent 1,160 residents, or 84%, of the residents in HSC homes
in Ontario. In the remaining 29% of homes that are not members,
we are aware there are homes operating and practising within our
standards that would be accepted by this association; however,
there may be others that would not. The association is presently
100% funded through annual dues by the members. All area and
provincial directors are volunteer and are elected by its
members. All area and provincial directors are volunteers and are
elected by the members.
Mr Mike
Dowdall: I'd like to carry on with page 2, explaining
the HSC program and when it was created, in 1964. At that time it
was to provide long-term care to people with a serious mental
illness. Over the past five to six years, through mental health
reform and the mental health system changing, the program has
evolved into both short- and long-term care for the seriously
mentally ill. The reason for our activities here today with the
CTOs is that we are basing ourselves as proof that if the people
are supervised and carry on with their medication in a proper
environment, their quality of life is enhanced greatly. Our homes
are heavily regulated by the Ministry of Health, as opposed to
the unregulated boarding homes etc which do not have the supervision and
assistance with medications and with daily life skills.
There's a level of care
expected in a home for special care, which of course would
enhance anyone with a CTO because they would have 24-hour
response to a problem or an oncoming crisis. As each individual
is different, these homes are geared to respond to the different
needs of each individual resident rather than to have a form of
response which would generalize the care for the people
involved.
In a lot of cases you're
allowed to assist these individuals of their own free will
because you have a trust engagement with the person. Persons with
serious mental illnesses have a great deal of paranoia when it
comes to trust. Whether it's trusting a medical professional, a
friend etc, you must open a relationship and make sure that
relationship is sustained.
Our homes: As you can see,
we've listed out many of the things that a home provides aside
from the roof, bed and meals. We make sure they have a medical
practitioner, whether it's a house doctor in some of the rural
locations or it's a personal physician in the more urban
settings. They get regular medical care as well as regular
psychiatric care, and if the psychiatric care is not available
close to the home, then we either make arrangements for a
psychiatrist to come and visit or we do the mileage and take them
to the psychiatrist. None of this would be left to the owner's
prerogative; it's all under the medical and psychiatric care of
their physician and psychiatrist.
The HSC program has proven
to be an extremely valuable resource for the province of Ontario
for people with serious mental illness who cannot live
independently. There are many who can manage their own affairs
and live independently. The people we house are persons who do
not have these abilities or have not as yet learned these
abilities to take care of themselves. That is the transitional
part of our program; it's people coming in who are unable to feed
themselves, unable to master their medications etc. We get them
on the program, get them straightened away and hopefully they
move out into more independent living, sometimes with a social
worker on a weekly visit and sometimes with a social worker on a
monthly visit. Obviously, the goal is to give these people a
better quality of life and move them out.
Many of the residents in
our program have come from less supportive housing environments
and their needs were not being addressed or met. These people
have turned into both satisfactory residents and normal human
beings, working within the community fabric, rather than being
isolated in a boarding house or sitting in a room by themselves
with no one paying attention to them.
In many cases we have taken
people from the homeless population through the different
hostels. These people, with a lot of encouragement and a lot of
care from outside agencies etc, have been a success and are
remaining stable in the homes.
A long-standing inadequacy
that's painfully clear is the current severe shortage of this
type of housing, and that's province-wide. We can tell you that
as close as York region the system is saturated, and as far away
as Thunder Bay the system is saturated. For these individuals
that you're looking to help with a community treatment order, we
need an end result. Housing is the same as the best medication
available. Stable housing makes a person comfortable and makes
them feel good. Therefore, they stay off the street, out of the
hospitals and out of the judicial system.
Right now, if the community
treatment orders were to be enacted, there are not enough beds in
the province to take care of all these new walking-well
individuals. There wouldn't be an option for them. They would
probably end up back on the street or back in a psychiatric
hospital, which is not a choice that any of us would like to
make.
We also have the ability
within our program to provide even greater levels of care than we
do today. We have investigated this with the Ministry of Health.
