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
Canadian Mental Health
Association, Niagara south branch
Mr Neil McGregor
Schizophrenia Society
of Ontario
Ms Selina Volpatti
Wellington Psychiatric
Outreach Program
Mr Robert Foster
Oak
Centre
Mr Shawn Lauzon
Mental Health Rights
Coalition of Hamilton-Wentworth
Ms Deborrah Sherman
Provincial Acquired
Brain Injury Program of the Hamilton Health Sciences
Corp
Dr Diana Velikonja
Ms Patti Leonard
Consumer/Survivor
Initiative of Niagara
Ms Judy Hoover
Ms Sasha
McInnes
Ontario Psychiatric
Association
Dr Alan Eppel
Dr Lawrence Martin
Mr Brian
Lane
Hamilton Psychiatric
Hospital Patient Council
Ms Patricia Landry
Mr John Schalkwyk
Ms Linda
Carey
Ms Marilyn
Smith
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)
Clerk pro tem / Greffier par intérim
Mr Tom Prins
Staff /Personnel
Ms Margaret Drent, research officer, Research and Information
Services
The committee met at 0958 in the Hamilton
Sheraton Hotel, Hamilton.
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.
The Chair (Mr Steve
Gilchrist): Good morning. I wonder if I could call the
hearings to order. The purpose of our visit to Hamilton today is
to consider Bill 68, An Act, in memory of Brian Smith, to amend
the Mental Health Act and the Health Care Consent Act, 1996.
CANADIAN MENTAL HEALTH ASSOCIATION, NIAGARA SOUTH
BRANCH
The Chair:
The clerk advises me that our first couple of presenters are
already here today. I know it's a couple of minutes early, but
all the members are present as well. So with your indulgence, I'd
like to call forward the Canadian Mental Health Association,
Niagara south branch, if they could join us at the witness table.
You have 20 minutes to make your representation. If you wish to
allow any time for questions, make sure you take that into
account, please.
Mr Neil
McGregor: Good morning. It's a real honour to be able to
appear here this morning and make a presentation to the standing
committee on general government regarding Bill 68, otherwise
known as Brian's Law.
My name is Neil McGregor, and
I am the past president of the Niagara south branch of the
Canadian Mental Health Association. I have been on the board of
directors for the Niagara south branch since 1992 and was
president from 1996 to 1999. I also serve on the board of
directors of the Canadian Mental Health Association, Ontario
division. I am also the chair of the board of directors for AIDS
Niagara, a local association providing supports and services to
people infected with or affected by HIV/AIDS. So you can see that
I'm certainly enjoying my retirement from working for many years
at Niagara College.
I believe you have in front
of you the outline of my presentation. It starts with a brief
description of the Niagara south branch of the Canadian Mental
Health Association. I just want to emphasize a couple of points.
This is a community-based association. It is a volunteer-led
association. Of course it is professionally managed, and it is
values-driven. As a result of that, our branch is quite concerned
about the amendments to the Mental Health Act, which we are
discussing here this morning. I have outlined our vision, our
mission and our philosophy, and I'm not going to take the time to
read all that. I have also indicated some of the supports and
services we offer the residents of Welland, Port Colborne,
Pelham, Niagara Falls, Fort Erie and the surrounding
communities.
I know I'm not telling you
anything new when I say that Brian's Law, which amends the Mental
Health Act and the Health Care Consent Act, is primarily directed
toward people with serious mental illnesses, and of course the
main focus is on the CTOs, the community treatment orders. I'm
not going to spend much time talking about that part of these
amendments this morning, because I know it will be addressed in
many other presentations not only this morning but at some of
your other hearings.
The concern of the Niagara
south branch is more about what is not in the amendments to this
bill, and what we would like to see. We would like to see-and we
support the Ontario division of the Canadian Mental Health
Association in this-more comprehensive health systems
legislation, which would ensure funding of a full range of
community health services which would apply to all persons who
require services, and which was recommended in the Ministry of
Health and Long-Term Care document called Making It Happen. I'm
sure you are all aware of that document.
The mental health legislation
should ensure that there is a basic core of services available in
a timely way to everyone in Ontario. These services should
include services needed to treat persons with mental illnesses,
services to support families and services supporting promotion of mental health and the
prevention of mental illness. From my understanding, that is not
a part of the amendments that are being proposed.
There is strong evidence that
providing treatment and comprehensive supports in the community,
which include employment and housing, improves people's quality
of life and reduces the need for hospitalization.
The next section of my
presentation indicates some of the gaps in services that we have
in the Niagara area for people with mental health issues. I have
just picked up on a few of those, which have all been taken from
a document the Niagara District Health Council put together.
Their document is dated 1997, which of course is three years ago,
but it is still relevant. Because very little funding has come
our way to address these problems, they are still problems.
I have indicated the gaps in
housing, especially affordable housing for people with mental
health issues. As I've indicated here, as measured against the
benchmarks, by the year 2007 there will be a need for 988
residential spaces, and we don't have that in the Niagara
area.
Community support case
management: For the 10 years from 1997 to 2007, it is estimated
that the Niagara area will be short 41 to 67 community support
workers or case managers.
Crisis care: There have been
some improvements with additional funding for crisis care in the
region, but we still do not have 24-hour coverage. We still do
not have seven-days-a-week coverage in some of the programs,
especially the safe bed program.
The last gap in service I
mentioned is the fact that there is a shortage of psychiatrists
in the Niagara area. Today there are 18 practising psychiatrists
in the Niagara region, and the benchmark established by the
Ministry of Health and Long-Term Care indicates that for the
population of our area there should be at least 50 psychiatrists
in the region.
Our branch is making five
major recommendations. These recommendations were adapted from
the position paper that was prepared by the Canadian Mental
Health Association, Metropolitan Toronto branch, but our branch
is in support of these recommendations. I also mention that
yesterday I talked to the executive director of the St Catharines
and district branch of the Canadian Mental Health Association and
the executive director of the Brant county branch of the Canadian
Mental Health Association, and they are supportive of the Niagara
South position on these.
Very quickly, then, our first
recommendation, that I have already mentioned, is that there is a
need to develop mental health systems legislation to ensure
funding of a full range of community services.
We agree with the Ontario
division of the Canadian Mental Health Association that the
government should not proceed with legislation on community
treatment orders, but instead should commit to meeting the fiscal
and service targets outlined in Ministry of Health and Long-Term
Care policies since 1988.
Should the government proceed
with CTO legislation, it should ensure that a province-wide
system of community mental health and housing services is in
place before legislation is proclaimed. Of course, that will
require money.
If CTO legislation is passed
and proclaimed, it should have a four-year sunset clause and be
subject to a rigorous evaluation. And if CTO legislation is
passed, it should be transparent with respect to the obligations
of service providers to ensure the separation of monitoring and
compliance from the provision of treatment. The community-based
agencies in the Niagara area are quite concerned about who is
going to be monitoring and who is going to be seeing that
compliance is taking place if the community treatment orders
legislation is passed.
Of course, legislation should
ensure adequate funding for all functions.
I would be happy to answer
any questions.
The Chair:
Thank you very much. That leaves us with about four minutes per
caucus, and we'll start the questioning with the Liberal
caucus.
Mrs Marie
Bountrogianni (Hamilton Mountain): Good morning and
welcome. If this legislation passes as is with the two
amendments, and the resources you recommend are not there, what
are your organization's fears? Exactly what are the
implications?
Mr McGregor:
Our biggest fear is who is going to be monitoring. Who is going
to be seeing those persons identified and for whom the treatment
orders are requested, who is going to see that that happens and
what is going to be the impact on the support workers?
I think one of our main fears
is knowing that most people think that as soon as you say
"community treatment orders" it means requiring the person to
take medication to try to control their mental health issues. But
there's a lot more to treatment than that, and what are the
impacts on that as well?
1010
Mr Richard Patten
(Ottawa Centre): Along the same lines, I know this is a
concern of many organizations and agencies, and that's the
relationship between the treatment relationship and the role
related to either the monitoring or the support and compliance.
My understanding of this is that the attempt is a consensual plan
that would have the agreement of the patient or the substitute
decision-maker and that the agency is not placed in a position
of, "Well, if you don't take it, we're forcing you to do that."
That is not the intent, as I understand it, or the spirit of it,
but I can understand the sensitivity.
When you say, "separation of
monitoring and compliance from the provision of treatment," how
would you see that?
Mr McGregor:
I'd like to make a comment on the first part of your question, if
I may. It is my understanding within the amendments that if the
community treatment orders are in place and if a person has been
requested to comply with these orders and they don't, that person
may be hospitalized. To my way of thinking, that removes choice
on the part of the person who is suffering a mental illness. It's no longer
voluntary; it's involuntary. If they don't do it, they will be
hospitalized. For many of them, that's a horrible thing to happen
to them.
The second part of your
question was how I see it being implemented to separate the
monitoring and compliance from the actual support the workers do.
I'm not a lawyer or a politician; I'm just a community volunteer.
But I would think it would have to be very clearly stated in the
legislation, or certainly in the procedures, exactly who is going
to do the monitoring and who is going to do the compliance, and
it should not be these community support workers, because that
would destroy their relationship with their clients.
Ms Frances Lankin
(Beaches-East York): I was interested in your comments
about the lack of resources in the region you are representing.
Much of the literature I have been reviewing, or at least a
synopsis of studies from US jurisdictions that have a similar
legislative initiative, indicates that the likely success of such
a program as CTOs-I think they call them IOCs or something like
that in the States-is jeopardized by the lack of on-the-ground
services. In particular-and I raised this in hearings Monday-I
heard from a number of heads of psychiatry at general hospitals
their concern about the broadening of involuntary committal
criteria and what that is going to mean. They say there are some
people who are not committed now, not because they don't meet the
criteria but because there's not a bed available, and that means
voluntary patients can't find a bed. I raised that when the OMA
was presenting and their response was that the use of community
treatment orders would open up a lot of beds, that there would be
excess beds in the system and that they didn't see a need to
revisit any of the hospital restructuring commission's reports.
They referred to a US study, in particular on the Web site of the
Stanley Foundation.
My quick overview of some of
the material, and also taking a look at your parent
organization's Web site and the review, is that there's a much
more mixed view of the success of CTOs in terms of lower bed
utilization. Do you have any comments to make on that? Do you
worry about the fact that we actually need more community
resources and, contrary to what your organization might normally
advocate, institutional-based resources to make this regime
successful?
Mr McGregor:
The Canadian Mental Health Association, Ontario division, has
done some very extensive research into that very point in trying
to determine how successful community treatment orders are in
those jurisdictions that have them in place. There is quite a
lengthy list about this research as well and it's all available
on the Web site of the Ontario division of the Canadian Mental
Health Association. I can't quote them all offhand; I do have-I
guess it's in my briefcase back there-a list if anyone's
interested, and I could leave it with you if you like.
Generally the research is
such that there is no evidence that community treatment orders
are successful in reducing the number of people who might require
hospitalization. It doesn't seem to make any difference in terms
of those people who become seriously mentally ill and so on and
so forth. What does make a difference, though, is the supports
that are available before they reach the point where they are
seriously mentally ill.
Ms Lankin:
One of the other issues I raised on Monday was my desire to see
in the legislation some protections around access to service,
minimum kinds of services that must be available, and you make
reference to something like that in your document. Also there is
what constitutes a treatment plan. The third thing, and this is
what I wanted to ask you about, was the establishment of a mental
health advocate. We currently have the Psychiatric Patient
Advocate Office, which is a rights advocacy base directed at the
patient. But in jurisdictions like British Columbia they have a
mental health advocate who reports to the minister about the
state of quality of care in the mental health system and makes
recommendations about what's missing, where the gaps are, how the
system is working together or not. Would you favour the
establishment of that kind of office and see that as part of this
legislation?
Mr McGregor:
Yes. If the CTO portion of the legislation is going to go ahead,
I certainly think there has to be an advocate of some sort to
make sure that everything is being done, that all supports are in
place before a person reaches that state of life where they
require forced treatment.
Mr Toby Barrett
(Haldimand-Norfolk-Brant): Mr McGregor, thank you for
your presentation this morning. I know you recommend that this
legislation on community treatment orders should not proceed.
There's been discussion this morning, and you're concerned with
lack of choice or the mandatory aspect of this. I would point out
that community treatment orders are issued by a physician or a
psychiatrist or medical practitioner, and that the person subject
to a community treatment order receives advice on their rights,
or if they're incapable of interpreting that advice, that
person's substitute decision-maker receives that advice.
We are hearing a divergence
of views from various stakeholders. You mentioned the research,
and there may well be conflicting research. There is a body of
research in the United States that community treatment orders
reduce hospitalization, many of the orders directing a person for
an assessment rather than hospitalization. I guess the question
I'm leading up to-you mentioned two areas-is, are there other
concerns that you have, reasons you would be opposed to this
legislation on community treatment orders?
Mr McGregor:
One of the points I made in my presentation is the lack of
practising psychiatrists in the Niagara region. To me, they would
be the main person who should be prescribing the treatment,
issuing the orders and so forth and so on. There is a major gap
in service right there. If we're going to have the community
treatment orders, I certainly would like to see some increase in funding so that we
will get the qualified people with expertise to issue these
orders.
It's fine to issue the orders
and to prescribe what treatment should take place. It is seeing
that it happens that is still our concern. I don't think the
psychiatrist or even the other medical practitioners would be
doing that. They don't have the time. It will fall on the
community support workers or family or friends or whatever.
That's a real onus to place on them.
Mr Barrett:
I share your concern. We have no psychiatrists in my area, south
of Hamilton. For that reason, these orders are issued by
physicians.
The Chair:
You have one minute, Mr Clark.
1020
Mr Brad Clark (Stoney
Creek): I have a quick question for you. You stated that
if a patient is not in compliance with a community treatment
order, they're hospitalized. Yet the legislation states that if
the physician who issued or renewed a community treatment order
has reasonable cause to believe that the person subject to the
order has failed to comply, they can issue an order for
examination. It doesn't say they can be hospitalized; it says
they can issue an order for an examination. Further, it goes on
to state that they can only do that if they're of the opinion
that the mental disorder is likely to cause serious bodily harm
to himself or herself or to another person or substantial mental
or physical deterioration. That's not quite the same as what you
stated.
Mr McGregor:
If I did not state, "may be hospitalized," I should have said,
"may be hospitalized." I didn't mean that they will be
hospitalized. I also recognize that sometimes the intent behind
legislation is not what happens in reality.
If I can digress just
quickly, I saw a very interesting program this past Sunday, 60
Minutes. One segment was talking about community treatment orders
which are being proposed in New York state. The second segment
was about the three-strikes law that was passed in the state of
California. The intent was to get violent criminals off the
street. Instead they're getting people serving life for stealing
a loaf of bread.
Mr Clark:
With respect, that has nothing to do with where we are today.
Mr McGregor:
No, but my point being intent.
Mr Clark:
I'm assuming you're not saying that if someone is not in
compliance with a community treatment order and a physician or
psychiatrist believes they are a threat to themselves or to
others, they should be allowed to remain at large, when they
could, in essence, commit suicide.
Mr McGregor:
There is no evidence that equates mental illness with
violence.
Mr Clark: I
asked about suicide.
Mr McGregor:
Pardon?
Mr Clark: I
said, in essence, they could commit suicide. Are you suggesting
that if they're deteriorating and the physician is concerned
they're going to hurt themselves, they should be allowed to stay
out and not take the medication and that they should not come in
for an examination?
Mr McGregor:
There is existing legislation that can take care of that.
The Chair:
Thank you, Mr McGregor, for coming before us here this morning.
We appreciate your comments and the time you've taken.
Our next group this morning
is the Schizophrenia Society of Ontario, Niagara region. They can
come forward.
Ms Lankin:
Mr Chair?
The Chair:
Yes, Ms Lankin.
Ms Lankin:
I'd like to make a request of legislative research. There has
been some reference to the US studies. I think there is a body of
information that could be helpful to us. In particular, on
Wednesday, Mr Connell from the OMA made reference-and I think he
was providing us with one of the studies-to the Stanley
Foundation, which does have a body of research on its Web site. I
would also like to ask that reference be made to the Bazelon
Center Web site. I do have that reference. I think the CMHA has
also indicated that it has a compilation.
There are four studies in
particular, however, that I would like to ask for a review to be
done on. The first is a recent study by Swartz et al, 1999, for
information of the committee. It is a study that looks at the
relationship between CTOs and psychiatric bed utilization. It
does find, for certain subpopulations, a very positive
relationship in lower bed utilization, and for other populations
not, and also supports the contention that the effectiveness is
multiplied when there is a strong support of community services
behind the community treatment order.
Geller, 1999, looks at
criteria for the success of community treatment orders.
The Bellevue study, which was
done by Steadman et al, 1999, was a study of 142 patients and
looks at enhanced community supports versus without enhanced
community supports.
The last specific study is
Torrey and Kaplan, 1995. It is the results of a US national
survey on the use of outpatient commitment and looks at the
legislative regimes and then the utilization and the success.
If we could do that, I think
that might be helpful for all of us, assuming that this part of
the legislation is likely to pass, in how we make it the most
successful it can be.
The Chair:
Thank you, Ms Lankin.
SCHIZOPHRENIA SOCIETY OF ONTARIO
The Chair:
Good morning, Ms Volpatti. Thank you for joining us here today.
We have 20 minutes for your presentation, and if you wish to
allow time for questioning, please factor that into your
presentation.
Ms Selina
Volpatti: Thank you very much, Mr Chairman. My name is
Selina Volpatti. I am here as the immediate past president of the
Schizophrenia Society of Ontario.
Let me tell you briefly about our association. It
was begun in 1979 as the Ontario Friends of Schizophrenics. We
changed our name in the first year of my term, in 1994, to
correspond with other associations across the country and the
Schizophrenia Society of Canada. It's no error and it's not a
surprise that our organization was formed in 1979, the year after
the Mental Health Act was rewritten-rewritten in a way which made
it very difficult for families to get help for their loved ones
who had schizophrenia.
My written presentation will
be forwarded to the clerk of the committee. I don't have it with
me today, but I do have some remarks.
I would like to tell you
something about schizophrenia, and I would like to state very
clearly that I'm not here to speak about mental health issues.
I'm talking about mental illness, and those people who do have
issues of mental health are probably in a whole other category
than people who have schizophrenia. Schizophrenia is by far the
most prevalent and the most debilitating of the serious mental
illnesses. It leaves those whom it attacks, unless the disease is
treated, with very little insight into the fact that they have
any problem at all and with very few resources. Unless they have
their families helping them, there is very little out there that
is actually going to help.
Schizophrenia is a medical
illness. The primary response to schizophrenia must be medical.
The extension of social services to people with schizophrenia, in
the absence of a concerted effort to extend medical treatment,
will fail. Medical treatment must be primary in a treatment
program that of course includes a comprehensive system of social
supports. We're all aware of that, and it's very important that
those supports be there. However, what families have found,
particularly over the last 20 years, is that when you have a
person who is incompetent, who is not able to make a rational
decision about treatment, then a substitute
decision-maker-whether that be the family or the state or the
province, whoever that is-must step in to make the decisions for
that person.
What we basically want to do
with our support of the changes to the Mental Health Act-and we
are in full support of the changes that are proposed-is to move
from a statute of risk to a statute of care, because we firmly
believe-we not only believe, we know from bitter experience-that
when you wait for dangerousness it is often far too late to be of
help to the person who is suffering. We need a statute of care in
that one of the main criteria should not be dangerousness but the
need for treatment. The obvious physical and mental deterioration
of a person should twig the need for treatment, particularly when
that person is not competent enough to make a treatment
decision.
We are aware that one of the
criteria in the act as it stands now is the need for treatment.
However, the language around that is very unclear. It talks about
"imminent" and that has been interpreted and probably
misinterpreted by professionals to say that the danger must be
immediate or the deterioration must be immediate. Our sense is
that if you have language in the act which is unclear, which does
not promote prompt treatment, or indeed which in some cases
allows a professional not to give treatment because it's used as
an excuse not to give treatment, then that language should be
changed.
1030
When we talk about
schizophrenia, we are talking of a matter of life and death. The
danger to others is discussed in the media so often, and that's
very real. We represent thousands of families across this
province with sufferers who have schizophrenia, and there are
very few families that will tell you schizophrenia is not
associated with violence, because it is. That's a very hard fact
for families to contend with, but there are very few families I
have spoken to across the province, and indeed across the
country, who do not tell me that untreated schizophrenia leads to
violence in most cases.