Our owners are quite willing to move forward, providing a more
supervised atmosphere, perhaps a more supportive atmosphere to
individuals who are finding it very hard initially. The owners
are willing to put their private funds forward and make sure that
there are buildings for those who need the extra care and
support. Of course, that must be funded. Today there is not
enough money in the system or in the program or being paid to the
home owners to allow them to progress in that direction.
In reality, the current
population in HSC may have few housing options altogether. If the
homes for special care program was to collapse in this province,
there's really little chance of their finding other suitable
housing. They would have to be taken back into psychiatric
facilities, or turn to the street.
In the overview section,
while the care component is mentioned in various statements
throughout, it becomes apparent that many underestimate what the
care element really is that's provided to the population in our
homes. In many cases the care component far outweighs the actual
housing component. It must be understood that these people have
repeated problems, spontaneous problems which happen
inconsistently, and you must have a person there who can respond
to each individual's needs on a 24-hour basis. Outside support
services are certainly valuable. They assist these individuals,
but they're not available 24 hours a day.
1750
The style of care in an HSC
home provides the resident with a familiar stability in their
lives, including their address, neutralizing a situation which,
under many other housing options, results in hospital
readmission, and that's very costly to the Ontario taxpayer.
Our resident population
consists of individuals who range in diagnosis from
developmentally challenged to psychiatrically diagnosed and
include those suffering from addiction, defective behavioral
management skills, and other affective disorders, who would not
normally or successfully fit into a less supportive environment.
The instability of their mental health leads to confusion and
accelerates the
decomposition process, which can result in a complete breakdown
of an already fragile ability to cope with life as they do. When
these situations appear, OHSCA is confident our homes have the
ability to recognize this situation, intervene and diplomatically
diffuse it, avoiding the possibility of a full-scale crises. When
you're dealing with persons on a CTO, if they are not stabilized,
they will cycle. They will then get well on their medication and
in many cases say, "Now that I am well, I no longer need my
medication," and be back into the system again.
The ability to intervene
and stabilize a crisis before it reaches a climax decreases the
cost of other community services such as ambulance, hospital,
police and the judicial system. This alone saves our government a
tremendous amount of health care dollars and other associated
government costs.
We have put forward some
suggestions. The following are some suggestions from the Ontario
Homes for Special Care Association to alter the HSC program in an
attempt to address the need when housing and 24-hour support are
a component of a community treatment order.
(1) Continue to bring HSC
under the umbrella of mental health reform and have HSC
recognized as a mental health provider that can be flexible to
the needs of a geographic region or area while remaining
consistent through the Ministry of Health administration and
control.
(2) Maintain and ensure
that home standards, safety, accountability and monitoring
measures are in place and enforceable.
(3) Ensure that the HSC
program and CTO are focused on the resident's quality of life,
enabling operators to provide for and assist an individual to
reach their maximum potential.
(4) Fund the HSC program at
the proper levels to allow the homes to be responsive to the
above and be profitable small businesses in Ontario, therefore
keeping the owners that you have today and attracting quality
ownership in the future.
(5) Community supports must
be put in place where they are absent and all "seriously mentally
ill" must have equal access to these supports.
The Chair:
Thank you very much. That leaves us with just slightly under five
minutes, let's say four minutes, per caucus. This time the
questioning will commence with the government.
Mrs Julia Munro
(York North): Thank you very much for coming here this
afternoon. I have to insert a personal message here in that I've
had the opportunity to visit both of your homes and several of
the homes in my riding. I think that your experience in homes for
special care and understanding some of the issues from your
perspective are really important to this committee. I certainly
want to compliment you, not only professionally on what you do
for the residents of your homes, but also for being able to be
here today to give us some input into this process.
I wonder if there are any
specific areas of amendment you would like to offer at this point
with regard to the Mental Health Act and the Health Care Consent
Act, given the kind of practical experience you have and
recognizing that you have provided us with some of these
suggestions at the end of your brief.