We support the changes to the
act. Of course the other part, separate from the legislation, is
the provision of services, and it's kind of a chicken and egg
question. What do you have first, the legislation or the
services? Our feeling is that you have the legislation in a way
that holds the government accountable to provide the services
that are demanded by the legislation. We strongly support that
the legislation must come first and that gives us a basis to
advocate on behalf of our relatives for the services that really
should be there.
We fully support having a
mental health advocate for people with schizophrenia, providing
that's not a member of the CMHA, because the CMHA deals with
people with mental health issues, and I want to say again that we
deal with people who have serious mental illnesses. If they were
mentally healthy, I probably wouldn't be here today.
The service issue is indeed
important and I want to state for the committee as well that I am
the mother of a 36-year-old son who is critically ill with
schizophrenia, who because I was able to access treatment for
him-don't ask me how because I won't tell you-after seven years
of institutionalization, and wonderful treatment in this province
in a system that is very hard to access, is doing marvellously
well today. He is living on his own, is driving his own car, has
a part-time job, is on disability but is certainly a success
story. Ten years ago, if someone had told me this was possible, I
wouldn't have believed it. I have been told by every psychiatrist
who has treated him that if it were not for the medication he
religiously takes today, he would be in an institution for the
rest of his life.
So I'm here as a living
example of what good law can do, but I had many opportunities at
my disposal to procure for him the treatment that really is so
difficult to procure for most families and most people who
suffer. Basically, that's my presentation.
The Chair:
Thank you very much. That's left us about three minutes per
caucus. This time the rotation will start with the New Democratic
Party.
Ms Lankin:
Ms Volpatti, thank you for your presentation and for also sharing
your personal experience with us.
I want to clarify one thing. My reference to a
mental health advocate is not for a person who would be an
individual patient or rights advocate; it's a systems advocate.
In the one in BC, that person is expected to monitor the
performance of the care systems and suggest policies, practices,
programs and services for people who are most seriously mentally
ill. I think it's an accountability that you were talking about,
the legislation, back to the government.
Specifically on that and
the cart before the horse, on services and legislation, I'm
proposing to marry the two. In previous legislation that existed
in this province, long-term-care legislation which is no longer
in effect, there was a provision for a list of minimum services
required in every region of the province. We don't have anything
like that for mental health services or treatment provisions for
the mentally ill. I'd like to see something like that built into
this legislation, as well as using some of the US legislation as
a basis, a definition of what constitutes a treatment plan, so
that it's not simply left open, that there are some elements that
must be considered for what a quality treatment plan is.
When I raised this on
Wednesday, the Schizophrenia Society of Ontario was supportive of
those ideas. Have you given any thought to that? Has the Niagara
region given any thought to that?
Ms
Volpatti: I would say that we would certainly support
that, providing that the treatment order included medical
treatment. To me and to people in Niagara region and to people
across this province, that is key. So often I think we've skirted
around the issue of schizophrenia as a medical illness.
Ms Lankin:
That raises something. When I met with the East York Sharing and
Caring group, which is the local Schizophrenia Society branch, we
collectively came away from that meeting thinking that there is
something so different about the experience that families of
schizophrenics, and patients, have from many other types of
mental illness that it almost requires a definition of treatment
and medical treatment options on its own, and that some of the
differences between psychiatric survivors of other types of
mental illnesses and their dispute with this kind of legislation
and the discordance that's occurred is a lack of understanding of
the differences. Do you think that's a valid observation?
Ms
Volpatti: It's my opinion, having thought about this for
some time, that perhaps the act does need a preamble to define
exactly who are the seriously mentally ill who should be
governed, I quite agree with that. I believe that's been done
with the Criminal Code. I think Priscilla de Villiers, for
example, was successful in getting a preamble to the Criminal
Code which clarified some issues that had been unclear for a long
time. I think the Mental Health Act could do with a preamble
indicating exactly who the persons are who are intended to be
covered by these sections.
Mrs Julia Munro
(York North): Thank you very much for coming here today.
You talked a little bit about the way in which a community
treatment order can benefit those who have schizophrenia. I just
wonder whether or not you could give us any specific examples of
how you see that particular mechanism being useful, being
helpful?
Ms
Volpatti: Yes. I'll give you an imaginary example,
because we don't have much experience in this jurisdiction.
Mrs Munro:
Yes, of course.
Ms
Volpatti: I would suggest a person who is being released
from a psychiatric institution into the community, who has
probably been back and forth to that institution many times, who
takes his medication while he's living on the ward but once he
gets out in the community, for one reason or other, does not take
the medication. Speaking from my own experience, two beers are
enough for a person with schizophrenia to forget, "This is the
time I have to take my medication." If they forget once, they'll
forget the next time, and on and on it goes, and before there is
any help for that person, he has deteriorated so badly that it's
back to the hospital.
I see the community
treatment order working in such a way that if that person-let's
say that when he's just released from hospital, he's going to
report to his team once every three days, and if he doesn't
report, they're going to have to look for him and make sure he
has taken his medication; if not, he is going to be brought back
into hospital. But when he's brought back in that way, he is not
going to have deteriorated to the degree he would have
deteriorated if he'd been left out in the street for 30 days, 60
days or 90 days. It's with this revolving door thing that we see
the community treatment orders really playing a factor.
I know that in New York
state, where they have not yet been implemented but where they
are using them, where they are talking about them, where teams
are talking about them, just saying to a person, "You must take
your medication, and if you don't, we have something in place by
which you're going to have to be brought back into hospital" is
enough to make that person take their medication.
Many doctors have said to
me, "We have people with cancer who take chemotherapy that causes
horrible side-effects and nobody really has a problem with that,"
but when we're talking about somebody who has schizophrenia, just
the least side-effect is enough to make some people out in the
world go absolutely screwy. We have to remember all of this, and
the fact that the medications have improved so much too over
time.
Mr Patten:
Thank you for coming today. I would like you, if you could, to
elaborate a little bit. When you talked about the need to move
from risk to care, could you expand on that?
Ms
Volpatti: Sure. I think, Mr Patten, that the criterion
of dangerousness is really a criterion of risk, that that person
is not helped until they become a risk to others in the
community. It's nice to think that it works if you're a risk to
yourself as well, but we all know that's probably not true. Once
you become a risk, a danger to others, then you're likely to get
treatment. We say that that is just too late, that we would like to have a statute that
shows caring for people, that when the physical and mental
deterioration begin, that's when you should get the help.
I would really like to
refer to a great body of literature, and to Dr Robert Zipursky
from the Centre for Addiction and Mental Health, who has done
extensive research into the fact that the earlier the medical
intervention with schizophrenia, the much better the prognosis is
over time. That's a really frustrating thing for parents and
families to know if they can't access that treatment in an early
way.
Mr Patten:
With the implication of that, by the way, would you have any
suggested amendments then?
Ms
Volpatti: We have a solicitor who is working on this and
he is sending those to the committee. That will be received.
The Chair:
Thank you, Ms Volpatti, for appearing before us here morning. We
certainly appreciate your comments and your personal
perspective.
1040
WELLINGTON PSYCHIATRIC OUTREACH PROGRAM
The Chair:
Our next group this morning is the Wellington Psychiatric
Outreach Program. I invite them to come forward. Good morning. We
have 20 minutes for your presentation, to be divided as you see
fit between actual presentation or question-and-answer
period.
Mr Robert
Foster: I'll try to be brief. I also left my glasses
back at the office, so I either need a long arm or I'm going to
pop out a contact lens so I can see what I'm doing.
I'm speaking on behalf of
Wellington Psychiatric Outreach Program, which is a case
management organization that provides case management, support
and treatment services to 155 consumers in mental health
services.
The perspective I would
bring to this presentation would be that of a service provider,
but also, I have to say that it comes from my previous experience
as a consumer and as a family member. That has to colour some of
my opinions that I would express today. They may not neatly tie
in with the organization I represent, but I think they clearly
do.
First, I would like to
applaud the efforts of this government in attempting to address
the needs of people who are experiencing a mental illness. This
is not a cause which has in the past generated much sympathy or
support from either government or the public.
In general, however, I
believe that this law will not accomplish the desired effect of
achieving public safety and getting the help to people who may
need it. However, I do believe that the government has a sincere
desire to provide protection to Ontario citizens from what is
perceived to be the danger presented by a person with an
untreated mental illness. Although there may be some who would
present a serious danger to themselves or others, I don't believe
they represent a large percentage of people who are mentally
ill.
I would like to limit my
comments to three main areas of the amendments: involuntary
committal, changes to the police powers and the community
treatment orders.
Terms of involuntary
committal: Changing the criteria by removing the word "imminent"
leaves the criteria too open to personal interpretation and
differential application across the province. If the goal is to
make it easier to get people admitted to hospital, where are the
beds to come from when there are no beds currently available for
those who are actually seeking treatment and would voluntarily
enter the hospital? I really don't think we would have the
resources to deal with the numbers.
What do the new criteria of
substantial mental or physical deterioration mean? It needs a
definition so that it would be fairly and equally interpreted and
applied. Left undefined, it is open to interpretation and
individual judgment calls. In the current Mental Health Act there
is already some latitude for interpretation of the criteria for
committal. What is the perceived need to broaden these
criteria?
Revisions to the police
powers and responsibilities: The change related to the police not
having to witness the acts they would use to judge that someone
is a harm to self or others potentially leaves this provision
open to abuse and misuse by family members and others. The
loosening of the criteria used by the police would also have the
effect of increasing the numbers of people they would have to
deal with. Do we have the police resources to deal with the
increased demand?
Community treatment orders:
Choice I think is one of the main needed features. One of the
features of the proposed treatment orders is that there must be
agreement on the part of the patient or their substitute
decision-maker. Since the agreement to the terms of the CTO is
also the key to release from hospital, there is some element of
coercion in that agreement. If there were more resources and the
patient could be offered true choices for treatment and support,
then the need to force treatment would be diminished.
Resources: The revisions
would appear to have the desired effect of getting more consumers
to the required services. The problem is that there is already a
lack of resources for people who are actually seeking services
and who will voluntarily participate in these services. Resources
are currently not meeting the needs in a number of ways. There
are waiting lists for community services such as case management,
a lack of hospital beds when they're needed and a shortage of
psychiatrists working in the community.
To be successfully treated
and integrated into the community, people need personal resources
such as adequate housing, social supports and adequate income.
Many consumers are subsisting in less-than-adequate accommodation
because they have to live within their means. There is a shortage
of affordable, subsidized housing, particularly in this city and
particularly for single adults. The level of income from ODSP and
Ontario Works is not
adequate to provide for decent market rent accommodation as an
alternative.
Most community mental
health services are provided on a voluntary basis, which is
premised on a trusting relationship between the consumer and the
provider. Participating in treatment under an order where the
provider of service plays both a care role and a policing role in
monitoring the order would significantly change the nature of
that relationship. For someone whose symptoms often include
paranoia, this is probably not helpful or therapeutic.
Responsibility for
monitoring and supporting the order may also fall to the family
member, particularly if he or she is the substitute
decision-maker. This may be an onerous responsibility for a
family member to undertake and it will certainty affect the
ongoing familial relationships and trust.
For anyone in the service
plan, there is an onerous and unrealistic responsibility toward
ensuring public safety. The person under the community treatment
order will be spending a large percentage of their time
unsupervised. The public must not be deluded to believe that
community treatment orders provide assured safety. Any community
treatment order will have severe limitations in this regard.
Necessary safeguards: The
community treatment order can seriously restrict a person's
rights for a lengthy period of time. It seems to me, therefore,
that it would not be unreasonable to expect it should take more
than one person, namely, a physician, to institute the order.
Certainly in other jurisdictions they have required two or more
physicians to be in agreement to create an order. Otherwise the
order could simply become the easy resolution of a difference of
opinion between physician and patient about the choice of
treatment.
I'm also concerned about
the potential stereotyping of mental health consumers as
dangerous, when more often it is the consumer who is more
vulnerable to bullying and abuse than they are likely to being
dangerous to other people.
In summary, I am personally
not convinced that CTOs are an effective solution, but if they
are to be implemented, and I think they will be, and if they are
to be effective, they will put a demand on the system for more
resources and services than are currently in place. If the
government responds with the concomitant resources as a response
to implementing these orders and other measures outlined in the
legislation, then maybe some good will come out of the
legislation.
The Chair:
Thank you very much. You have left us just shy of three and a
half minutes per caucus. The first round of questioning this time
will start with the government.
1050
Mr
Barrett: Thank you, Mr Foster. You stated in your
presentation, with respect to people who are a serious danger to
themselves or others, that you don't believe they represent a
large percentage of the population, and that's correct. This
represents certainly a very small percentage of the population
who have a mental health problem.
Secondly, you stated, "If
the goal is to make it easier to get people admitted to the
hospital," and that is not the goal. In fact, with a community
treatment order coming through a medical practitioner, the goal
is to provide assistance for people in the community, to refer
them to a psychiatric facility for assessment, but not
necessarily hospitalization. Given that the goal is flexibility
in this legislation, so that they can be treated in the
community, could you suggest any additional provisions that would
further enhance flexibility in this legislation so that patients
can be better treated in the community?
Mr Foster:
I guess what I was advocating was alternative resources. We have
a number of proposals that are waiting for funding locally,
community crisis beds and other things that would be
non-institutional and within the community and still provide
safer treatment both for the patient and for the community.
I would beg to differ
briefly on your point that it doesn't imply hospitalization. I
thought the criteria ensured that people needed to be in hospital
at least a couple of times before they could qualify for a
community treatment order.
Mr
Barrett: There are a number of criteria, and again it's
at the discretion of a psychiatrist or a physician-violence in
the community, for example, resulting from an ailment. But we are
going the same direction as far as getting assistance in the
community rather than in hospital is concerned.
Mr Clark:
Just a quick question on your concern about the revisions of the
police powers and responsibilities: At the present time the
police have to observe disorderly conduct. Are you aware that
Ontario and Newfoundland are the only two jurisdictions in Canada
left with that requirement, that the rest have gone to reasonable
and probable grounds?
Mr Foster:
No, I'm actually not aware of that. I'm more aware of working
with the police on a day-to-day basis around some of the current
provisions and just know how difficult it is when they have to go
and spend hours and hours waiting with the people. If we loosen
this up, it will be an issue of resources. To say that they don't
have to witness doesn't mean that this act will get implemented,
because if you don't have the resources it may not happen.
Mr Clark:
The fact that other jurisdictions have moved to where they use
reasonable and probable grounds has not led to abuse by the
police.
Mr Foster:
I hear what you're saying.
Mrs
Bountrogianni: Welcome today. You mentioned that
participating in treatment under an order where the provider of
service plays both a care role and a policing role and monitoring
could significantly alter the relationship, and for someone whose
symptoms often include paranoia, this is not therapeutic. I can
tell you, as a registered psychologist for over 18 years, those
things happen anyway in a therapeutic relationship, particularly
if paranoia is involved. Relationships significantly change. It's hardly ever a
smooth-going tea party when you're with your patient. I think
that's a bit misleading. I think we can all agree that we need
adequate resources for any of this to work. If there were
adequate resources out there, would you still be against
CTOs?
Mr Foster:
I would never be black and white on anything. There are probably
a few very isolated cases where it may work.
Mrs
Bountrogianni: But I think that's what we're talking
about, sir. We're talking about isolated cases and I think it's
good that we're having these hearings because I think this has
really been misinterpreted, that we're going to be throwing
people in jail or in hospitals for ever. This is for those very
few cases where there is a perceived and very probable danger to
that person particularly or to someone else.
Mr Foster:
OK, and that doesn't come through clearly in this
legislation.
Mrs
Bountrogianni: Well, maybe that should come through more
clearly. Thank you.
Ms Lankin:
I think there are a lot of people who are concerned that, just
like the current legislation is misunderstood, the future
legislation may be.
I want to specifically talk
about the criteria for a person being placed on a community
treatment order. Mr Barrett indicated that a person would go
through being sent to a facility for an assessment and then may
not be involuntarily committed, but may be sent out to the
community. In fact, as I read the legislation, there is no
requirement for an actual assessment to take place. If an
individual, having been previously institutionalized, meets a
number of other criteria, and a physician-it's not necessarily
even a psychiatrist-feels or is of the opinion that the person
meets the form 1 criteria, just to be sent for an assessment,
they don't even have to be sent for the assessment, they could be
put on a CTO.
I'm a bit concerned about
the sequencing there because the intent of this is that a
community treatment order be supportive and be less restrictive
than an involuntary commitment, and I think that's what Ms
Bountrogianni's referring to, too. But the sequencing in the
legislation doesn't seem to support that.
I want to put that on the
table and pick up on your suggestion about it taking two doctors
to make this decision. In some jurisdictions in the States there
is provision for right of access to an independent second
opinion, both about the appropriateness of a community treatment
order and about the nature of the plan itself, the right to
challenge which medication, for example. If you know, as the
patient, that you respond better to one and the doctor has placed
you on another, there's a legitimate dispute.
Could you comment both on
the right of access to an independent second opinion about CTOs
and the nature of the treatment plan, and on whether or not it
truly is less restrictive if someone's not even provided with a
psychiatric assessment that indicates involuntary committal would
be warranted before they're put on a CTO.
Mr Foster:
I guess I share your concern, and I was offering one solution.
Having another objective person, whether it's a physician or a
rights adviser or a social worker or whoever, would be very
helpful. I was assuming that if two people had to see them that
would force some form of assessment and not be an arbitrary
decision that just happens to be made by the person who's been
treating all the way along.
Ms Lankin:
Thank you.
The Chair:
Thank you for coming before us here today. Thank you for your
presentation.
OAK CENTRE
The Chair:
Our next group this morning is from the Oak Centre. Join us at
the witness table, please. Just a reminder to you that you have
20 minutes to divide as you see fit, between either presentation
or question-and-answer period.
Mr Shawn
Lauzon: Good morning. I come from Oak Centre and I'd
like to tell you a little bit about Oak Centre. It's clubhouse
model. It's a community mental health program. We work with
people in a small part of the Niagara region, but we welcome
anyone who can come in and can find transportation to our
program.
Our program is grounded in
the belief of developing real relationships with people and
developing trust out of that relationship. Part of what we do in
having that relationship with people is that we develop goals
together and find our dreams are starting to come out, and all of
those things that happen that go along with real relationships.
It's out of that real relationship that people start being aware
of their own wellness and start finding good strategies towards
their own wellness. We believe people should be self-determined
in what they're doing.
My name is Shawn Lauzon.
I've come here today from the Niagara region and would like to
thank you for the opportunity to share my thoughts and concerns
about the proposed changes to the Mental Health Act, community
treatment orders and what is working and not working in our
present mental health system. Much of what I'm going to say today
I've already said in my presentation to Dan Newman, legislative
assistant to our health minister, Elizabeth Witmer, at the
consultation with consumer-survivors which took place at the
Raging Spoon in Toronto.
On February 19, 1998, I
said the following: "I feel that I can address these issues from
two perspectives: first, through my own experience as a
consumer-survivor, and more recently in my life as a provider in
a community mental health organization that has a broad vision of
what people with mental health problems can accomplish in their
lives.
"Just a short time
ago"-thinking back, this is 1998-"I experienced once again what
it was like not to have the available resources in my community.
I was supporting a gentleman who was without a home and who
seemed to have no support. He sought out help after having all of
his money stolen from him while sleeping on the street."
1100
I engaged him in
conversation actually. This was at a community resource and
action centre at the soup kitchen. We had a call from someone
else in the community to say that he was sleeping on the street
and maybe somebody should go and talk to him. After engaging him
in that conversation, he followed me back to the program and
that's where we started to have some relationship.
That's when we started
looking at the local housing help centre which "was able to put
him up for one night and directed him to a volunteer shelter
program in the community. There he would receive a hot meal and a
clean, safe bed for the night and over the weekend. However,
after the weekend other arrangements would have to be made to
transport him to another city where he could access shelter for
part of the week as the program in our city was only available
four nights of the week.
"During this time, he was
hooked up with a case manager connected with public health who,
like us, was working diligently trying to find ways to improve
his situation until he received his next cheque. In speaking with
the case manager, I was shocked and appalled when I was invited
to form a game plan that would entail coercing this man into
staying at the hospital until his cheque came in.
"It was thought by this
well-intentioned case manager that he needed to be stabilized on
some sort of medication." What other reason would he be on the
street, right? "Fortunately, I work in an organization that
believes like I do, that if he had enough presence of mind to
come for help in meeting his needs, he did not need saving from
himself through hospitalization, but needed services that would
help him to meet his self-determined needs. The proposed action
of the case manager, in our opinion, would have had a tremendous
impact on the delicate balance he already had within the
community and the system.
"It was during this
shocking experience that I realized and was once again reminded
of how the present system had failed me in my own process and
continues to fail us today. In my own experience, like this
gentleman, I knew what I needed and had very little options. For
me, hospital was not the way I wanted to go. So I found myself
bumping around in the mental health community only to find that
the services I felt I needed would cost me more money than I
had."
"What I see in the reform
is a shift away from the institutional sector but not enough
going back into community resources. What is needed is more
resources to provide safe housing and job opportunities for
people as they deal with their life issues. The amendments to the
Mental Health Act should not happen. Everything in it already
protects the civil rights of friends, family and the community,
as well as the individual. Yes, there are times when an
individual should be detained so that they cannot harm themselves
or bring harm to others, but the Mental Health Act already does
this with the rights of the individual still intact."
This was already said by
Michael Bay, something this ministry already paid for, to go
around and educate people and to discuss the Mental Health Act.
This is something this ministry already paid for. Somebody's out
there saying that we don't need to have the changes. All of the
things are in there.
Along with these thoughts,
I would like to express my disagreement with the inclusion of
community treatment orders to the Mental Health Act. In my
opinion, this would be a form of correction that says individuals
have no right but to follow the middle-class mindset of what is
good or bad behaviour.
If community treatment
orders come into effect and are coupled with ACT teams, I fear
that the teams will become not only hospitals without walls but a
new breed of community police, instead of doing what they should:
acting as trust builders who give support to the idea that people
can be self-determined and can be active in their own process, as
well as bridge builders to jobs and safe homes in the
community.
To close, I wish to read a
letter to the editor in our local newspaper on April 6 from Dr Ed
Pomeroy. He expresses the issues in a very succinct way:
"Your recent ... articles
on whether the government [should] be able to force treatment on
the mentally ill would have been much more informative if it had
been framed as, `should the government continue to be allowed to
neglect the mentally ill and pass off the need for forced
treatment as a sign of caring?'
"In instances where the
community commitment orders are in effect, they have been shown
to be effective only when an elaborate network of concerned and
committed support workers are available to enforce them.
"In these same
circumstances, there is little need for community treatment
orders because the seriously mentally ill are supported and cared
for in contexts that are appropriate to their individual
circumstances.
"The government sent its
own very competent expert, Michael Bay, around the province last
year and he quite convincingly demonstrated that existing
legislation enabled all the intervention that was appropriate and
necessary.
"The current move by the
government is no more than a sleazy effort to"-I didn't write
this; I missed the word sleazy-"direct attention away from their
incredible neglect of the community mental health system. They
would like us to believe that there is some system in place that
can solve the problem if people would just use it.
"In reality, there is no
such system.
"Hospitalizations and
medication are helpful to many people and many people use those
resources willingly. When the possibility of forced treatment
exists, however, many who might use the system become fearful of
losing their rights and delay seeking help.
"Many of those who resist
help in spite of much pressure are persons who have learned that
what we have to offer does not help them.
"We must respect this fact and seek to provide help
in ways that do not cause further injury. Community committal
does the opposite of this.
"It is repressive and
counterproductive, driving a wedge between those needing help and
those offering help."
I can back this last
statement around driving the wedge. In my work, I've had many
members of Oak Centre come to me, as I was collecting the
information around this stuff. A lot of people, reading the
things in the paper and stuff, were coming to me and saying: "I'm
not coming here any more, because you guys are going to get
slanted into this. You guys are going to be doing the community
treatment orders, so I'm going to have to come here. I'm not
coming here."
What an impact it has on
you, when you think you have this trusting relationship with a
person and you're working on goals. It's difficult to have that
kind of integration in communities; it's difficult to deal with
the stigma. But to have as part of my job this wedge in my
relationship with these people, and that they're going to be
fearful that I have to maintain a community treatment order or be
part of this, is terrible. It's awful. I work every day at trying
to build relationships and trust with people. I can't imagine
being put in a position where they're going to be afraid of me,
that people are going to be afraid of me. It's difficult. I'm
speaking as myself, as a consumer-survivor; I'm not just speaking
as a provider in the community.
I don't usually say this. I
don't usually bring this out. It's even difficult for my family
to deal with the idea that I come out as a consumer-survivor. For
my own brother, hospital was a part of his wellness. It was
self-determined, but we had to wait for a long time before he
would take that step. We waited, and we were scared for him. We
were afraid for his life a lot of times. We didn't know what was
going to happen. If we had just forced him into the hospital, how
would that have impacted on his life? What kind of trust would he
have had for me and my family?
The other part is that I
have two cousins in the same family, and they are both living
with schizophrenia. I've had the opportunity to talk to my aunt,
who struggled with the loss of her sons. To see them come
back-one has a more difficult time. He struggled and has many
more barriers to face. He's with her. They've tried every route.
When he didn't want to take medication, she opted for trying
holistic kinds of medications. They sorted things through
together. I asked: "What would have helped? What could you have
done?" She said, "The only thing I could have done is keep him
close." How do you do that when you put a community treatment
order on a person?
Thank you for
listening.
The Chair:
Thank you very much for your presentation. That leaves us about 9
minutes, so three minutes per caucus. This time the rotation will
start with the New Democrats.
1110
Mr David
Christopherson (Hamilton West): Thank you for the
opportunity to join the committee as we travel around the
province. Thank you for your presentation. It takes a lot to talk
about your personal experiences, but it's very helpful to us in
considering the issues at hand. So thank you for that.
I know from my own
experience, both personal and as an elected person dealing with
this issue in the community, that one of the big concerns from a
survivor's point of view is the notion that, as you say on page
3: "In my opinion this would be a form of correction that says
that individuals have no right but to follow the middle-class
mindset of what is good or bad behaviour." The concern, of
course, is that in a free society we all have the right to live
our lives the way we choose within the laws, and acting weird is
not something that is prohibited. If it were, half the members of
the Legislature wouldn't be allowed to sit there. There's always
a concern that something that is seen as different or strange
becomes fearful, and then we use the force of the law to take it
out of our sight, because it's disruptive. I assume that's why
you use the term "middle-class mindset."
The proposal has two
criteria. The second one, with regard to behaviour, is (a) a
person causing himself, herself or another person serious bodily
harm-to cross that threshold-or (b) substantial mental or
physical deterioration of the person, or (c) a serious physical
impairment of the person. Can you give us an example, especially
if you've experienced it but one you can imagine, of behaviour
that would be unusual, strange, eccentric-characterize it any way
you wish-that you fear would cause someone to cross one of these
thresholds and have them under a community treatment order when,
in your opinion, that's really not called for? Could you help us
envision that?
Mr Lauzon:
You have a very long question.
Mr
Christopherson: I'm like that. You're lucky: At least I
wasn't loud.
Mr Lauzon:
You addressed the idea of the "middle-class mindset." I thought
about that as I was getting dressed this morning. I thought, "My
God, I don't think I have the clothes for this." I looked through
my closet and I needed to find it. I was trying to fit into the
middle-class mindset, to try to fit into this group. I don't wear
this kind of clothes every day. It gives you a picture; it gives
you a frame. When I look at everyone around the table, I wonder
how many of you have had to even-and I don't even think my
circumstances were that bad when I was homeless and living in a
trailer and had to move 11 times in five years. Is that unusual
behaviour? I don't know.
When I look at you, I
think, "OK, you have a very nice suit on." But if you started
coming in to work and you had the very same suit on for two
weeks, is that eccentric? Is that unusual behaviour? What mindset
am I looking from? I'm looking at you and I think, "Hey, you're
looking really good." But two weeks from now, when you're wearing
the same suit and you're starting to smell, maybe that's a little
bit of unusual behaviour. Does that allow everybody else to look at you and
say, "Hey, you need to either clean up or we're going to slap on
a community treatment order, because we think you're
deteriorating"?
How are you defining it?
That's what I want to know. You need to define it. It depends; it
always depends. That gentleman I met on the street-it's all he
could afford. He really had no clothes. He had all his bags and
everything else. Is that unusual behaviour for a person who
actually just lives on the street? He wasn't doing anybody harm
when that case manager came to me and said, "I think we need to
stabilize him." He had wonderful stories. If you listened to this
man, he had beautiful stories. He knew people. He would look at
people and he would tell you all about yourself. I don't find
that unusual behaviour. She did. That's what makes me afraid.
Who are you putting in
power? Who are those case managers going to be? Who are going to
be the decision-makers? What kind of life did they have? Is it
fair to make them do that? I don't know. You need to decide. Do
you want to do this? You guys are making this kind of decision
that's going to directly impact on people's lives, and you'll be
entrusting this legislation to be acted out by people you don't
know, who are also going to be making decisions on people's lives
and who are also going to be implying unusual behaviour. How much
observation do you need before you can really define it? That's
what I want to know.
Mr Clark:
You're right. We're looking at legislation that is going to
impact and affect lives, and that's the intent of the
legislation. How do we address, for example, the numerous
families who have contacted my office? I can think of one lady
whose son was schizophrenic and in a revolving door. He would go
into the hospital, get treatment, get stabilized, come back out
and, within a month or two, refuse to take the medication, and
back and forth. She consistently cried out for help. He'd go into
the hospital, be stabilized, released back out and around and
around. He jumped into Devils Punch Bowl and killed himself.
The community treatment
order in itself is designed specifically to help people like
that, so that when they're on their medication they are
stabilized. All the resources we're talking about are providing
that; it's a consent-based model. I hear what you're saying about
the analogy of the clothing and about what's appropriate or
normal for me may not be normal for someone else.
Mr Lauzon:
That's the steps leading into it.
Mr Clark:
We're not talking about that. We're talking about people whose
psychiatrist is stating are a danger to themselves or a danger to
others. We're talking about that young man who jumped into Devils
Punch Bowl, whom we should have been able to save, but we didn't.
How do we address them when they refuse the treatment?
Mr Lauzon:
When you bring a person into hospital to stabilize them, you get
them on medication and all that other stuff, then they're
released, right? How much effort and how many resources are put
into connecting that person in the community? How many resources
are put into breaking down some of the stigma and breaking down
some of the barriers so that person can have a job? It's sad to
see that there is loss, but that's not for all the people.
You guys are making this
decision. It's really unfair when you think that the media take
one story and you see all these other stories, right? Then it
makes a generalized notion of what it is. You're talking about
what happens and how we can have some effect on that person so he
doesn't jump into Devils Punch Bowl. But how many times was he
disappointed that there wasn't a whole hell of a lot coming out
of the hospital?
Mr Clark:
With respect, there are cases right across the province. When we
were in Sudbury, there was a situation where a schizophrenic
killed his parents-20 years of revolving door, where they would
stabilize him. He had counselling. He had vocational help. He
refused to take his medication.
Mr Lauzon:
But this is not the majority.
Mr Clark:
Exactly. We're trying to help the small percentage.
Mr Lauzon:
But the legislation you're proposing is going to be blanketed
across everyone.
The Chair:
Thank you, Mr Clark.
Mrs
Bountrogianni: I hear you loud and clear. And if there's
that kind of fear out there, I think we have to really make sure,
whether it's with preambles the way Mrs de Villiers did with the
other act, whether it's very clear legislation, whether it
limits-it will be limiting, as far as who can give these
orders-we have to make it very clear so that your fears are
allayed. But I do hear you and, again, as a psychologist, the
hardest sentence I had to say was, "Everything here is
confidential, except if I find there's harm to yourself or to
someone else." You know that right away they tighten up and don't
trust. But then it's my responsibility to win that trust
regardless, you see? So, please, I hear you and I'll be vigilant
in looking at the language, as a professional as well as a
legislator. But at this point, I believe, unless it can be proven
to me that your fears are unfounded-I understand why they're
there, and I agree with everything you're saying about resources
and the stigma of mental health, and I speak both from personal
and professional experience.
The way it's written, I
don't believe it will be blanketed across. This is more of a
point than a question, although if you want to comment, please
comment. We will be looking at the language vigilantly.
Mr Lauzon:
You say it's not going to be blanketed. How can you ensure that?
It goes right back to who's looking at it. Who's looking at it?
How do you know? It's like saying: "We're always struggling to
have valued resources put into the hands of consumer-survivors,
because they're the ones who are using the services. Why
shouldn't we have access to those valued resources to make those
decisions?" I don't see enough of that. I see it as a top-down
approach. What about the people who should be involved in this? You can't say this
is only going to happen for a chosen few. Do you mean there are
going to be rules? How are you going to manage that?
1120
Mrs
Bountrogianni: I actually can relate to that. Even the
safe schools stuff in the schools-different principals suspended
different kids for different reasons. They didn't have the same
level of tolerance, and I think that's a similar analogy. How do
you ensure the same level of tolerance? That's why we have to be
very vigilant and continuously vigilant, not just write the
legislation and then leave it alone; I can assure you that I will
be throughout the process.
Mr Lauzon:
I'm reminded of some money that kind of came our way in the
Niagara region-it was kind of all over the province. It was out
of the Opportunities Fund money; I don't know if you've heard
about it. It's HRDC money. But one of the occurrences that
happened was, all this stuff was written out and they had the
eligibility criteria and all those things that were put into it
and everything else. Everybody in the whole province got
money-pockets all over the place. One big problem: Everybody had
a different interpretation. How will you deal with that?
Mrs
Bountrogianni: Good point.
The Chair:
Thank you very much, and thank you for coming forward and making
your presentation today. We appreciate it.
MENTAL HEALTH RIGHTS COALITION OF
HAMILTON-WENTWORTH
The Chair:
Our next group is the Mental Health Rights Coalition of
Hamilton-Wentworth. I wonder if they could come forward please?
Good morning, and welcome to the committee. Again, we have 20
minutes for you to split as you see fit between presentation and
question and answer.
Ms Deborrah
Sherman: My name is Deborrah Sherman. I want to thank
you for making the copies. It's not in our budget.
I've come to this
consultation wearing the hat of executive director of the Mental
Health Rights Coalition of Hamilton-Wentworth. I have to tell you
that that's a new hat for me, one that I only put on about six
weeks ago. My purpose here is to speak on behalf of the members I
work for, many of whom I've not yet met. Like any new hat, this
one is still a little tight. It feels a little different, because
I've worn a few other hats. I sat for nearly 13 years as a
community member on the Consent and Capacity Board in Ontario, so
I'm fairly familiar with the three existing acts that some of our
members have had applied to them from time to time. In some
cases, I may very well be one of the people who applied it to
them.
I have also worn the hat of
a concerned family member of someone with a mental illness.
Finally, I have worn the hat of a consumer. So, although I'm here
to represent the consumer perspective, it's inevitable that when
I look at this legislation, I can still feel some of those other
hats on my head.
The Mental Health Rights
Coalition is a consumer-survivor initiative. Our mission is to
enable, empower and encourage the voice of consumers of the
mental health system. Our aims and objectives are to reduce the
stigmatization of mental health consumers, to reduce their
isolation, to increase the accessibility of services, to support
reintegration into the community and to promote their
participation in society, in our organization and in their own
lives.
The coalition attempts to
do these things by educating-we educate consumers, families, care
providers and the public. We provide peer support and advocacy,
we support research, we participate in the mental health planning
processes in and around the city and we provide a place where
consumers can come to socialize with their peers in a
non-clinical, non-judgmental, safe and supportive atmosphere.
Our membership currently
exceeds 425 people, all of whom endorse being consumer-survivors
of the mental health system. We have diversity in our membership,
although I must say it is a bit weighted at one end. We have
cultural diversity, socio-economic diversity and educational
diversity. For some of our members, the condition or illness they
suffer from is pervasive to the point of being a visible
disability. Others have good jobs, nice homes-and who's to know?
Some of our members can't read and others have one or two
degrees. Some have a lot to give and others are very needy. Some
have amazing social skills and others can be troublesome to deal
with now and then.
What I'm saying is that our
members are as diverse as any other group of human beings. The
one thing that they have in common with each other and that sets
them apart from others is that they live with the challenge of
some form or degree of mental illness. The other thing they have
in common that sets them apart from most of society is that they
all accept that about each other and don't hold it against one
another.
It is difficult to
represent the consumer perspective, because there is no single
consumer voice to represent. I've been listening to my members,
my government, the media and the general public talk for the last
six weeks about this legislation, and I've learned that the
consumer-survivors have as many different opinions on what was
promised as any other diverse group of people has. For my own
part, I've tried not to form any opinions until I could see what
the act says for itself.
When I say that there are
as many different opinions as there are people, I'm saying that
some of our members are for community treatment orders. Some of
our members are for non-voluntary committal. Some of them are
very much against it. It's important to realize that there are
people who are saying to me, "I wish they had had CTOs when I was
acting up and gave my family a bad time." I've got other people
saying to me, "If my brother had the opportunity to use a CTO
against me, my life would be hell." There are different
opinions.
There are many items in the actual draft
legislation which mental health consumers are going to find
objectionable. Several parts are ambiguous. Some parts seem to
contradict others. Several are just plain impossible to practise
in the real world. Some may contradict basic human rights and
principles of law. I know what some of the other speakers have to
say about those things and I'm not going to go too far into
them.
For me, when I finally got
to read the draft, the first and single most objectionable and
disappointing thing for any mental health consumer about this
legislation is in the first five words of it, "An Act, in memory
of ...." Naming legislation after any single person is a very
American way of doing things; it's a very PR approach. It's
difficult to trust the intentions of legislators, no matter how
well-meant the legislation is, when they choose to package a law
and send it to market that way. I think that in Canada we prefer
our laws to be approached a little more soberly.
There are those who have
argued that this particular legislation is a knee-jerk reaction
to a few high-profile tragedies that aroused public outrage. The
title of this law and the choice of a victim connected with the
media can only lend credibility to their argument. It taints the
legislation with a strong odour of stigmatization. If the authors
of the draft had to name the law after a person, they should
remember that there are far more people who have fallen victim to
their own illness than there are victims of people with
illnesses.
The newspapers contain far
more stories of deaths by suicide, deaths by exposure, deaths of
isolated people who can go unnoticed for weeks at a time than
stories of people who have mental illness and commit murder. By
attempting to exploit one tragic victim's name under the guise of
doing that name honour, the authors of the draft may be doing
dishonour to countless tragic victims whose name no one
remembers.
In reading the text of the
act, the tribunal hat inevitably came on for me, and I could
picture the many problems that are going to come before the CCB
if this law passes as it stands. I can see a contradiction
between the criteria for application for a psychiatric assessment
and the criteria for a treatment order.
Under section 33.1, the
criteria for an order say, among other things, "A physician may
issue or renew a community treatment order under this section
if," and then the act sets out some conditions under (a) and (b).
If you look at (c)(ii), "the person meets the criteria for the
completion of an application for psychiatric assessment under
subsection 15(1) or 1(1) where the person is not currently a
patient in a psychiatric facility." If you continue down through
the ifs, at the end of the clause, you'll see the word "and"
followed by the criterion that, "(f) the person or his or her
substitute decision-maker consents to the community treatment
plan."
So the person who meets the
criteria for an assessment under subsection 15(1) must now turn
around and consent to the plan. If you look at subsection 15(1)
below clause (b), you see that it says, "and if in addition the
physician is of the opinion that the person ... (e) is apparently
incapable, within the meaning of the Health Care Consent Act,
1996, of consenting to his or her treatment ...."
If the criterion for a
treatment order is the same as that for an ordered assessment,
then the person who is deemed not to be competent to consent to
treatment is being asked to enter into a consensual agreement. I
think you need to change the wording in clause (f) and maybe
eliminate the person and leave it all up to the substitute
decision-maker.
Likewise, the criteria for
an order subsection 33.1(2) say that "within the 72-hour period
before entering into the ... plan, the physician has examined the
person and is of the opinion ... that, ...
"(ii) the person meets the
criteria for an application for ... assessment," and
"(iv) the person is able to
comply with the community treatment plan."