Mr
Dowdall: We would just like to comment that obviously we
are in favour of this type of order, community treatment orders,
because we have personally been through the results of successful
medication treatment for individuals who are not stable. Once you
make these persons stable and get them into an environment of
safety, then they no are longer a danger to themselves or a
danger to anyone else, whereas some of the residents we acquire
over time have a lengthy record with the police department. In
some cases we're still going to court seven and eight months
after they've been admitted to our homes, all over some violent
issues, drug dealing etc. It just seems that when they get into a
stable environment and get on a medication themselves so that
their schizophrenia or paranoia is not affecting them, then they
stabilize and they're quite normal human beings. I think it's a
terrible shame that somehow in Ontario we've found a way to allow
people to deteriorate and we don't have a choice to turn that
direction around.
Ms Lankin:
Sorry to interrupt. I just want to offer my apologies. I have a
scheduling conflict and I have to leave. I appreciate your
presentation and I'll be sure to call you if I have any follow-up
questions.
Mr
Dowdall: Certainly.
Mrs
McLeod: Just a couple of questions. The funding that
would support the psychiatric care that many of your residents
need would be Ministry of Health funding. Is that right? In terms
of the establishment of any new beds, you would be eligible or
members of your association would be eligible to apply for
capital funding for the creation of new beds?
Mr
Dowdall: No.
Mrs
McLeod: So all the capital funding has to be-
Mr
Dowdall: Private.
Mrs
McLeod: -leveraged privately, which is often difficult
in the not-for-profit sector.
Then my next question is,
with the community beds that are being developed for people who
have psychiatric difficulties-and there's a three-phase program
the government has introduced-are you participants in the first
phase of that? Is there a possibility that homes for special care
would be able to establish that there would be some funding for
actually establishing new beds as well as receiving ongoing
operating support?
Mr
Dowdall: Actually, the way it has to work under the
criteria today is that homes for special care would have to be
linked to an existing transfer payment agency to access that
funding. To date, none of our homeowners have opted to align
themselves in that way with a transfer payment agency, but
certainly that is available. Within the ministry itself we have
been, over the last six to eight months, dispensing beds in
various areas of the province where there's need and licensing new homes for
these same individuals.
Our involvement with the
homeless criteria has always been stable and has always been
active, because the shelters in Toronto, Thunder Bay, Brockville
Kingston, Hamilton or wherever they happen to be already utilize
our homes as stable housing for the individuals once they get
them in off the street. The only thing we don't access is the
capital funds. Our owners capitalize their homes themselves and
then of course want the beds filled by the ministry.
Mrs
McLeod: But the housing initiative relates very directly
to the bill because it is, as you've said, a significant part of
providing the community support. Maybe, Mr Chair, I could ask for
this as a clarification just for my own information. I don't have
the actual dollar figure in front of me, but I think it's
something like $40 million, $41 million over the next three
years-
Mr Clark:
It's $45 million each year for the next three years.
Mrs
McLeod: Is that capital funding or is that considered to
be the operating-
Mr Clark:
It's operational funding.
Mrs
McLeod: That's operational support. So then the capital
funding to establish those beds has to come from the private
sector? Thank you. I appreciate that qualification. I've probably
now used my time, have I? I have another question.
The Chair:
Please go ahead. I must apologize. When I recognized Ms Lankin, I
didn't realize Mr Clark had a question as well. So feel free to
take half of her time and Mr Clark can have the other half.
Mrs
McLeod: I won't abuse that. I wanted to ask, in the work
that you do, do you find that your members are often working with
individuals-I guess I want to follow up on your last response to
Mrs Munro. Do you find that there are individuals where you just
can't provide the help they need and a community treatment order
would be of assistance? I'm just wondering how you see that being
helpful to you in a specific way.
1800
Mr
Dowdall: Certainly there is an opportunity for that to
take place. Today we get residents who, as you say the nice way,
you can't handle, and if you had access to an outside agency to
assist you with that individual and they were forced to take the
assistance or to be assisted, then certainly you might be able to
stabilize them and keep them in the home.