1130
Once again, this person who
is deemed incapable of consenting to treatment is not only
entering into a consensual agreement, but now he's supposed to be
able to comply. Furthermore, in the other provisions for the
content of the order, clause 33.1(4)(d) now asks this incapable
person to give an undertaking to comply with an order they've
consented to while incapable. It's not making a whole lot of
sense.
Again, in the criteria for
an order under 33.1 the physician must be of the opinion that,
"(v) the treatment or care and supervision ... are available in
the community." What we want to know is, is the doctor just of
the opinion that the services are available or is he supposed to
make certain?
Under 33.5, it says he's
"responsible for the general supervision and management" and that
any others who agree to provide treatment are responsible.
Under 33.7, the treatment
order must name all the people who agree to provide treatment.
This includes, under 35.1, any regulated health professional,
social worker or any other person, all of whom may share
information about this person. So he goes out into the community
with a treatment order to protect him and to protect society from
him, and this order tells him that he must attend certain medical
appointments and programs.
To ensure compliance,
section 7 says that copies of the order will be given to him, his
decision-maker, where applicable, and any other health
practitioner or any other person named in the plan, all of whom
are responsible for providing care because they agreed to this
plan.
Unfortunately, the patient
and the substitute decision-maker are the only ones who have to
undertake to comply, and although they are responsible, section
33.6 absolves all the treatment providers of liability for any
default or neglect by the other treatment providers. Nowhere is
there any mention of any liability for default or neglect of the
plan by anyone other than the person, who is to comply with a
treatment plan that he or his caregiver consented to, which could
only be initiated after he'd been first found incapable of making
that consent.
If you put on the consumer hat and look at that
person's situation, there he is in the community. He's expected
to comply with an order that says he'll attend appointments and
programs, and to ensure his compliance a number of people have to
be informed and have to agree to provide certain aspects of that
plan. What's missing are the resources, as we've heard from other
presenters, the things that help overcome those practical
day-to-day impediments, like having enough money to live on, let
alone get around the city to attend these appointments, simple
impediments like being by nature of your own illness
disorganized.
A few years ago, the Mental
Health Rights Coalition advocated on behalf of people with mental
illness to provide them with free bus passes. That's a necessary
element to their compliance with treatment. Lately, there's been
some cutting back. I have people walking into my office with
forms that need to be signed and letters that need to be written,
showing some worker at some agency somewhere that this person is
a member who is attending our premises to do volunteer work or to
partake in psychosocial rehabilitation. They need these things
signed in order to deserve that bus pass.
One of these forms that I
saw recently looked very much like a typical work schedule. The
social worker or whoever it was had filled out days and times
that this person was to be at our premises volunteering. Aside
from the fact that we have work to do, I have a philosophical
problem with filling out these forms. It suggests that someone
thinks people with mental illness don't deserve to get around
town unless they're doing volunteer work. God forbid that they
should be taking the bus for social purposes. They need to be out
there putting something into society-the same one that asks them
to live on next to nothing. But there's a greater problem with
this.
My peer support coordinator
came to me a little while ago when I was looking at one of these
forms, and said that the young person who brought in this form
suffers from frequent recurring bouts of severe depression,
suicidal thoughts and behaviours; he's been hospitalized many
times. He has low self-esteem and easily triggered guilt.
For him to have his bus
pass, he is pressured by a third party into making a time
commitment to us. We are not comfortable with that, because we
know that letting people down is a big issue for this guy. We
have to keep telling him that it's OK if he doesn't feel like
coming in. We don't want him back in hospital because someone
else is making him feel guilty about his commitment to us.
Whoever the person was that made out the form is obviously
concerned with ensuring that the bus company doesn't get ripped
off. The person has no concept of who he or she is dealing with
and the kind of pressure a simple little thing like this schedule
is causing for the person.
This is only one person,
only one practical example; there are many. When community
treatment orders come into effect and people's liberty depends on
complying with them, they're going to need greater access to all
kinds of supports, like free bus passes, free recreational and
rehabilitation services, medical costs; you name it, they're
going to need a lot of support. To ensure these things are
available, the doctor issuing the order is supposed to secure the
agreement of everyone named in the plan. So suddenly the
patient's life is an open book to all of these people-not just
health care providers, not just the social workers, but like the
act says, any other person, like the ones who come up with these
volunteer work schedules.
We are very concerned for
the benefit of our members and all people with mental
disabilities, if they are going to be forced to have their needs
met by bean counters who have no sensitivity whatsoever to what
they are dealing with, and no idea that what they are asking for
should not be asked of certain people.
The greatest problem of all
in the act is that it opens the doors wide to all kinds of
abuses, not just systemic ones like the example I just gave, but
intentional and malicious ones as well. Anyone with a history of
mental illness, regardless of their current condition, can be
reported to the police by family members, neighbours or anyone
else who says they are behaving strangely. The police are no
longer required to observe the behaviour themselves; they can act
on the information and take the person to hospital.
If the person in question
happens to be under a CTO, then the police are to take them, as
the act says, into custody-it doesn't say what sort of
custody-and they're supposed to bring them promptly to the
physician who issued it, who is likewise to see the person
promptly.
I don't see physicians
responding to calls in the middle of the night, on weekends or on
holidays, unless they happen to be in the hospital at the time.
There's no point in taking the person to the emergency psychiatry
if there is no emergency behaviour being observed. The officer is
stuck with the option of staying at the hospital or taking the
person into some other kind of custody.
Police officers in a
community policing system are keenly aware that the public is not
being protected if they are sitting around cooling their heels at
EPT for half their shift. If there's no behaviour to indicate a
psychiatric emergency, but there is a CTO and there is a report
by a third party, then what sort of custody option is left to the
officer? The only thing that comes to mind is the
Hamilton-Wentworth Detention Centre. For how long? You want to
hope your neighbour doesn't choose a statutory holiday weekend to
report you for acting weird.
The act does not address
the issue of responsibility or liability for a person who,
through self-interest or malice, or because of their own illness
or just plain ignorance, might make a complaint or report against
someone who happens to have a history.
These are just a few of the
things we see in the act. There are many more that we have not
been able to address because of the short notice of this
consultation, but I am sure they will be addressed by other
presenters.
I thank you for your time
and attention. I want to reiterate that I'm not here to take a
stand against community
treatment orders or against the act. I'm simply saying that
consumers, like everyone else in society, have a wide variety of
opinions on it and a wide variety of feelings on it, and that the
act, as it is written, does not guarantee safety and does not
guarantee that the right people will be put into the right
programs and given the right supports.
The Chair:
Thank you very much. You've left us with about 50 seconds in your
time.
Ms
Sherman: Oh, good.
The Chair:
Recognizing that neither my colleagues nor I would be able to
give our name in 50 seconds, never mind ask a question, if you
care to elaborate on any particular point?
Ms Lankin:
Actually, Mr Chair, I would like to ask for unanimous consent.
I'll give the reasons why. Given that current members of the
Consent and Capacity Board have, and I think appropriately, been
directed not to appear before this committee because they have to
adjudicate the results of this legislative change, this is a rare
opportunity to have someone who spent 13 years on that committee.
I'm wondering if we could at least have unanimous consent for one
question from each caucus, although I'd like much more. Perhaps
we could shorten our lunch just a little bit to accommodate
that.
The Chair:
We've already had a request that would take us a few minutes into
lunch break, and another gentleman who has asked that if there
was a gap-I don't think there will be.
Ms Lankin:
This is a request for one question. If we stop talking, we might
be able to have lunch quicker.
The Chair:
I'll tell you what. We'll grant one question to the New
Democratic Party.
Ms Lankin:
He's so accommodating. I'm just amazed. OK.
The Chair:
This is the old Steve. You just didn't ask the right questions in
the right tone.
Ms Lankin:
Thank you very much, Mr Chair.
There's much I would like
to ask you, but I specifically want to reflect your experience on
the Consent and Capacity Board. Some of the other amendments in
this legislation are actually to the Health Care Consent Act.
We're not having much discussion about that here today.
1140
One of the clauses allows
for a person responsible for authorizing admission to the care
facility to apply to the board to obtain permission for the
substitute decision-maker to consent to the admission despite the
wish. In other words, if a person makes prior capable
determinations about their life, this now allows a care facility
to apply to overturn those prior capable wishes. Of course, "care
facility" is defined in the current legislation and it covers
charitable homes, nursing homes, but it also covers rest and
retirement homes.
One of the things we need
to take a look at is that there isn't an inadvertent effect of
the legislation. I'm thinking about psychogeriatric patients in
the community, the lack of resources that currently exist in the
nursing home and regulated sector and the number of people who
end up vulnerable in the unregulated sector without substitute
decision-makers. In this situation, we're giving new powers to
the care facility to come to seek to overturn prior capable
wishes. There are many other questions I would have, but let me
put that one to you. Do you have a sense, does that open the door
broader than perhaps what this legislation should be concerning
itself with?
Ms
Sherman: It may. I know that with a lot of patients who
came before the review board, the argument often was, "They need
to keep me here because they need the bucks." We all know that
most places are filled to capacity and that there are plenty of
replacement patients. I guess there is some room for abuse in
some sectors, but I don't see the Consent and Capacity Board as
letting something like that happen if they become involved. The
Consent and Capacity Board would recognize if there was a
self-interest involved, if that's what you're getting at.
Ms Lankin:
I guess I was wondering why we are putting in place the capacity
for the care facility to do this.
Ms
Sherman: I imagine because there may not be anyone else,
especially in the case of, as you said, psychogeriatric patients.
Quite often there is no one else and quite often there is no one
else willing.
Ms Lankin:
Which brings us to the role of the guardian's office. That's
another question for another day. Thank you.
The Chair:
Thank you very much, Ms Sherman. I appreciate you coming forward
and bringing your perspective today.
PROVINCIAL ACQUIRED BRAIN INJURY PROGRAM OF THE
HAMILTON HEALTH SCIENCES CORP
The Chair:
That brings us to our next group, the Hamilton Health Sciences
Corp acquired brain injury program, if they could come forward,
the representatives from that group. The clerk advised me they
are here. Good morning. Just a reminder that we have 20 minutes
for your presentation this morning for you to divide as you see
fit between presentation or question-and-answer period. Perhaps,
since there are more than one of you, you could introduce
yourselves for the purposes of Hansard.
Dr Diana
Velikonja: I'm Dr Diana Velikonja, neuropsychologist in
the acquired brain injury program at the Hamilton Health Sciences
Corp.
Ms Patti
Leonard: I'm Patti Leonard. I'm the program director of
the acquired brain injury program at Hamilton Health Sciences
Corp.
First of all, I'd like to
thank you for inviting us to be here today. It really is a great
privilege to be here, and I'd like to applaud the recommendations
that I have seen in this most recent mental health reform
legislation that you're proposing.
Let me just take a few minutes to go over our
brief. I was just reading it out in the hall and I noticed that
there are a couple of typos, so I do apologize for that.
In the existing Mental
Health Act, a mental health disorder is defined as any disease or
disability of the mind. Individuals who suffer the sequelae of an
acquired brain injury resulting from trauma to the head, disease
caused by conditions such as stroke, lack of oxygen to the brain,
infections of the brain or space-occupying lesions such as
tumours frequently exhibit disabilities in cognitive functioning
and behavioral control while retaining intact verbal reasoning
abilities.
Dr Stephen Hucker, forensic
psychiatrist from the Hamilton Psychiatric Hospital, recently
presented important issues related to consent, capacity and
responsibility for criminality at an acquired brain injury
conference. In his presentation, Dr Hucker cited several
non-psychiatric personality and behavioural changes that result
from an acquired brain injury. They include: increased anxiety
and agitation; depression, mood swings and apathy; poor impulse
control; irritability, aggression and rage; lack of
self-awareness; social disinhibition; denial of deficits, which
is the inability to appreciate the fact that deficits exist;
delusions and paranoid thinking; malingering and somatisation;
and drug and alcohol misuse. Dr Hucker further cited statistics
that indicate 70% of those suffering from severe traumatic brain
injury experience significant aggressive and irritable behaviour.
It is estimated that approximately 67% of inmates on death row in
the United States have an identifiable diagnosis of brain
injury.
According to the Ontario
Brain Injury Association and based on information obtained from
Statistics Canada in 1996, approximately 16,948 Ontario residents
experience a traumatic brain injury each year. Of those,
approximately 4,000 die, while 1,465 are considered to have
suffered a severe traumatic brain injury, another 1,205 have
suffered a moderate brain injury and 11,053 have suffered a mild
brain injury. These numbers, however-and I think this is
important to recognize-do not include non-traumatic brain
injuries, those experienced due to cerebral vascular accidents,
disease etc.
It is our intention not
only to inform this committee about the large number of Ontario
residents significantly impacted by brain injuries, but also to
raise your awareness of the challenges presented to caregivers,
families and society resulting from the lack of specific
inclusion of this population into the Mental Health Act.
Consequently, decisions from the consent and capacity review
boards have failed to provide the individual with a brain injury
adequate provisions for treatment, and thus fail to afford
adequate protection for the individual and society.
By way of illustration, we
are providing a number of case examples to highlight these
issues. I won't read them all, but perhaps I'll at least read the
first one, because I think he really provides a good example of
some of the typical problems.
Case example 1: Male, age
40, 15 years post-traumatic brain injury. You might be interested
to know he spent several years in the United States in an
acquired brain injury program. He is physically independent, with
some balance and gait problems. He lacks insight into his
behavioural dyscontrol and denies his deficits. His verbal skills
remain intact and he has above-average vocabulary. Thus, based on
his verbal-conversational presentation, he gives the impression
of an individual with insight and appreciation of the
consequences of his actions and the capacity for behavioural
control. However, due to the nature of his brain injury, he is
unable to execute appropriate behaviour when he is actually faced
with normal daily situations. This individual has had numerous
and lengthy admissions to specialized ABI treatment facilities.
Community integration attempts have been unsuccessful, as this
individual, deemed competent, refuses to accept the support he
requires to live in the community.
His actual behaviour
demonstrates that he is a high risk to himself and others through
acts of physical violence when confronted by any normal demand.
He further offers to babysit small children despite a history of
aggressive behaviour towards them. His behaviours include verbal
and physical aggression, suicidal gestures such as walking in
traffic, bizarre rituals including urination around territory,
and hoarding items such as food and garbage.
Repeated efforts to have
this individual deemed incompetent have been met with reversal of
his involuntary status at Consent and Capacity Board hearings due
to his excellent ability to verbalize adequate knowledge, despite
a brain injury that prevents him from carrying out this knowledge
behaviourally. On the street, this individual experiences
significant difficulties with behavioural control and poses a
threat to himself and others within 24 hours of release.
I invite you, at your
leisure, to read the other cases. Many individuals with acquired
brain injury do not have a psychiatric diagnosis as their
symptoms are not encompassed by these diagnostic criteria and are
treated and cared for outside of psychiatric facilities and
mental health agencies. Hopefully these examples provide you with
a sense of the challenges we face in providing support to ABI
populations when they present with severe behavioural
difficulties.
1150
The deficits of individuals
with an ABI typically encompass cognitive difficulties, often
resulting in behavioural problems as a result of frontal lobe
damage that impacts to varying degrees on their ability to
appreciate the impact of their actions. These individuals can
articulate a verbal understanding of the circumstances being
presented to them, but the impact of the brain injury prevents
them from acting in a manner congruent with their verbal
abilities. Cognitive impairment such as perseveration,
impulsivity, cognitive inflexibility, attentional problems, and
poor planning and judgment impede their ability to behave in a
manner that is safe or functional.
While we recognize that
there is considerable controversy regarding the potential
restrictive nature of Bill 68 if inappropriately implemented, for some
severely brain-injured individuals this bill has the potential to
create less restrictive community living options. For many
individuals, the cycle of repeated hospitalizations and
incarcerations for behaviour resulting from frontal lobe damage
is sentencing them to a life of unnecessary restrictions. For
these reasons, we would like to make the following comments on
the proposed changes to the bill:
We support the removal of
the word "imminent" from the current committal criteria to
increase the flexibility in engaging patients in treatment.
We support the development
of community treatment orders for people with serious mental
illness, but request that the category of acquired brain injury
explicitly be recognized as a disease or disability of the mind
under the Mental Health Act.
We support the removal of
the requirement for the police to observe disorderly conduct
before acting to take a person into custody where police have
reason to believe that their behaviour meets committal
criteria.
We support changing the
definition of "attending physician" to include "any duly
qualified medical doctor." However, a provision should be made
for a requirement that the qualified medical doctor be familiar
with the implications of a CTO.
We would recommend that
consent and capacity review boards be required to examine
neuro-cognitive information in conjunction with psychopathology
when dealing with an individual who has a diagnosis of brain
injury. This will facilitate the incorporation of the cognitive
limitations that may impact on an individual's capacity to make
safe and responsible treatment decisions.
In addition, we pose the
following questions to the panel members:
What role do you foresee
for the Consent and Capacity Board in relation to CTOs in terms
of reviewing the appropriateness of the orders?
To ensure appropriate
application of CTOs, what training will be provided to
physicians?
Finally, how will the CTO
be applied to individuals who are not in schedule 1
facilities?
Thank you very much.
The Chair:
Thank you very much for your presentation. That leaves us with
about seven minutes, so just over two minutes per caucus.
The questioning this time
will start with the government.
Mrs Munro:
I certainly appreciate what you have brought to us
today-obviously a different perspective, given the people that
you're talking about.
As I listen to you-and
obviously in the context of the other presenters perhaps what we
should be talking about-you ask for specific inclusion and
support for community treatment orders and other people have a
great deal of fear around them, I'm just wondering if you have
any comments to make to that issue of the problem always of a
legislator being all things to all people. I think you
demonstrate in your ideas here, as I say, in contrast to some of
those we've heard this morning, that issue. I just wondered if
you had any comments yourself, I assume having heard some of the
concerns raised by others. Do you see some specific
recommendations that might alleviate those fears that have been
expressed by other people?
Dr
Velikonja: I think the important thing will be the
criteria. One of the important things we're advocating is that
what be reviewed is both the cognitive status as well as the
behavioural. We don't want to restrict it to a very simple score
on this test or look at this. We think there has to be a
combination of things that are looked at and criterion for both,
so that they are well defined and so that an individual has to go
through a fairly strict process to ensure that they meet those
criteria. That's why we've added both, to try to address that
issue, because we do appreciate that that's what it would look
like, very restrictive.
Ms
Leonard: I think, as well, the questions that we posed
at the end really speak to that sense of criterion. Clearly we're
talking about a very severely behaviourally impaired population.
We wouldn't see this applying to all individuals who have a
diagnosis of acquired brain injury, and that would be very
concerning. We are really talking about a population where this
type of legislation could actually allow them to live more safely
in the community.
We have individuals who are
going to end up in jail, and I think that's criminal. This type
of legislation has the ability to help us provide support to
allow them to live in the community and not get into the kinds of
situations that result in repeated and costly psychiatric
admissions and potentially into the jail system. Currently we
have one individual in our in-patient unit who has been ordered
there by the courts, and they don't know what to do with him
because he has had about four or five arrests in his
community.
Mr Patten:
By the way, that was an excellent presentation and I thought you
made excellent points. I'll have one question, due to the
limitation of time, and I will personally take a look at this in
far more depth because I think you make an excellent point. I've
had some personal experience with this. If we're talking about
some people with brain injuries or head injuries, what is your
experience? Some of these people do not necessarily need, for
example, a plan for medical treatment; what they need are some
supports, with an ability to support some positive
behaviours?
Dr
Velikonja: Yes.
Mr Patten:
In that sense it's different. I'm finding the term CTOs now quite
a useless term. It's a generic term, an umbrella term. In some
cases it's by the courts; in other cases, and in this particular
legislation, it is only by a physician. In your particular
instance you're asking two things, that this should be part of a
consideration for mental health legislation, as well as
consideration of these individuals who perhaps have been
misdiagnosed and treatment attempted under another diagnosis that
was not correctly applied. Is that correct? Do you have any
comments on that?
Dr Velikonja: Or people try to
get them to fit under certain diagnoses and then that would imply
a certain type of treatment which may include certain types of
medical treatments that aren't necessary or required, because
you've tried to make that depression or something fit into a
diagnostic criterion. So in and of itself, you're right, the
acquired brain injury category does not specify specific medical
treatment that would be unnecessary, which we think is also very
important. A lot of our patients come in with medical treatments
and so on under those diagnoses that are really inappropriate and
actually contraindicated considering the central nervous system
damage.
Ms Lankin:
Wow, you just opened up a whole new area that we have got to take
a look at. I recall during the time I was in the Ministry of
Health working with your program and with a number of people in
the association as we tried to repatriate people from the United
States in the beginnings of setting up our own network of
programs here. There is so much help that could be here.
There are two things that
strike me. First of all, I've been arguing for some definition to
treatment plans containing some scope of what must be contained
in the treatment plan so that it's not simply what some people I
think fear and what some of the apprehension out there is about,
that it's sort of chemical imprisonment in the community, and
that there be a mechanism for seeking an independent second
opinion to challenge some of that, because you're right: There
are people for whom medication may be prescribed and it's not the
right solution. There isn't an easy mechanism in this legislation
to get at that.
I guess I'd like to ask you
if you support those concepts, and what is the actual barrier now
around the diagnosis of mental illness? What do we have to do in
the act to open it up to ensure that people with acquired brain
injury are given some consideration of support and help, what the
positive intent of the government is with respect to this
legislation?
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Ms
Leonard: I think we talk about having acquired brain
injury explicitly, and I use the word "explicitly" because it is
buried in there in terms of disease or disability of the mind.
One can say an acquired brain injury is that, and that can be
argued, but that really leaves it to the interpretation of the
particular psychiatrist, potentially, or expert who is seeing the
patient. Our experience has been that psychiatrists don't always
have an appreciation for some of the issues of acquired brain
injury. They're not mental health; they're quite different.
That's why we are
encouraging, through this process, to have even "such as acquired
brain injury," or to have very clear guidelines put in there so
that this population isn't ignored and isn't sandwiched into
mental health kinds of rules. When that happens, that's where we
fall through the cracks, and that's where we have tremendous
problems.
It's lovely to see you
again, by the way.
I think the issue we're
trying to raise-and I want to go back, because I think your
comments are very similar in terms of the word "treatment" under
CTO-is that it's not always medication; in fact, in brain injury
sometimes it is and sometimes it isn't. And it's not treatment.
As my examples will demonstrate, these are people 15 years and 20
years post. They've had every piece of treatment you could
possibly imagine. This is support. This is, how do we put
somebody in who will enable them to make safe decisions, to clean
up their apartment every day, to buy groceries, to interact
appropriately in their neighbourhoods? It's that type of thing,
and it may be lifelong living.
The Chair:
Thank you very much. We appreciate very much your bringing your
presentation and your thoughts to us here today.
CONSUMER/SURVIVOR INITIATIVE OF NIAGARA
The Chair:
That takes us to our next group, the Consumer/Survivor Initiative
of Niagara. I wonder if they could come forward, please. Good
morning and welcome to the committee. You have 20 minutes for
your presentation.
Ms Judy
Hoover: My name is Judy Hoover and I'm the coordinator
of the Consumer/Survivor Initiative of Niagara. The main focus of
our agency is that we are an alternative to regular
organizations. We do self-help throughout the Niagara region. At
the present time we are supporting almost 2,000 people. We have
12 self-help groups and there's only myself and one other staff
to do this.
I am speaking from my
experience in my work with the Consumer/Survivor Initiative of
Niagara. We are an organization that supports people in our
communities who struggle with their mental health, through
self-help groups. I have learned many things about how to work
with people who experience serious mental health problems. I have
learned that we must listen to people and hear what they are
saying. Many people say that they want someone to believe in them
and they want to be treated as equals. They say they want the
same as other people: a good roof over their head, a place to
work and to be among friends. We just need to ask what they
need.
How community treatment
orders help to achieve what people want and will make a
difference in their lives does little to make these things happen
for people.
Community treatment orders
frighten me. It makes some other person in charge of someone
else's life. If you ever have the chance to read a novel called A
Mind That Found Itself, you will read one young man's story of
how he was gradually taken over by his psychosis and how his
well-meaning family committed him to a series of mental
institutions. He was brutalized by the treatment that his family
so trusted. He tells his story of how he had fewer and fewer
moments of sanity, but finally came out the other end to rise in
his own recovery. It is truly a story I hear repeated among the
people I work with today. Clifford Beers told his story in
1908.
Do you want to be responsible for imprisoning
people in their own communities, in their own homes? People who
are already struggling day to day with poverty, stigma and
isolation have said many times, collectively what they need: a
home, a job and a friend, not forced treatment. We know that
having a job makes a difference and prevents hospitalization. We
know people want to go to school and they want good people in
their lives. The people I know do not want forced treatment.
I came today to tell you
what I have heard from people about what they want and do not
want. I came to tell you about the fear in the community and in
me. I am fearful that you will not hear me and that you will
listen to people who have a lot more power than me. My trust will
be broken, and the mental health system will be used against us.
Please don't let this happen.
The Chair:
Thank you very much for your comments. That leaves us with about
13 minutes to be divided equally among the caucuses. This time
we'll start with Mr Patten.
Mr Patten:
Have you had a chance to read the legislation?
Ms Hoover:
A little bit.
Mr Patten:
I can sense your fear, and I gather there is a fear out in the
community and particularly among consumer-survivor groups.
Frankly, I find it quite disturbing. I think there's a
perpetuation of an extreme mistrust of almost anybody else to do
anything when the legislation specifically addresses a very small
percentage, an extreme minority within the general mental health
population. I've met with various consumer-survivor groups. I'd
like to ask you, though, how do you define the term
"consumer-survivor groups"? What does that mean?
Ms Hoover:
For us, it's people who have used the mental health system, who
have been in hospital and have survived the treatment that they
got.
Mr Patten:
My experience is that that's a negative, perhaps a negative
reaction. I don't know whether it's to the existing system or to
a former system. Recalling some of the history, certainly there
is deep concern and there is reaction to the abuses that took
place. I think those are quite historic. Maybe it happens
somewhere today but certainly not as it used to. I find that the
consumer-survivor groups have an immediate mistrust. There
doesn't appear to me to be any openness of talking about how you
treat that specific individual and how you get continual
treatment, not just stabilization. The problem I have, and you've
seen it especially in this community-you're going to say I'm
using extreme examples. I can give you lists of hundreds of
people who literally go in and out and they never get
treated.
Do you not feel that people
have a right to treatment, and that once we can stop this
syndrome and not just say, "If you provide them with a job and
provide them with a house, provide them with all these
supports"-I have friends who work in that field. I used to be in
the social field myself. They say: "No, it's not good. You've got
to break that syndrome somehow. You've got to find a way." I've
met people, and it happens to be more in the area of paranoid
schizophrenics, who said, "Thank God, somebody was able to get me
in and do that." People threaten me. A friend of mine was ready
to kill me. Afterwards, he said: "Imagine that. I thought you
were part of a conspiracy." We had to take him to the hospital
and he had to have sustained treatment. Just stabilizing someone
and saying, "Now go out," I think is cruel. I think we're
condemning that person to eternal mental disability, and with
recurring episodes people are damaged.
I ask you, do you not think
that there is a circumstance under which you want to break that
kind of a cycle? The only way you do it is that there is a
dimension of involuntary treatment.
1210
Ms Hoover:
For sure I think sometimes people need to go to the hospital. If
we're going to talk about people who have schizophrenia, unless
you're really listening to them-I know a young man with
schizophrenia. He took his medication faithfully. Some of the
medications they take actually kill them because they destroy
their liver. You think you're doing good for them, but in the end
they are going to die with this or something else. This young man
killed himself because the medication wasn't working. He told his
doctor his medication wasn't working. He said, "The voices won't
leave my head, ever." I went to school with him. He belonged to
the Clubhouse Oak Centre. He was very well dressed. You would
never know. But he couldn't live within himself.
It's sad that he died, but
the doctor wasn't listening to him, obviously. If he says, "This
stuff is not helping me," it's a shame that he ended up dying.
For sure, I think that sometimes people need to go to the
hospital. I will disagree with you, though. That treatment isn't
happening. I can go to the hospital any time, and people are
being tied into, I'll call them high chairs, because I don't know
what you would call them. They're tied in there. When they're
forced into a rubber room and have no clothes, but I'm walking
around the ward and I look at the nurses' station and I can see
whoever is in there naked, how demeaning that everybody knows you
have no clothes on. I see people still tied to two beds, so I
have to disagree that it's not a nightmare.
Ms Lankin:
I think this is the most difficult part of pursuing legislative
changes in this area. There are two worlds of experiences. One is
the experience of psychiatric survivors who have something
negative-I think Richard is right in making that connection-to
say about the system. But my understanding is, because they've
lived it and they've come out of it, they've got an experience
that we need to hear. We need to understand that.
Then on the other side
there are families, in particular families of patients with
schizophrenia, the most obvious example-and there may be other
illnesses, other disorders or diagnoses that are similar, and I'm
not an expert so I don't know-who talk about just the nightmare
of trying to get the appropriate treatment. Some of it is because
there's not enough treatment available, there are not enough
community supports of medical and non-medical, social, all of that; some of it is
because of the nature of the disorder itself and the lack of
awareness of the disorder and the denial of the disorder. I've
got to tell you I just feel tortured around these two polarities
in trying to deal with this legislation.
From your perspective,
because we're hearing a lot from the other perspective, can you
help us understand, from the psychiatric survivors' community
point of view, is there a time when someone lacks the capacity to
make these kinds of decisions about treatment and should be
forced to have some treatment? Is the fear that people who are
capable of making the decision and want to reject treatment for
totally legitimate reasons are going to be forced into treatment?
Tell me where the fear gap is and how we bridge that as
legislators or as people who want to provide the right service to
you.
Ms Hoover:
I can just use myself as a consumer-survivor. When I was in
hospital, all the things I'm saying I saw were there and they
haven't changed. I feel bad that you're not looking-I'm not
saying you. When I have a 15-year-old or a 12-year-old in a
psychiatric ward because they're runaways, I don't understand
that treatment.
As a human being, I would
never, ever like to be forced to go back in the hospital, never,
ever like to be forced to take medication. When I'm having a bad
time, I know I'm having a bad time and I'll go to my doctor and
say, "I'd just like to go back on my medication." They'll say,
"OK, how long?" and I'll know, and if I feel better, I just stop
taking it. I don't want someone coming to my house and saying,
"If you don't take this medicine, you're in trouble." I don't
think that's right.
My fear is
mostly-"seriously mentally ill" obviously, since 1908, is not a
new thing. Why hasn't anybody found solutions? Instead of more
treatment, why aren't there more solutions to how to support
people in the communities? Having more psychiatrists isn't the
answer because, if they're not good, who cares how many doctors
you give them? You need to be careful because we aren't a unique
bunch. This could happen to anybody. So whatever you're going to
put in place, you'd better hope you never end up where I am,
because it's going to be you. You're going to make this happen to
you. I think a lot of people feel the same.
I'm good right now. I have
no guarantee I'm not going to get sick again and I don't want
someone taking care of me whom I don't want there.
Mr
Barrett: Ms Hoover, thank you for your presentation. We
hear what you're saying about the concern or the fear in the
community about people being forced into the hospital. One goal
for these kinds of community treatment orders is to cut down on
the requirement for people to be in hospital, an order, again
signed by a physician or a psychiatrist, for the person to access
treatment in the community. If that doesn't work out, they're
referred to the hospital or a psychiatric facility, but they're
referred for assessment, not necessarily hospitalization.
My question is, do you have
any further ideas on the kind of the flexibility that should be
in this legislation so that there's less necessity for people to
be referred to the hospital and more assistance in the
community?
Ms Hoover:
In an assessment, you're just going to give them another label. I
could go and get assessments five times and I'll just have five
new labels. So what do I really have? Do I have schizophrenia? Am
I manic-depressive? Am I bipolar? It's already too much for me. I
don't even know what label I'm supposed to be following this
time. I already got my medication changed 10 times.
My fear is that you're
going to have forced treatment put in the community, and I don't
think hospitals should be part of my home. If you're going to
force me to have a community treatment order person, I will kill
myself because I don't want them there. If you're going to force
me to take my medication, which I know is already killing me,
then what choice would you-I think you're going to tie consumers'
hands. Right now, I don't really feel that the rate of people
killing themselves is so high. There are probably fewer people
than you think who are actually killing themselves.
Mr
Barrett: You're concerned with forcing people into
treatment. These community treatment orders are based on the
consent of the person or, if they're in a position where they
can't give consent, they're based on the consent of the person's
substitute decision-maker. In addition to that, the physician
involved in this order would have to be satisfied that the person
has received advice on their rights, and there are other
mechanisms. We had a presentation earlier from a person who sits
on a committee, the Consent and Capacity Board. So there are
other appeal procedures in place to ensure that a person's rights
are protected. Do you feel there should be further measures in
place to provide additional protections?
1220
Ms Hoover:
Sure.
Mr
Barrett: Do you have any suggestions?
Ms Hoover:
I already know. I go to support people all the time at the
hospital and they say, "I don't want to take this medication."
But they've got their nurse beside them saying, "If you don't
take this medication, we're just going to just force you to stay
in here longer." Then I say: "Well, you have rights. You can get
the patient advocate." They make you take the medication before
they let you see the patient advocate. There's no choice already.
You're already saying, "I'm not taking it." They're saying, "Yes,
you are." "I want a patient advocate." "Oh, sure, but you can't
see him for three days. Take the medication."
The Chair:
Thank you very much for coming before us here today. We very much
appreciate your taking the time.
SASHA MCINNES
The Chair:
That takes us to our last presentation of the morning session.
Sasha McInnes, come forward, please. The clerk indicates you'd
like a minute or two extra. We'd ask you to try and stick to
that, if you could, please.
Ms Sasha McInnes: Good
afternoon. My name is Sasha Claire McInnes and I'm an artist. I
welcome the opportunity to speak at this hearing.
It is not primarily to you,
the committee members, however, that I will be addressing my
comments, because I suspect that these hearings are pro forma
only and have no meaning in the context of what this government
intends to do with Bill 68. In other words, I don't believe that
anything I say will change the minds of the MPPs voting on this
legislation. It's not just the PC members of the Legislature who
are complicit in what I consider to be a repugnant, violent and
degrading law but the NDP and Liberals as well. It was, after
all, a Liberal MPP, Mr Patten here, who first developed the
forced treatment model for Ontario and three NDP governments in
Canada have shamelessly already brought it in.
My only purpose here is to
ensure that my view makes it into the public record. I will not
remain silent while individuals, who are elected public servants,
promote legislation that violates the civil and human rights of
citizens they are hired to serve. I remind you that you are our
employees, and it is our right to confront you when we feel it is
necessary. I feel it is necessary. I also want it to be very
clear that I feel a lot of compassion for individuals struggling
with family members in crisis. I've been there and I understand
how very difficult it is to manage. However, this bill is not the
answer. The forced and legal drugging of Ontario citizens should
be anathema to any civilized and caring individual, particularly
so when one considers the apparent hypocrisy with which this
government has dug in its heels with respect to another
substance, cannabis, that has proven benefits for certain of our
citizens enduring unspeakable physical pain.
It's apparent to me that
this bill is not at all about caring for the mental health of
Ontario citizens. If it were, the enormous amount of tax dollars
required to implement the bill would be used instead to develop
and strengthen existing services that increase the self-esteem,
personal and physical safety, personal dignity, independence,
opportunities for jobs and housing and community for individuals
who are isolated and in emotional crisis.
What is most pernicious
about this bill is that it will allow forced treatment based on
an assumption of harm an individual might inflict on self or
others at some future date-I repeat "might." What an incredible
display of blatant self-aggrandizement, ignorance, violence and
discrimination against a small community of vulnerable Ontarians.
You will be aware that the MacArthur study in the US clearly
showed that individuals with psychiatric labels are no more
likely to commit violent acts than any other individual, and if
they do, they most often occur in combination with substance
abuse such as alcoholism, crack cocaine or cocaine addiction.
Unfortunately, the Ministry of Health has not done its homework
with integrity but has been swayed by the odd high-profile case
where tragedy ensued.
You will also be aware that
current mental health legislation allows action to be taken when
an individual clearly demonstrates behaviour which might endanger
his or her life or the life of another. There are also laws
against assault, threats and various other criminal behaviours,
and if these are not working well enough now, we ought to be
focusing on strengthening them. If an individual commits a crime,
he or she should be prosecuted for it to the full extent of the
law, regardless of whether or not they have a psychiatric label.
Too many violent men are claiming mental illness as a reason for
their violence and ending up not in prison but in our
communities, where they can continue to prey on others. If they
are mentally ill and commit a crime, appropriate mental health
treatment ought to be available in prison, not in our communities
or on our streets. If you intend to get tough on crime, do it,
but not on the backs of innocent others who are being scapegoated
by self-interest, expediency and lazy thinking.
One also needs to consider
the recent data that illustrate the connection between the use of
psychiatric drugs and subsequent violent behaviour. It appears to
me that whoever drafted this legislation failed miserably with
respect to their research or simply had an agenda other than the
truth.
My question to you then is,
why? Why is this very small, vulnerable group of Ontarians being
singled out for "special" treatment at such great financial cost
to the public purse? I can only speculate. Is it because
distressed family members can no longer cope with the odd
behaviour of a loved one and are much more comfortable with a
more placid, if somewhat emotionally and brain-dead, relative?
They deserve much better than what is offered in this
legislation, although one can only question the motives of those
who have encouraged it when their organizations and their
personal jobs are supported financially by the drug companies.
I'm referring here specifically to the Schizophrenia Society of
Ontario, its board of directors and staff. Or is it because drug
treatment, of which psychiatry is so enamoured today, is a
cheaper alternative to concerned and compassionate community
supports which allow individuals with emotional problems to find
havens of safety, friends, meaningful activity and a home of
their own? We don't need to allocate dollars to community
resources if our family members are numbed out on psychiatric
drugs, right?
Could it be that the
multinational pharmaceutical industry, arm in arm with the
psychiatric profession, and now apparently governments, has
pathologized and medicalized so much of human behaviour and
emotion, manipulating us into the belief that all uncomfortable
feelings are bad and can be fixed with a pill? For a price, of
course, and in terms of dollars, the legal drug manufacturers are
making very big bucks off the emotional pain of others. New
psychiatric labels emerge weekly, with designer drugs on their
heels to feed this greed. Soon all of us will be considered
mentally ill because we're human and we feel. I, for one, want
and cherish my humanity, and that includes the ability to feel
deeply sadness and grief as well as elation, joy and
satisfaction. Feelings and emotions are what make us human. We
are not widgets to be
fixed and we are not broken to begin with.
It can't simply be that we
are so sure of our science that we can predict a potential for
violence and, on that basis, usurp an individual's civil and
human rights and force dehumanizing, degrading, disempowering and
dangerous drug treatment on them. If potential for harmful
behaviour is the ground on which this bill stands, there are far
greater indicators than some pseudo-scientific judgment about an
individual coping with a mental disability. What about a husband
who beats his wife? These individuals are known to the courts and
are far more likely to commit violent offences in the future.
They also commit more murders. How about drunk drivers? They may
lose their licences and maybe even do some time in jail, but
nobody suggests they should be drugged into a half-life even
though they commit far more havoc in society and in the lives of
individuals than persons with psychiatric labels. What about men
who rape? Should we drug all boys just in case they might, like
many of their fathers, become violent as they mature?
Stats tell us that young
black men, especially those who are disenfranchised and living in
poverty, commit significant violence in our society. Should we
forcibly treat them with drugs? I expect, if we were to try,
there would be a huge hue and cry from the public, and rightly
so. Why is it, then, that a specific group in our community is
being targeted by this mean-spirited, bigoted, violating and
retraumatizing legislation when only 4% of all violent crime is
committed by individuals with psychiatric labels? What about the
other 96%? Are you planning on drugging them too?
1230
While I feel deeply for his
family's loss, it is very offensive to me that you've chosen to
name the legislation Brian's Law. Tell us, please, will you be
developing a law called Every Woman and Child's Law because it is
both these groups of citizens who are most frequently battered,
raped, victims of incest, emotionally abused and otherwise
violated and traumatized in today's Ontario, including the loss
of their lives to violent men? How can any compassionate or
responsible person not be appalled by what is happening in
Ontario today?
Nor will this legislation
work, as New York has recently discovered with their Bellevue
study. In fact, it will work against the very thing we are trying
to accomplish: the mental health of Ontario citizens. The bottom
line is that many individuals in our communities will not seek
the help they need and want out of fear that they will be
forcibly drugged with toxic substances that have horrible
effects, some of which will last a lifetime, even after
withdrawal.