The way it is today, of
course, you can't force them to take the medication, you can't
force them to work with a community service. So you have to go to
the ministry and say, "This individual is upsetting to the
environment of the home to a point where they're a danger to
others or a danger to themselves, and could you please place them
elsewhere?" It's pretty much understood that if we can't handle
them, there isn't going to be much of a community-based housing
element that can handle them, and they normally return to
hospital or end up homeless.
Mrs
McLeod: But if the individual is non-compliant with
their medication, which would make them a candidate for the
community treatment order, and they're still saying, "No, I'm not
going to take my medication," how do you enforce compliance?
Mr
Dowdall: We wouldn't. We would certainly use whatever
services were available. We'd try to coerce the individual to
take it, but if a person is going to be forced to take
medication, it's going to be by someone other than a home owner
or a home operator in a home for special care.
Mrs
McLeod: Do you think just the existence of the order is
almost like an agreement that would encourage them to be
compliant?
Mr
Dowdall: I think so.
Mrs
McLeod: I'm leading a little bit.
Mr
Dowdall: In many of our homes, people are told: "You
must be a reasonable individual with the others in the home. When
you don't take your medication, you're not a reasonable
individual. So therefore you have to make a personal choice here.
Do you like where you live? Do you enjoy the individuals you live
with? Then you should take your medication. Otherwise, I think
you should go looking for another place to live."
Mr Clark:
I just have one question. First, I want to make a statement. You
stated in your suggestions that you wanted to focus on the
residents' quality of life and try to assist patients,
individuals, to achieve their maximum potential. I would argue
that everyone in this room would agree that is the obvious goal
we're all trying to accomplish.
That being said, the
previous witness had raised skepticism about community treatment
orders and whether the supports would be there in the community
and told a hypothetical story about that.
The legislation talks about
a plan for treatment for people. Hypothetically speaking, what
would be your ideal form of a community treatment order? We heard
while we were on consultations that a physician would be not only
looking at supportive housing and medication but would be looking
at vocational counselling and making sure the supports are in the
community to encourage the individual to reach their potential.
What would be your ideal community treatment order, for example,
if I was in need of such an order?
Mr
Dowdall: First of all, you'd have to have the persons at
the first contact educated as to what a community treatment order
covered and what was involved, and when you saw, observed, heard
about this individual acting irrationally, so that they fit the
criteria of a community treatment order, you would have to have
those people knowledgeable about what they should do with that
individual right away, who they would contact, whether it would
be: "Do we take them to a hospital? Do we take them to a
treatment centre?"
Once the person has made
first contact, then they must make sure they make this individual
understand, "This is not now your choice; this is an order and
you must comply," or the other option; you must offer another
option, whether it be
jail or whatever. But there has to be a criterion. It's the same
reason why I don't walk into IGA and steal bread: because I know
there's a good chance I'm going to get caught. They must
understand that there is something back there if they don't
follow the community treatment order.
Once they have complied or
offered to comply with the treatment order, you must make sure
they have stable housing, you must make sure they have both
medical and psychiatric facilities available to them right away,
because there are a lot of people with a psychiatric illness not
on medication who don't realize what their medical disorders are.
Those must be dealt with immediately. Then, after you have them
stabilized, you must give them something for their mind to do now
that their mind is operating. So you need vocational help, you
need support workers, you need social workers. You need all of
these individuals to reacclimatize these individuals to the
community, because realistically before they've gone on their
medication, although they've lived in the community, they
wouldn't recognize the community. So you have to reaccess them to
what is available in the community, and you must make sure you're
consistent. It must continue on. It can't be something that's
three months and, "OK, Johnny,"-or Suzie-"go out and do your
thing," because it won't work.
Mr Clark:
So, not meaning to put words in your mouth, community treatment
orders for you are not just about medication?
Mr
Dowdall: No, they're about changing their whole
lifestyle. This gives these people an opportunity to have a
quality of life that a lot of them will never realize unless you
force them to realize it.
The Chair:
Thank you very much for coming before us here and, again, our
appreciation for your accommodating a later schedule. I
appreciate everyone else who has come to listen to the
proceedings today.
The committee stands
adjourned until 10 o'clock at the Sheraton Hotel in Hamilton,
Friday morning.