There's another issue here
that is of great concern to me. Women comprise over 75% of those
using mental health services. Study after study has shown that
they are in the system because of sexual, physical and emotional
abuse. This legislation, accessible to and manipulated by
unscrupulous others, may have devastating consequences for
already traumatized individuals. Consider how it might be used
against a woman or a young person fleeing a physically and
sexually abusive parent or spouse, breaking silence and
disclosing to others what is happening to them. In addition, many
homeless women and children are living on the streets because of
family abuse. This legislation, as I understand it, means to
include the homeless as one of the target groups. Is drugging
abused women and children the answer to their despair? I don't
think so.
Consider also what might
happen if a family member wants access to the money of their
elderly parents and manipulates others in order to acquire it.
Because of time constraints, these are only two examples of how
this legislation might be used by self-interested others, but are
you willing to take the risks associated with them?
I am not arguing for no
response to people in distress. Many individuals suffer traumas
that make their lives miserable. Supports are required to help
them find acceptance and a safe place in society. We have
examples of excellent, low-cost responses that not only support
people but help them to maintain their dignity, that offer them
choices, that accept them as they are. Instead, we bow to the
hysterical yammerings of people who have forgotten history. Let
me remind you and them of it. It was the mentally ill who were
among the first to be targeted for extinction in Nazi Germany,
referred to as "useless people." Today we don't murder them, but
we might as well, because chemical lobotomies aren't even close
to what one might characterize as life.
Despite the lessons of
history, we bow to those who would serve up the vulnerable on the
altar of multinational, shrink-wrapped, high-tech, big-money
responses in order to force so-called normalcy on a vulnerable
population to supposedly let all of us sleep a little safer at
night. I, for one, do not feel safer with this proposed
legislation. Far from it. My own experience with it tells me that
there's far too much hocus-pocus in psychiatry to think that this
approach won't lead to grievous abuses of individual liberty and
health. Today it is individuals with psychiatric labels who may
fall under this vile legislation. Tomorrow it may be you, because
all of you sitting there have the capacity, because you too are
human, to feel and to feel deeply.
In the years to come, when
your lives in politics are over and you're looking back on your
careers, I expect this Legislation will give you, your children
and grandchildren little pride. In fact, I believe you may live
with the shame of it for the rest of your lives, and the shame of
it will continue in the lives of your family members. Remember a
lesson from our First Nations communities, who first consider the
impact of any decision down seven generations. Do you want to be
remembered as the Legislature that decimated the civil and human
rights of vulnerable Ontario citizens? I hope not.
I'd like to end with a
quote from Martin Luther King: "So the question is not whether we
will be extremists, but what kind of extremists will we be? Will
we be extremists for the preservation of injustice ... or will we
be extremists for the cause of justice?"
Scrap this bill. Develop respectful services for
people who need them and strengthen the successful ones we
already have.
Thank you, and good
afternoon.
The Chair:
Thank you very much for your comments. We appreciate you coming
forward here today.
With that, the committee
stands adjourned until 1:30. See you all back here then.
The committee recessed
from 1236 to 1339.
ONTARIO PSYCHIATRIC ASSOCIATION
The Chair:
Good afternoon to members and guests. We resume hearings on Bill
68. Our first presentation this afternoon is the Ontario
Psychiatric Association. We'll welcome them up to the witness
table. As an expert panel, you've been given 30 minutes for your
presentation and you may divide that as you see fit between
talking to us and taking questions.
Dr Alan
Eppel: My name is Alan Eppel. I'm the immediate past
president of the Ontario Psychiatric Association. With me is Dr
Lawrence Martin, who is on the faculty at McMaster University.
Both of us work at St Joseph's Hospital in the department of
psychiatry here in Hamilton.
I'm going to be quite brief
in my remarks because I'm sure you have an overwhelming amount of
information that's been presented to you. What I would like to do
is to convey some key principles and key issues that I know have
come up. You have a copy of our brief, which is brief, and I just
want to focus on the summary which is the first after the face
page.
The Ontario Psychiatric
Association supports the proposed amendments in Brian's Law
because they will: reduce suffering of patients and families;
reduce hospitalization; reduce the imprisonment and
criminalization of many of those with mental illness; respond to
recommendations of numerous coroners' juries over the past
decade; maintain the human rights and legal protection of
patients in accordance with the Canadian Charter of Rights and
Freedoms; and finally, will allow the restoration for many
patients of real freedom, autonomy and dignity.
Another major point I'll
make, as it has come up frequently in discussions of the existing
Mental Health Act, has to do with the language of the act. The
language of the act must be clear and understandable, and not be
made hamstrung or unworkable by complicated and repetitious
procedures.
For these reasons Ontario
Psychiatric Association supports the changes put forward by the
Ontario Medical Association earlier this week in their brief to
this committee. I'd like to thank the government for the
opportunity to provide some input into this process. In the
following pages of the brief, there's some elaboration on the
points I have made, and I won't repeat those.
I will say something,
though, on the issue of human rights, because that is central to
any issues concerning mental health legislation. We believe that
our Constitution offers as a right, life, liberty and security of
the person. Under the current act, many people who are so
seriously ill that they do not realize they are ill are deprived
of that right and don't have the opportunity for health, recovery
and the ability to work, make relationships and have some quality
of life. So we see no contradiction in the present amendments and
the guarantees of the Canadian charter, and the present Ontario
laws provide for very extensive and rigorous rights
protection.
I will conclude by calling
upon all you who have the true interests of patients with severe
and incapacitating mental, psychiatric illness at heart to
support Brian's Law and our proposed modifications. Thank you
very much and I'm open for questions.
Dr Martin has had personal
experience in New Zealand in the use of community treatment
orders, so he may respond to some questions pertaining to
that.
The Chair:
Thank you and you've left us lots of time for questioning in each
caucus. This time we'll be starting with the government.
Mr Clark:
Thank you for coming. I do appreciate it.
Earlier today we heard from
a group that had some concerns about acquired brain injuries. I'm
wondering if you might comment. Their position was that they had
a concern that acquired brain injuries fell outside of all this
and that they wanted to make sure that community treatment orders
for those who were seriously mentally ill as a result of an
acquired brain injury would fall into this legislation that is
proposed. Could you comment?
Dr Eppel:
Under the current Mental Health Act, the definition of "mental
illness" is quite broad and certainly would include people with
acquired brain injury. Brain injuries, organic brain syndromes
are psychiatric conditions. They are documented in psychiatric
classification systems. So I don't see any difficulty, where
someone has impairment of thought or perception or memory and
meets the other criteria, in their being included under these
orders. As I say, that depends on the definition of "mental
illness" or "mental disorder" which is in the existing act.
Mr Clark:
My second question, if I may, Chair. There's been some discussion
in our consultations, in this round of the hearings, about a
preamble to the legislation. I guess that over the years there
have been preambles which identify the spirit, the intent. Is it
your position that a preamble would be helpful in this case in
terms of what the spirit of the law is supposed to be?
Dr Eppel:
The Ontario Psychiatric Association does support the idea of a
preamble to generally explain the purpose of the act. The present
act is more of a police act. It is really characterized by a
focus on dangerousness rather than care and treatment for people
who are very ill. So we certainly would like to see a preamble,
if that were possible, explaining that the purpose of the act
primarily is to provide the care and treatment to individuals who
are very severely ill, particularly those who may not realize
that they're ill and may not be able to consent to or refuse
treatment.
Mr Clark:
Just two last ones and then I'll pass it on to my colleagues
here. There had been discussion throughout the consultations that I chaired across the
province that the nomenclature was something that was a concern
for people. The idea that it was being called a community
treatment order seemed to be somehow inconsistent with the fact
that it was consent based. Do you have any concerns about that or
comments on: Is this a community treatment order or is it
actually a community treatment agreement or a plan?
Dr Eppel:
I don't have any trouble with the change in nomenclature if the
present nomenclature is not acceptable to certain people. I don't
think that is the main issue. The main issue is the content of
the law and whether it will be workable and practicable. I don't
think the name change will be a problem for the OPA in any
way.
Mr Clark:
The last question that I have for you is, there have been
discussions and I think it's only come up maybe once or twice so
far in this set of hearings, but in the other consultations there
were discussions about the right to treatment, that somehow we
should include that, that there should be a right to treatment
for mental health patients. Would you care to comment on that
ideal?
Dr Eppel:
I guess something like that could go into a preamble. In my
remarks I did refer to the Canadian Charter of Rights and
Freedoms. Certainly I think there's a valid interpretation that
there is some right to life, liberty and security of the person,
which means equal access to health services. If you are unable to
access them because of the nature of your illness, your right to
that should not be taken away from you. So in some sense, that
may be an idea that might fit in with the rest of the act,
yes.
Mr
Barrett: In your brief you indicate support for
amendments in part because community treatment orders would
reduce hospitalization, and that's my understanding of the goal
for this. However, if a person is not confined with a community
treatment order, they would perhaps be referred back to a
psychiatric facility for an assessment, not necessarily
hospitalization. That depends on the assessment.
Dr Eppel:
Right.
Mr
Barrett: Could you tell us a bit more about the
assessment tools that are used or the length of an assessment or
what is an assessment? There's no law requiring an assessment, as
I understand, but I would assume most institutions now do an
objective assessment, rather than just putting someone in a bed
without checking them out.
Dr Eppel:
The key method in psychiatry is the interview of the patient and
perhaps their relatives or other key people whom they will
consent to allow you to interview. We assess people on the basis
of their mental functioning, their thinking, their perceptions,
whether they have hallucinations, their mood, whether they're
very depressed, whether they have thoughts of suicide or
attempted suicide or any homicidal thoughts or intentions,
whether their memory is intact. So it's a clinical assessment,
although we're not too far away from the point where MRI scans
and so forth may play a role in some of the more serious
disorders. Essentially in psychiatry it's a clinical assessment,
and there are no simple blood tests and so forth.
1350
The issue of
rehospitalization is clearly an area that has caused some
confusion. The studies show reduction in rehospitalization and
length of stays in hospital. The question of the person who does
not follow the community treatment order and then is readmitted,
those patients are in the system already now and they are
relapsing and being admitted many times. They constitute the
revolving-door situation. So in fact, with that group, with
community treatment orders there will be less of a revolving door
and fewer admissions. That seems to be the impact in the North
Carolina study and some of the other studies that you may have
heard of already. Does that answer your question?
Mr
Barrett: Yes, that helps a great deal. I understand in
the existing Mental Health Act the administrator of the hospital
can release a patient. Does that compromise this direction if we
are bringing in community treatment orders?
Dr Eppel:
Are you referring to the leave of absence which has to be
authorized by the officer in charge? Is that what you're
referring to?
Mr
Barrett: I'm not sure.
Dr Eppel:
That sometimes can be cumbersome. CEOs, being removed from the
clinical situation, may be concerned about liability and so
forth. It would make sense that the CEO delegate that to a
clinical person, the attending physician or the chief of
psychiatry, so that that would spare them the concerns they may
have.
Mr Patten:
Thank you very much for coming today. I have three questions. You
need not do it right now, but would you share what you believe
are the best studies available that demonstrate the value of
community treatment programs or agreements or whatever they're
called? I'm tending to not want to use the term CTOs any more,
because it raises such ominous reactions. If you would do that,
that would be very helpful, number one. Secondly, some groups
come before us and say there is no evidence to suggest any better
value or any improved condition of the patient.
Then, Dr Martin, I'd be
interested in your experience in New Zealand. What was going on
there, what has happened, and how do they deal with this?
Dr Eppel:
Do you want to respond first?
Dr Lawrence
Martin: My description is from four years ago, before I
came to McMaster. I worked for one year on an acute care
in-patient ward and followed patients in an outpatient setting as
well. The range of illnesses we saw there were what you would see
in Canada. It's the same worldwide.
The hospital had a
population, in- and out-registered patients, of approximately
1,000, and of that, I would estimate-and this is not a hard
figure-that fewer than 20 were on CTOs. It was in fact not
abused. It was used quite sparingly. The physicians were quite
aware of the fact that people on the whole do not wish to be on a
CTO and used it only in cases where it was clearly necessary,
where problems with non-adherence were leading to many
readmissions. The process involved a hearing before a three-person panel
and the criteria for being on a CTO were the same as for
involuntary commitment.
The CTOs, as I say, were
used quite sparingly and were very nicely amalgamated or part of
a more assertive outpatient program. If someone was known to have
problems with adherence, had recurrent bipolar illness or
psychotic disorders, the nurses would go to the home and follow
up. So often it wasn't necessary to invoke the CTO; it was simply
a matter of making contact with the patient when they were
disorganized or beginning to lose grip.
Where the illness had
advanced beyond that, patients were brought into hospital. This
happened, over the course of one year, in only four cases that I
can think of. The patients who were on CTOs-I think that as
psychiatrists we tend to be quite mindful of the impact that this
can have on a person, to be placed under a mandatory treatment
order. I think that's one of the reasons it was used sparingly.
But I thought it was an invaluable part of the mental health
system and I noticed the difference as soon as I returned to
Canada.
What was very different was
that, although many of the individuals on CTOs did not initially
wish to be on the order, by maintaining health they were able to
build on their skills and to be much better integrated into the
community. What was very striking was that instead of a pattern
of recurrent illness and, if you wish, a career of illness, they
were able to attend regular workshops, participate in programs
and be employed because there was consistency in their lives.
That consistency was something they had not had previously, so it
allowed for active rehabilitation.
One last comment: There is
a problem having to do with the type of diagnosis patients will
have on this order and it was there largely for patients with
psychotic disorders. It was not-and on rare instances that I saw,
I think there was only one case of a patient who had bipolar
illness-used to require treatment that was non-pharmacological,
in what I saw. It was not used to require that patients with
characterological disorders or personality disorders be required
to attend treatment. It was largely restricted to use where
treatments were known to be effective.
Dr Eppel:
About the studies, they are complex because the conditions are
not always the same in each state or each jurisdiction. North
Carolina is probably the one that's been most well studied. Their
latest report was in the British Journal of Psychiatry of April
2000. I can get back to you with other information.
Mr Patten:
Thank you very much.
Ms Lankin:
I thank both of you so much. This is really invaluable
information and direct experience that you're providing to the
committee.
I'm very interested in your
comments, and the last comments you just made about the majority
being patients with a psychotic disorder. It speaks, Dr Eppel, to
your comments around perhaps the use of a preamble. We've asked
for a number of studies to be provided already. One of them is
the Swartz study from the States, which shows that the success of
CTOs in reducing hospitalization is pronounced for the
sub-population of patients with psychotic disorders and is not
pronounced for the sub-population of patients with mood
disorders-I'm not sure of the right terminology to use, but you
will know what that means-also, that the success of it is
multiplied by the degree of community supports in place to
support the CTO.
In a sense I've been trying
to circle the square, square the circle, whatever that expression
is, between the fears among some people in the psychiatric
survivor community and the real plea from families, particularly
families of patients with psychotic disorders.
I'm wondering, if the
studies indicate this and the experience indicates this, is there
a way to clinically narrow the application of CTOs so that
people-and I'm going to ask you a few questions in a moment about
the actual language here. I think what people fear is
inappropriate application of the language or the language being
inappropriately structured and that it will capture a broader
group of people. Have you given any thought to a clinical
narrowing?
1400
Dr Eppel:
We have, actually, and that's a very good point. Our solution to
that was to narrow the current definition of mental illness in
the present Mental Health Act so that it would apply only to
people with serious incapacity, with impairments of perception
and judgment and behaviour and so forth. That would narrow it
down and it might reassure some of the people you are referring
to that they wouldn't be scooped off the street and medicated and
all this fear-mongering that we've heard.
The intent of the act is
certainly not to do that. It's aimed at a certain group of people
that is small in number but yet who are suffering a great deal.
We had thought that one way to go would be to narrow the existing
definition of mental illness so that it would exclude certain
groups to whom it clearly wasn't relevant or wouldn't apply. That
would be one possible way of doing that.
Ms Lankin:
Perhaps we can contact you later to get some ideas about
that.
Dr Eppel:
Sure.
Ms Lankin:
Having said that, one of the things that bothered me as a
layperson in reading the actual structure of the legislation
about how a person gets put on a community treatment order-you
mentioned in the experience you had that a person came before the
three-person panel. It was the same criteria for an involuntary
commitment.
In this legislation, to use
the shorthand language, a physician-not necessarily a
psychiatrist, and we understand the reason for the language being
written that way-if a physician is of the opinion that the
patient meets a number of criteria, but one of the key ones is
that they meet the form 1 criteria, that patient can be placed
straight on to a CTO.
I've talked to some heads
of psychiatry of the hospitals who say there are people who are
form 1 who come for an
assessment who, when given an assessment, sometimes are not
involuntarily committed. Yet an individual here could end up,
without ever having that psychiatric assessment, on a CTO. What
he backed that up with was that the legislation allows for
regulations, granted, that say what kind of physician and/or
background.
But in rural communities
where there is no access to a psychiatrist, where you have a
physician and the relationship with the family member, the
criteria as they stand don't necessarily get you to the kind of
patient you're saying would be appropriate for a CTO. I think
that's where some of the concern rests. Do you have any thoughts
that there should be at least at some point a reference that a
psychiatric assessment is actually involved in this?
Dr Eppel:
It makes sense that certainly there should be a clinical
examination. As you know, in parts of the province there are no
psychiatrists-there are very few-and that has always been an
issue in Ontario, so we have to make provision for that. But
certainly the patient should have a thorough clinical
assessment.
The criteria in Ontario are
very strict for involuntary admission and it's not that easy to
meet them, and that's again another protection. They are probably
at this point some of the strictest in the world because there
has been a swing back from the very strict dangerousness
criteria. We believe there are all kinds of protections within
the act, including the criteria and also the appeal
mechanisms.
We make some reference in
here to the wording in the current amendment about community
treatment orders. It does tend to be rather cumbersome and a bit
repetitive. We would like to see that section simplified and made
more understandable. But in terms of protecting peoples' rights,
nobody has to use a CTO if they don't want to. Nobody is
compelled.
Ms Lankin:
I'm not actually even looking at protecting. I'm looking at
ensuring-this is supposed to be less restrictive. I just want to
make sure that these are the kinds of patients who would in fact
be involuntarily committed and the kinds of patients who in fact
are as you describe them and would benefit from the CTO. I do not
want to make it more cumbersome. In fact, I think narrow it down
and make it a little bit clearer.
Dr Eppel:
Yes, we feel that with the addition of section 15(1.1), which is
the new involuntary criteria, the existing criteria will only
embrace people with very severe illness who may benefit from it.
If I understand you correctly, I think, based in the criteria,
that should protect, or ensure that it's the right people.
Ms Lankin:
I'm a layperson, but I think a situation where a physician in the
community can come to the opinion that a person could be form 1
and sent for an assessment, can put them on a community treatment
order, isn't quite enough. When you look at the criteria about
previous hospitalizations, those could have been voluntary
hospitalizations. They're not necessarily involuntary
hospitalizations. I'm just looking for a way to make sure that
your profession and that kind of an assessment are in there
someplace as we go through this process. I don't know how to
accomplish that.
Dr Eppel:
I'd have to give some thought to that. Some reference to an
appropriate assessment might be indicated.
Dr Martin:
They would still have access to the appeal mechanism, of
course.
Mr Patten:
Can I just ask for a point of clarification on what you have
raised, Frances, that someone can be put on a community treatment
order without an assessment: I don't think that's there.
Ms Lankin:
Yes, it is.
Mr Clark:
That's not my understanding of it.
Ms Lankin:
Maybe we can actually clarify that later, but if I could tell you
briefly my understanding: The criteria that are there say that
the individual has to meet, in the physician's opinion, the form
1, which is to get you to the assessment. You don't have to go
and have the assessment. That's what I was saying in reference to
what Mr Barrett said earlier.
When you put that together
with the criteria about previous hospitalization, the fact that
those two hospitalizations in the previous three years could have
been voluntary hospitalizations, it allows for a broader net. I'm
not saying that would be applied, but I think we could be clearer
in what it is that we expect to be applied. That's what I'm
looking for.
Mr Clark:
If I may clarify, and we should clarify further, I understand
that we have one section that you're referring to, and then
clause 33.1(2)(c) talks about a "72-hour period before entering
into a community treatment plan, where the physician has examined
the person ...." So there is an actual examination of the
patient.
Ms Lankin:
If I may refer you to subclause 33.1(2)(c)(ii): "the person meets
the criteria for the completion of an application for psychiatric
assessment under subsection 15(1) ...." It's the application for
a psychiatric assessment. It's not the next step, the form 3
psychiatric assessment and determination of eligibility for
involuntary committal or not. That's the issue I've been trying
to raise.
Mr Clark:
I understand. It's covered under clause 33.1(4)(b): "A community
treatment order shall indicate the facts on which the physician
formed the opinion referred to in clause (2)(c)," which is the
actual examination. We can ask for some clarification on it, but
I think it is covered off.
Ms Lankin:
But it's not necessarily a psychiatric assessment. It should
be.
The Chair:
I think you have your undertaking from the parliamentary
assistant to seek that clarification, Ms Lankin. I'm sure we'll
all look forward to getting that at one of our future
hearings.
Gentlemen, thank you very
much for coming before us today. We appreciate your bringing your
expertise to us.
Mr Clark:
Mr Chair, if I may: ABI, acquired brain injury, was brought up
earlier today and whether or not it would fall into this. Can
legislative research investigate whether there's a legal opinion on it for this
act and how other jurisdictions dealt with acquired brain injury
in their mental health acts.
The Chair:
Thank you.
BRIAN LANE
The Chair:
Next up is Mr Brian Lane, who is here. If he could come forward,
please. Good afternoon, Mr Lane. Welcome to the committee. You
have 10 minutes for your presentation. If you wish, you can
either use that time to talk or you can leave some time for
question and answer.
Let me just suggest to the
members around the table that with individuals there sometimes
isn't enough time for all caucuses, so I will follow the same
rotation, with all the time going to whichever caucus is next in
the rotation, if that meets your approval.
Mr Brian
Lane: I'm going to look at this in terms of human rights
issues. To me, this smacks of Nazi dictatorship. That's the view
I have of this. I'm from the Dundas-Flamborough-Ancaster area.
I've got the local paper. All it's talking about is dictatorship
and criminal activities in the local towns. The mayor is talking
about Nazi-style tactics and this type of thing. I feel that this
government has gone much too far in that vein. This legislation
is a sort of pinnacle of what I see as Nazi legislation.
I talked about this a
couple of days ago to a doctor who's Jewish. I said, "What do you
think about this legislation?" First of all, she didn't believe
that anything like this would be introduced in Canada. Then I
said to her, "Well, what's your view?" She said, "This is what
the Nazis did." I said, "What do you mean?" She said: "The Nazis
went after the mental patients first. They rounded them up. They
identified them. They put them in hospitals. They took away all
their human rights. They started doing all these experiments with
them. Then eventually the psychiatrists started killing
them."
Hitler was in power for a
few years-I've got a quote here. This is from a psychiatrist.
Hitler said, "I have nothing to do with this program." Hitler
hadn't started it, but he took over the killing centres and their
psychiatrists and used them to train his SS to kill Jews. That's
where the SS learned to kill, by killing not Jews but German
Christian mental patients.
1410
All we need to do is go
back to see how Nazi Germany got underway and ended up killing
six million people. It started with the mental patients. You take
away people's human rights. They had good intentions, even in
Canada and the United States. They were going to create a
superior race. They were going to sterilize these various groups
of people. That's what they did. As you know, it even went on in
Alberta until the 1970s.
It started out with good
intentions. The psychiatrists eventually started killing their
patients, a massive euthanasia program. Hitler came along, took
over the killing centres and had the psychiatrists train the SS
to kill Jews. It's well documented. If you look at who's getting
the funding among Holocaust survivors, one of the four groups is
mental patients and the disabled. We've been down this road, we
ended up with six million people being killed and we don't want
to go down this road again.
In terms of violence in
society, I have a residence in a very expensive neighbourhood.
When I moved in there-I'm single-the neighbours said, "You can't
move in here because you're single and this is only for
families." They further said to me: "Since you're single, you're
probably a homosexual. We don't want our kids harassed by a
homosexual." These are the doctors and the nurses and the top
bureaucrats. These are very wealthy people with very expensive
houses in this neighbourhood. I was threatened with arson, I had
a fire behind my house, I've had dog attacks, and last week I had
shots fired through my window sort of as an encouragement for me
to leave. There's violence at all levels of society. Of course,
if you're at the higher level, nothing happens. When I went to
the town about the dogs attacking me, they wouldn't do anything
about it because you don't take on lawyers, you don't take on
doctors and this type of thing.
I just want to point out to
you that to try to stigmatize one group because of one incident
is completely unfair. I could find an Italian, a black, a white,
a woman, a man and I could say, "Let's create a law because of
what this one person did." That's unfair, especially when you're
dealing with the most vulnerable people.
I strongly support choice.
I think that's where you should be looking. You should be
supporting and empowering people, choice and normalizing mental
illness. It says one in five people has mental illness and
seeks-that's what the Clarke Institute reports. Surely some of
the members of Parliament therefore must suffer from mental
illness. It would be nice if someone stood up in question period
and said: "Look, I'm a member of Parliament but I have a mental
illness. I just wanted the public to know that it's OK to talk
about having mental illness. It's OK to seek psychiatric help and
normalize things."
This is going to do the
opposite. Who's going to go to their doctor and voice that they
have a mental illness? They're going to be terrified. Police are
not even allowed to make any judgment. They're supposed to just
go in and pick up the person. Say a person is in his
neighbourhood or he's in his job and suddenly the police come in
and pull him out. Everyone says, "What's going on here?" "Well,
this person has a mental illness and we have to take him in for
forced treatment." Suddenly, he doesn't have a job any more. His
social standing is shot. No one wants to have anything to do with
him.
As I say, it's Nazi
tactics. If you want to help psychiatric patients, you want to
put funding and control in their own hands to forge relationships
with the patients and say: "We've got X amount of money that
we're willing to put into the mental health system. We want to
make sure that we get the biggest bang for the buck. What can we
do that's going to help you? If it's seeing the psychiatrist, if it's taking your
psychiatric medication, that's fine." Most people would support
that.
But if there's something
else, if your immediate need is housing, because we have all
these people living on-Mel Lastman says they're living on $10 a
day as homeless people. Mel Lastman claims that's the government
policy, to just shove them out on the streets and let them live
on $10 a day as homeless people until they die. Whatever money
you're going to put in, let the patients have control over their
own lives as much as possible and find out on an individual basis
and on a collective basis what their needs are and then address
those needs directly.
My brother, who is a
psychologist, was telling me that they brought in some guy who
was living under a bridge and they did all these tests on him.
They spent about $20,000 or $30,000 in tests. That's what it cost
for all the psychiatrists, nurses and everything else when they
had him in the hospital there. At the end they did the diagnosis
and that was it. They had it all figured out. Then they sent him
back, and he's living under the bridge again. What kind of sense
does that make? That $20,000 or $30,000 should have been used to
actually address that person's specific needs and work with the
person instead of working against the person.
I've met all kinds of
doctors and psychiatrists because I've been involved in this type
of thing for several years. Psychiatrists need to examine: If
they can't form relationships with patients, then what are they
doing in the profession? Some people are good at forming
relationships and some people are good at establishing a
doctor-patient therapeutic relationship and some people aren't.
One of the things that really concerns me-and Mr Clark will find
this interesting because he was involved in working with the
companies that were trying to dump pollution in Taro and whatnot.
I'm sure when he pointed out to the big companies some of the
problems that were being caused by dumping these toxic chemicals
into the soil, he found out that the companies didn't say: "Well,
thanks, Brad. You're a really good citizen. We want to clean up
our act, because all we care about is serving the public good,"
and that type of thing. They didn't really do that, I don't
think, Brad. I think they probably hit you with about a
$20-million lawsuit and did everything they possibly-I talked to
one fellow, and they put a microphone outside his house so they
could tape his private conversations with his wife and whatnot.
This is what I heard, anyway.
You have to understand that
the pharmaceutical companies are interested in market share and
profit. They want all of us to be on psychiatric drugs, to have
our moods lifted and dropped. That's their business. They want
market share; they want profits. They want the psychiatrists to
use their medications.
I did a study across the
province of mental patients, past and present, and I found that
about half of them said they were actually surviving the mental
health system. In other words, they were like Holocaust survivors
or sexual abuse survivors. Half of them were survivors. The
government doesn't want to put millions and millions of dollars
into, so-called, helping mental patients and having half of them
say: "Holy man, I survived. My friends over there committed
suicide under the system. They couldn't handle all the side
effects of their drugs. They couldn't handle what was going on
there." That's not what you want. You want 99% of the patients to
come back and say: "Thank God for the mental health system. Thank
God for government spending." Whatever you spend in the system,
you want the people to benefit from it. You have to work with
them.
One of the things you have
to do is really work in terms of the community. When the
community sees this legislation, they're going to say: "I knew
it. I knew they were all dangerous. I knew they had to be picked
up by the cops or they were all going to kill us." That's the
exact opposite of-you want the normalized things. You want to
build relationships. You want to say to the community: "Look, one
in five Canadian citizens with full rights has an illness, and it
could be your mother or your brother. It could be anyone." It's
probably higher than one in five. And they're coming back into
the community, because we don't want them all stuck in the
hospital. For one thing, we can't afford it. You want your tax
breaks and everything else. They're coming back into the
community. Sure, we're going to want those patients to work along
with everyone else to do what they can, to stabilize their health
as best they can. But we're not going to allow the community to
harass them, to abuse them and to do all the things that are
going on right now towards mental patients. This legislation is
just reinforcing that stereotype.
The Chair:
Excuse me, Mr Lane, we've actually gone over the 10 minutes.
Could you make some closing comments?
Mr Lane:
OK. I've sent some material in, and I'll pass some more to the
committee.
I think you want to move
away from where you're going and move towards working with the
patients and patient groups, supporting patients' funding. Under
the NDP-I thank God for Bob Rae-I did get some funding. I was
pushing for change and, to a certain extent, I was welcome.
Then-again, as Brad Clark will know-the powers that be, the
bureaucracy in the government, the pharmaceutical industry and
whatnot, said: "Hey, wait a minute. We don't want to lose market
share. We don't want to lose control. This guy is talking about
choices. That means the patients might find other ways for
treatment instead of our drugs." So there was a real backlash
against me.
Move forward, people. These
patients are you and me and your mother and your sister and your
brother. These are full Canadians. Treat them as full Canadians.
If they have an illness, let's all work together to treat it as
full Canadian citizens and not diminish anyone's rights.
Thanks very much for your
time. I'll send some stuff in, and hopefully you can consider
it.
The Chair:
Thank you very much, Mr Lane. We appreciate your coming before us
here today.
1420
HAMILTON PSYCHIATRIC HOSPITAL PATIENT
COUNCIL
The Chair:
Our next group is the Hamilton Psychiatric Hospital Patient
Council. Could they join us at the table, please. Good afternoon
and welcome to the committee. We have 20 minutes for your
presentation.
Ms Patricia
Landry: I'll be reading, if you don't mind. Our preface
is at the beginning of our presentation. You can go over that at
your leisure.
Respected committee members
and guests, I am a facilitator for the patient council board of
directors at Hamilton Psychiatric Hospital. The HPH Patient
Council's mandate is to "forward the concerns of in-patients,
outpatients and former patients to the hospital administration to
help promote better conditions and treatment for all." We work in
systemic advocacy on behalf of consumer-survivors in HPH, in the
HPH catchment area and in the province. I have brought our
brochure with me for any of you who are interested in reading our
goals and philosophies.
We are concerned about Bill
68, and I have been asked by my fellow patient council members to
share our concerns with you and trust you will take them
seriously when you consider any legislative changes to the
existing Mental Health Act and Health Care Consent Act.
It is important to note
first that our board has not issued a statement for or against
the proposed changes, or the implementation of community
treatment orders. Some of us feel, in fact, that CTOs may be
necessary at times. Others disagree altogether and subscribe to
the statement issued by the Psychiatric Patient Advocate Office
that, "Society's interest in protecting people from themselves
must be balanced against society's interest in preserving the
fundamental freedom of its members." We've included that document
in your package, if you choose to look at it. The HPH Patient
Council does, however, share several important concerns. They are
as follows:
(1) In a recent letter to
you, we wrote that the community consultation process regarding
the bill, headed by the ministry, did not allow any time
beforehand for stakeholders and consumers to prepare statements,
establish consensus or to even attend the consultations at all.
We extend this objection to the timing of the hearings this week.
The time for debate on this bill is sliding by too quickly, and
we wonder if this is an attempt to prevent public objection.
As we wrote to you
recently, we also object to the bias by which the community
consultations by Brad Clark were conducted. You will note that
the agenda only allowed discussion for the implementation of
community treatment orders, and certainly not whether people were
for or against them. We would ask you to take more time before
you make your recommendations, and that you directly consult with
consumer-survivor groups before the debate over Bill 68 goes any
further.
(2) We feel that stigma and
media sensationalism have played a part in the introduction of
this bill. The media, in a way that criminalizes the mentally
ill, has exploited recent horrible tragedies. Here in Hamilton,
during the recent inquest into the death of Zachary Antidormi by
Lucia Piovesan, the horror story was told over and over again by
journalists, reinforcing the negative stereotype that people with
severe mental illness are dangerous killers and stalkers. This
plays on and adds to the escalation of public fears.
The majority of people with
mental illness suffer for it and face threats to their freedom to
make treatment decisions. We would ask you to seriously research
the effectiveness of CTOs in the manner that was done by CMHA
Ontario in their published literature review before you consider
any legislative changes. We would also ask the Ministry of Health
for money to be invested directly into extensive public education
to combat negative stereotypes, especially if this bill is
introduced.
(3) We feel that the name
given to the act, Brian's Law, plays on public fear and
sentimentality. Again, given the stigma that mentally ill people
face, the name of this bill brings to the fore an assumption that
it must be introduced for fear that people who would otherwise be
put on community treatment orders would commit a horrendous act
like that experienced by Brian Smith. How unfair and how untrue.
Again, with the title of the bill, all mental health consumers
are criminalized and connected with a murder. Perhaps public
support for the bill might have been far less because of the
questions the proposed legislation poses about encroachment on
the rights of consumers if it had not been attached to a murder,
an isolated incident that screams, "Get these people off the
streets," to the general public. We would ask you to retract the
name Brian's Law from any new legislation regarding the Mental
Health Act and the Health Care Consent Act.
(4) We support what Lyn
McLeod has recently said, that, "It's hard to believe that the
government could have completed two consultations on mental
health, leading to a significant piece of legislation that they
want to introduce this spring, and yet not put anything in the
budget to back up that legislation." She went on to say that,
"Every person who has knowledge of the needs of mental health,
whether a supporter of community treatment orders or not, agrees
that there must be more money for community treatment."
We say that Ontario does
not yet have the comprehensive range of services and supports,
and choices thereof, necessary to keep consumers healthy and from
slipping back into illness. Services and supports that provide
employment options or economic stability are barely available,
and the ODSP allowance is too low. Housing options are scarce for
people on such a limited income, and the lack of basic
necessities can lead to low self-esteem, social isolation and, in
the long run, illness. If society took care of its people with
mental illness-for example, as it would someone with cancer-Bill
68 might not even be necessary. We would ask you to recommend to your peers that
more money be put into the mental health care system.
(5) Specifically, we would
ask you to recommend that more money be considered especially for
meaningful activity, employment, dignified housing, innovative
mental health programs that subscribe to psychosocial
rehabilitation philosophy and opportunities for consumer-survivor
empowerment. All of these lead to overall wellness. More
investment is needed for consumer-survivor initiatives, lodging
and care home reform, the development of safe houses and respite
beds as an alternative to hospitalization, the expansion and
development of 24-hour mobile crisis teams, opportunities for
consumers to obtain counselling or psychotherapy, which are not
covered by OHIP, and case management that focuses on the best
quality of life with the least intervention for its clients.
Investment in these services will decrease pressure on in-patient
beds and lighten the load on emergency rooms. Further, we
understand that if people defy their CTO, they will be committed
to hospital. We are sure many people will not comply with CTOs,
and there will be even more of a strain on hospital beds.
(6) We are worried that
community treatment might encompass an obligation to take
medications that cause serious side effects and that it will
impede the ability of consumers to negotiate treatment. Consumers
generally know what their bodies can tolerate in psychoactive
medication and what they cannot. Some psychiatrists do not allow
for much expression of insight into one's illness, and CTOs might
simply be an opportunity to exercise their subjectivity in the
treatment of mental illness. In this respect, Bill 68 may further
estrange consumers from their caregivers.
Recent research, for
example, at the Centre for Addiction and Mental Health-you have a
copy of an Internet publication on the study-has indicated that
people with schizophrenia can function well on far less
medication than they are usually prescribed. We would ask you to
provide a venue for service negotiation and collaboration between
providers and consumers in the event of a committal to a hospital
or the community in any legislation, along with the patients'
bill of rights. In extension to this, it is the responsibility of
doctors to relay any and all risks or side effects to a person
expected to take a given medication.
(7) We are concerned that
the appeal process will not happen quickly enough. We see what
long waits for review board hearings do to patients in the
forensic system, and we are concerned that those committed to
community treatment will experience the same delays in appeal and
review. Provisions must be made whereby review or appeal happens
within an acceptable period of time-in weeks, not months. This
leads me to our last point.
1430
(8) The introduction of any
new law comes with the obligation to protect the rights of those
who are subject to it. The adequate provision of advocacy and
rights advice must be readily available. This means expanding the
Psychiatric Patient Advocate Office in Ontario, increasing
consumer self-advocacy in the mental health system and including
provisions in the act whereby, if rights advice and advocacy are
not provided upon committal, the person issuing the order faces
penalties.
We trust you will consider
these recommendations and that you will heed what
consumer-survivors have to say during your review of Bill 68. As
I said, we have supporting documents for you in your package.
Thank you for allowing us to present today.
The Chair:
Thank you very much. That leaves us with about two and a half
minutes per caucus. In the rotation we'll start this time with
the Liberals.
Mr Patten:
Thank you very much for your presentation. I'm assuming you had a
chance to review the bill.
Ms Landry:
Yes.
Mr Patten:
My impression is that you think the idea of a community treatment
order is pretty widely applicable. In your opinion, who might be
subject to a CTO?
Ms Landry:
In our perception, most likely people with severe mental illness,
people experiencing a psychosis who have made threats to
themselves or others.
Mr Patten:
I don't know if you heard Dr Martin, who was here before with the
Ontario Psychiatric Association and his experience. I think the
point that's important is that we're talking about a very small
population, even within the mental illness category, a very small
subgroup. For example, when we look at figures for Saskatchewan
or BC, Dr Martin mentioned that of 1,000 and some patients, they
had about 20. We're talking about less than 1% of even that
population. That's why I'm wondering if you're feeling this is
something that could get away from the system of really
addressing a very small number of people who are not aware of
their own condition and are a threat to themselves or someone
else.
Ms Landry:
As we said, our board has not issued a statement for or against
community treatment orders. In fact, some people think they are
necessary, whereas some of us agree with what the Psychiatric
Patient Advocate Office has said about balancing the rights of
the individual with the rights of society. What our focus is, and
what we would like you to focus on, is the funding that's
necessary in the community. If you read our preface, you'll note
that. We have to get our attention off criminalizing the mentally
ill. By putting money back into the community, this bill might
not even have been necessary. If we take care of our people who
have mental illness and provide them with dignified services and
what they need to live, perhaps this may not have been necessary,
and perhaps-I'm venturing to say this with caution-a tragedy like
that which happened to Brian Smith might not have happened.
That's our focus, and that's what we'd like you to consider.
Mr John
Schalkwyk: There's also COAST now, which is the
community-
Ms Landry:
The community outreach and support team. I don't know if you've
heard of that here in Hamilton yet.
Mr Schalkwyk: They have come
into being since the inquest. Also, we feel that rather than
community treatment orders, resources should be put into
community supports.
Ms Landry:
Can I add-
The Chair:
Could we go on to Ms Lankin, and if we have an opportunity-thank
you.
Ms Lankin:
Perhaps I'll leave enough time for you to continue that thought
as well. Towards the end of your presentation you were talking
about the balancing act of human rights and rights advice. There
actually is a fair bit written into various parts of this
legislation. But I was struck that you were asking us to consider
penalties for those who issue committal orders who don't provide
access to rights advice, which suggests to me you find that that
happens. Could you elaborate on that?
Ms Landry:
Yes.
Ms Lankin:
That's shocking.
Ms Landry:
I'd be speaking from personal experience, which I'd rather not
do, and I'd rather not speak on personal experience on behalf of
our board, which has asked us to make this presentation. But
things like this do happen. Forms are not filled out. Form 14s
are not filled out. Rest assured that this happens. If you speak
with consumer-survivors, you'll probably hear that people know
very little about their rights, and you'd probably ask yourself
why. With something like this, it is so important that
consumer-survivors who are subject to community treatment orders
are educated.
Ms Lankin:
One of the things that has been raised as a possibility in the
community treatment order section, where it gets into rights
advice and access to rights advice, is that there actually be a
prescribed form set out that the individual must sign to indicate
that they have received their rights advice. While it doesn't
solve the problem if they don't, it does become part of the
evidentiary record on appeal. Would that be something that you
would think, in addition to your recommendations about penalties,
might be useful?
Ms Landry:
Yes, of course. Providers in the psychiatric system, especially
those who work in hospital, are rushed, and these things just
don't happen. It's all well and good on paper and to talk about
it, but I believe it has to be spelled out clearly that if this
isn't provided there's something to pay for that.
The Chair:
Thank you, Ms Lankin.
Mr Clark:
Just three quick statements. With reference to the consultations
you spoke about where it was facilitated around the discussion of
implementation and there wasn't an opportunity to say yes or no,
that's incorrect. Everyone in all of the groups had an
opportunity to say yes or no and they were all recorded. We have
the facts and the records on it.
Ms Landry:
It was not on the agenda. That opportunity was not on any agenda.
If fact, when we broke off into the focus groups, some people
chose to make their point. I disagree, for example, with
community treatment orders. It wasn't an opportunity that was
given-
Mr Clark:
With respect, I chaired them and I raised it every single time
and gave everyone an opportunity to say yes or no up front.
With respect to your
question about funding and the comment you refer to about Lyn
McLeod, the budget actually does refer to $110 million for
psychiatric services, so you might want to check that out. It is
in there.
Ms Landry:
We've read the background.
Mr Clark:
Secondly, you've also spoken about COAST, which I'm very pleased
is working well in Hamilton-Wentworth. That was also funded by
the Ministry of Health. We've reinvested about $150 million since
1995. I'm not saying that's enough. We all agree at this table
and in the community that in order to actually reform mental
health, the act, the system, to have that continuum of service,
there has to be both ends. We have to have a good system and a
continuum, which means we need support in the community. We do
agree there, but I'm just making that point.
The last point I want to
clarify for you. You stated, "Further, we understand that if
people defy their CTO, they will be committed to hospital."
That's incorrect. It's a consent-based model. They can actually
request to withdraw from the CTO. If you read the legislation, it
gives significant rights advice, legal advice to the patients
themselves. It also states very clearly that if they're in
non-compliance, the physician and psychiatrist can go for
reassessment on the patient. It doesn't talk about
hospitalization.
Ms Landry:
We're concerned that that won't happen quickly enough.
Mr Clark:
That's a valid point in terms of appeals and reviews, and that's
a concern I think we all share. But I wanted to make the point
that simply because they're not in compliance does not mean
they're going to be locked up in a hospital. They go back in for
reassessment, and that's the way the legislation is written.
The Chair:
Thank you very much for taking the time to make a presentation
before us here today.
Ms Landry:
Do I have time to make one last point?
The Chair:
Very, very briefly.
Ms Landry:
You talk about funding, Mr Clark. We're talking about funding for
dignified services. We're not talking about funding to expand
workshops and lodging homes. We're talking about dignified
housing and dignified employment options-things that keep people
well. We know from first-hand experience that this is true. This
will reduce your costs in mental health.
The Chair:
Thank you. We appreciate your coming.
1440
LINDA CAREY
The Chair:
This takes us to our next individual, Ms Linda Carey. If Ms Carey
is here, could she come forward, please. Good afternoon.
Ms Linda
Carey: Good afternoon.
The Chair:
Welcome to the committee. You have 10 minutes for your
presentation.
Ms Carey: I do not have a
written presentation, but I will be submitting one at a later
date which will encompass the comments I'm making today.
I would like to start by
thanking you for the opportunity to come and make comments on the
proposed changes to the Mental Health Act and the Health Care
Consent Act. I am very concerned about the rights of each and
every individual in Ontario and particularly the rights of
individuals suffering from serious mental illness. It is
important that we protect these individuals' rights. We ourselves
value our rights, we value our liberty, and one of the issues
that I personally value is allowing myself to make decisions
regarding my own treatment. If we are going to take away a right
from a person, it must be done in an appropriate manner and it
must be done with appropriate safeguards so that the person whose
liberty or right is being taken away is protected.
In the proposed legislation
there are numerous changes to issues which already exist, for
example, applications for psychiatric assessment, powers of the
police department, powers of justices of the peace.
I'm very concerned
regarding the removal of the word "imminent" from criteria for
having people brought to hospital as well as criteria for
involuntary status. The word "imminent," for myself, is a
protection. It says that I not only have to be in danger of
serious physical impairment, but it must be a serious physical
impairment that is going to happen relatively quickly. It can't
be something that's going to happen in a year, two years, eight
years down the road; it has to be something that my doctor can
really foresee and look at as coming along very, very quickly.
That's a great concern.
The use of the words
"substantial mental or physical deterioration"-again, I have
great concern. Whose opinion is that? The doctor's probably. May
he consider my decision or my feelings about it? Yes, possibly,
but in all likelihood, no. Again, there's no definition of that.
There doesn't appear to be any assistance in the legislation to
help the doctor figure out exactly what that means. That is
something that obviously the courts would have to deal with.
The other one that I find
very problematic is "apparently incapable." In one of the new
criteria, the person must be apparently incapable of consenting
to treatment. We're asking someone to make this decision, for
example, a justice of the peace who doesn't even know the person,
who has never met them, has never talked to them. We're asking
them to make this decision based on information they get from a
third party. That is very problematic. You're asking someone who
has never met or talked to this individual to take away something
that is very, very important to us, our right to liberty and not
to be taken off to the hospital by the police department.
I am opposed to community
treatment orders for a number of reasons. It's forcing an
individual to do something in the community that they may not
want to do. We have to look at assisting people with things such
as appropriate housing, getting sufficient money to live, having
something to do during the day besides sitting around on the
sidewalk, having work, having social outlets where they can meet
people and be friends and not living, as people in Hamilton in
second-level lodging homes do, on $112 per month.
When a person is placed on
a community treatment order, it says that the person or the
substitute decision-maker may consent. Will that consent, if it's
the person, be informed and voluntary? What if they have the
impression that if they don't sign that piece of paper they're
not ever going to get out of the hospital? I can tell you that
many clients, many people are going to have that impression. That
is not a voluntary and informed consent.
The issue of rights advice
needs to be spelled out much more strongly in the legislation.
The doctor is to be satisfied that the individual has seen a
rights adviser, but there's no obligation for the doctor to
notify the rights adviser that he is going to issue this
community treatment order. There's no obligation for the rights
adviser to be able to see the person at any time if they want to
do it. We have to spell out the role of the rights adviser much
more specifically to ensure that the individual's rights are
being protected.
A person, or a substitute
decision-maker, can withdraw their consent to the community
treatment order. The legislation is very specific; it says that.
But if you do, you get a whole new bunch of things that you have
to do. You have to show up and be examined by the doctor so he
can decide or whether you should go into hospital, or you should
be on another community treatment order, or whether the community
treatment order can be terminated. It's not just, "I don't want
to do it any more," and that's the end of it. It's "I don't want
to do it any more," and "Now we're going to force you to do
something else which may again put your liberty at risk by being
brought in to the hospital."
The legislation, the way I
read it, allows one hearing in each six-month period on the
community treatment order. Many things can happen to an
individual in six months. The ability to have a hearing should be
more frequent, to allow the person an opportunity to demonstrate
that their circumstances have changed, that now they do not need
a community treatment order, that things have changed and they
are able to live in the community quite successfully. The
legislation needs to include either a more frequent time period
or perhaps the ability for an individual to ask for an earlier
hearing based upon a change of circumstances such as is contained
in the Health Care Consent Act regarding treatment issues.
The issues regarding
treatment also concern me, because there is a change which allows
a health practitioner to apply to the Consent and Capacity Board
to depart from a person's wishes. I find that very problematic,
because the substitute decision-maker may be saying, "No, you
cannot give that treatment," for a very specific reason. I find
the health practitioner having that much power over a person's
treatment decisions very troubling. A person may make a wish for
a very specific reason and feel that their substitute decision-maker is
going to carry that through. Now you're saying that even if the
substitute decision-maker is following through, they may be
overridden by the Consent and Capacity Board. That's very
troubling.
I would ask if there are
any questions that anyone may have regarding my statement.
The Chair:
Thank you very much. We do indeed have about three and a half
minutes left. Ms Lankin, the rotation puts you first. I'll leave
it up to you whether you want to take all that time or share it
with your colleagues.
Ms Lankin:
Oh, I see. That's the total amount of time?
The Chair:
Yes, just over three minutes.
Ms Lankin:
Very quickly then, I'll see if I can touch on two things and
leave some other time. The provision that you just talked about
in the Health Care Consent Act, I had some concerns about that
too. My particular concern was where it was a care facility that
can also seek to overturn prior wishes. My reading of it is,
though, that they can seek to get permission from the substitute
decision-maker to overturn prior wishes, so the substitute
decision-maker is still involved. But in the case of some care
facilities, particularly unregulated rest and retirement homes,
and where the substitute decision-maker is distant and far away,
I worry about coercion in that situation. "Otherwise we're going
to kick this person out and they're going to be back on your
doorstep, family member, for you to take care of."
With respect to the
physician, do you still have that same concern, knowing that it's
to seek permission for the substitute decision-maker to override
previous capable wishes?
Ms Carey:
I think, particularly where you're talking about care homes and
things like that where people may not be as involved with their
relative as one would hope, that in fact they may just leave it
to the doctor to do it all. That's very problematic, because the
substitute decision-maker, under the legislation, has very
specific obligations. I don't think people should be allowed to
just say, "I'm just going to pass my obligation on to the doctor
and let him do it." If the substitute decision-maker does not
want to fulfill their obligations under the legislation, I think
they should say, "I don't want to be the substitute
decision-maker," and maybe someone else would be happy to fulfill
that role as is required by the legislation. That's one of my
concerns, that they're just going to pass it off and someone else
is going to do all the work.
Ms Lankin:
I'm going to make one quick comment and then pass it over. Your
comment about "apparently incapable," I actually raised a concern
about that when I went through the briefing, not so much for the
JP but for the physician doing the referral for assessment. It
seems to me physicians have to make a decision all the time
whether the person is capable of giving consent or not capable of
giving consent. I don't think it's appropriate to apply a lesser
standard in these circumstances of "apparently incapable." So
it's one of the things that I'll be looking for an amendment
for.
The Chair:
I'm afraid that has used up the time.
Ms Lankin:
I'm sorry.
The Chair:
No, that's fine, Ms Lankin. You were next in the rotation.
Thank you very much again
for coming before us this afternoon. We appreciate your
perspective.
1450
MARILYN SMITH
The Chair:
That takes us to our last presenter of the afternoon here in
Hamilton, Ms Marilyn Smith. Good afternoon. Welcome to the
committee.
Ms Marilyn
Smith: To start, I've already offered my apologies to
your clerk for the quality of the print of my draft. I had a
non-compliant computer printer.
I am here as a private
citizen. If you want any information on my background, if time
permits at the end, I'll be happy to share with you.
Tragedy has led us here.
Innocent persons have faced peril because of mental illness.
People have died by their own hand or as a result of actions of
persons with mental disorders. Systems-legal, medical and
social-have failed us all on too numerous occasions.
The Mental Health Act is
often the element chastized for the loss of life associated with
mental illness. The most frequently cited concerns with respect
to the law have been centred on the inclusion of the word
"imminent." Critics of current law have charged that the law
renders care providers incapacitant to help seriously mentally
ill persons at risk of harming themselves or other persons. It is
highly distressing that semantic interpretations of this word by
some of the most learned in our society has segued to the point
where we now deliberate on drastic physical impositions on the
most seriously mentally ill in our community. If one word can be
the source of such confusion and destruction, I fear the outcome
if certain proposed amendments to the Mental Health Act should be
adopted.
Most contentious of the
proposed changes is the adoption of community treatment orders.
The parameters that define who may be subject to a CTO, despite
references to hospitalization and length of stay, are extremely
broad. There does appear to be potential for abuse in this
component of proposed amendments. An individual who wants
treatment, care or support should not have to stand at the back
of the line for treatment because another or others have legally
mandated provisions for care. Neither should an individual have
to face possible unlimited loss of independent life direction by
agreeing to a CTO as a condition or requirement for
treatment.
Ostensibly these changes
have been introduced in response to perceived failures in our
current system to ensure that extremely ill and dangerous persons
who are unwilling and/or unable to seek treatment are assisted.
However, correcting such perceived inadequacies should not create
a situation whereby those wanting and needing help are unable to
receive it.
While the notion of forced treatment in and of
itself is objectionable, the unspecified scope of potential
inclusions in a CTO are even more so. For example, it would seem
within the realm of possibility that CTOs may spell out similar
terms and conditions as those to which convicted criminals must
abide as part of parole and/or community sentencing, such as
place of residence stipulations and curfew or social relationship
restrictions. Mental illness continues to be a source of stigma.
We must not perpetuate this with any undertone or perceived
conveyance of a criminalization of the mentally ill.
Other areas of concern
related to community treatment orders include subsections 33.1(5)
and 33.5(4), which would seem to reflect that there does not have
to be a designated and/or acting substitute decision-maker to act
on the patient's behalf. Just for your quick reference, the first
is contained on page 7 of 20 and the second reference is
contained on page 10 of 20. That is the source of my concern.
While this would not
present a problem if the community treatment order subject's
legal and previously expressed wishes were assured, this does not
appear a certainty. Proposed changes do permit for applications
to be made to the Consent and Capacity Board for a departure from
wishes. It would seem reasonable that there be an individual
given authority and moral obligation for such an onerous
undertaking.
Certain proposed changes to
the act earn merit, for example section 5, referencing section 17
of the Mental Health Act, which broadens the authority of the
police to detain and escort an individual for the purpose of
assessment based on reasonable and probable grounds and that it
would be dangerous to proceed under section 16, an order by a
justice of the peace. Too often police officers must face the
distressed and deceased. It seems reasonable to permit them
greater authority to assist in the avoidance of bodily harm to
any member of the community.
By way of general comments,
I wish to reflect that the first sentence of the explanatory
notes of the bill begins by stating, "The bill proposes
amendments to the Mental Health Act that would allow persons ...
to live outside of a psychiatric facility ... ." Few people
actually live in a psychiatric facility, as you or I would define
the word "live." They are patients in hospital to receive
treatment, similar to any other person with a health problem
which may require in-patient treatment and care. When a patient
is discharged, he usually goes home, not to a "community
residential setting," as is defined in literature provided during
the initial stage of community consultations regarding
legislative changes to the Mental Health Act, and I make specific
reference to a document released by the Ministry of Health on
March 22, The Next Step: Strengthening Ontario's Mental Health
System.
There are members of the
legal and medical communities and the community at large who
believe that current legal provisions for the forced detention
and treatment of the mentally ill are quite broad. Review boards
meet frequently, and often at great length, to deliberate on
issues pertaining to patients' status. Despite and because of
this, many patients who do not wish to receive treatment or a
particular type of treatment continue to receive care. There
remain, though, those who wish and require help but remain on a
list or in a waiting room until their name is called or they
choose to leave.
In closing, I have some
suggestions, four specifically, for the creation of a stronger
system of mental health.
Recommendation 1: While I
recognize there is documentation of efforts to undertake public
education on the law, in my view those undertakings most recently
have apparently failed, so I would again encourage that the
government undertake an exhaustive education program on the
Mental Health Act, the Health Care Consent Act and the Substitute
Decisions Act.
Recommendation 2:
Prioritize delivery of this program to members and students of
both the medical and legal communities. Sadly, it does seem there
are medical practitioners who are unaware of their legal
obligations, and sadly, it does appear there are lawyers and
justices of the peace who are unaware of their legal obligations
under current law.
Recommendation 3: Recruit,
retain, educate and regulate highly skilled, innovative and
emotionally sensitive mental health practitioners for our
community.
Recommendation 4: Ensure
our mental health system is optimally resourced, based on the
prioritization of the delivery of patient care, not the policing
of patient care.
Thank you for your
time.
The Chair:
Thank you very much for your comments. That leaves us with just
about a minute and a half. Next up in the rotation would be the
government.
Mrs Munro:
Thank you very much for being here today to give us your views,
and perhaps more importantly, your suggestions, because obviously
the purpose of this committee is to look at the responses by the
public to the proposals that are set before us.
You mentioned at the very
beginning your concern about the community treatment orders.
Earlier this afternoon it was brought to our attention that in
other jurisdictions where similar legislation already exists
there have been safeguards put there which ensure that a very
small percentage of people would actually fall into that category
and need that kind of regulation.
We've had a lot of
discussion about the need for some kind of preamble that would
demonstrate the idea or the spirit behind the legislation,
because very often legislation has by its nature to be in very
strict legal language and doesn't provide an opportunity to set
forth objectives or the intention. I'm just wondering whether,
given the kinds of discussions we've heard in relation to the
care with which community treatment orders have been used in
other jurisdictions, it would serve your purpose and your
concerns if there were such a preamble as I've discussed.
Ms Smith:
Based on my understanding of some population of people whom this
legislation is more than likely targeted towards, based on what I
assume that group of people to be composed of, I don't think that
would even console, if
you will, any of my concerns. I think that for effective
treatment to happen, there has to be the establishment of a
therapeutic alliance that involves trust, faith in a care
practitioner. You can't trust somebody who is not willing to
listen to your concerns and act on those concerns and try and
make the best of it, "This is what I think, based on my medical
expertise, and this is what you think." On that point, I don't
think it would be of any help.
Second, I think we have
current systems which would allow people who have concerns about
the most difficult to treat, the hard to serve, the
non-compliant-at some point in time over the past few years there
must have been a period of lucidity that that person achieved. If
they have a family member who is so concerned about their
well-being, if they can find a time when that person is lucid and
try to explain and understand the way of current provisions in
appointing a substitute decision-maker, saying: "When you get
sick, what do you want? This is how you are when you're sick.
You're not like that now, but if you are like that again"-get
their legally expressed advance wishes, and then if somebody
chooses to allow themselves to become psychotic and very ill-and
I know this will challenge most people's stream of thought, but
if somebody could make that type of decision, for whatever
personal reason, in a state of lucidity, the right to regress is
something I believe must be respected, if it's a legally
expressed wish and the person is competent and lucid when they
make it. If there are questions you have about how that is
possible or if you wish to say, "I don't think that is ever
possible," I'd really like to hear the yea or nay to that.
The Chair:
Maybe you and Ms Munro can continue that discussion. Thank you
very much again for taking the time to appear before us. We
appreciate your presentation.
Mr Clark:
Mr Chair, before we close, I think what's going to happen as this
thing unfolds is there are going to be some proposed amendments
that will come out of it from all sides. Some incredibly good
suggestions and valid suggestions have been made already. I would
like to suggest to all the members that they feel free, and I
encourage them, to deal with ministry counsel. I have asked
ministry counsel to work freely with the members to deal with
their amendments and make suggestions in terms of what the intent
may be, where it might fit in the legislation, perhaps in wording
or a clause, whatever. Feel free to take that up and deal with
the legal counsel and they'll help you craft the amendments you'd
like to propose for the committee.
Ms Lankin:
Just very briefly, may I say thank you, Mr Clark. It was my
experience on the other side of the table that that helped in
working with opposition critics, in making sure it fit in the
right section of the bill. Working with leg counsel is helpful,
but that is invaluable. I had hoped that would be the case and I
am very gratified to see it is. Thank you.
The Chair:
With that, just before I adjourn, if the members of the
subcommittee could stick around for a second, we'll discuss some
issues related to Monday's scheduling. Aside from that, the
committee stands adjourned.
