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SEPTEMBER 2011 voluME 3, NuMBER 3 Publications Mail Agreement N

Contents l Mental Health Services l Volume 3, Number 3 Introduction 5. Breaking Down Invisible Walls
Wendy Nicklin Preventing Youth Suicide Through
A Collaborative Fitness Pilot Project for
Comprehensive Mental Health Care
Clozapine-Treated Patients
Ian Manion Llana Phillips, Kevin Kok, Marg Petty, and Nicky Gitlin Improving Mental Health Outcomes
Preventing Aggressive Behaviour in
One Connection at a Time
Mental Health – An Integrated Approach
Alan Stevenson and Patti Lauzon Danielle Corbeil, Marc Pineault, David Bérubé, and Louise Beauvais Transforming the Mental Health System
36. Louise Bradley Accrediting Community-Based Mental
14. Health Services and Supports
Karen J. Kieley Mental Health and Addiction
40. A Blended Reality
Delena Tikk and Darien Thira A Systems Approach to Mental
18. Health Service Integration
Bruce H. Swan In Closing Pursuing Quality Initiatives
46. Bernadette MacDonald Reproductive Mental Health Services
24. in Atlantic Canada
Coleen Flynn and Joanne MacDonald Qmentum Quarterly: Quality in Health Care is the product of a partnership between Accreditation Canada and Les éditions du Point.
Accreditation Canada is a not-for-profit independent organization that provides health services organizations with a rigorous and comprehensive accreditation process. We foster ongoing quality improvement based on evidence-based standards and external peer review. Accredited by the International Society for Quality in Health Care, Accreditation Canada has helped organizations strive for excellence for more than 50 years.
Les éditions du Point is a specialized publisher. One of its journals, Le Point en administration de la santé et des services sociaux, is intended for health professionals and administrators and has been published for seven years. Les éditions du Point's publications target administrators, managers, and professionals in health care. The publications are intended as tools for information, support, professional development, and continuing education, as well as for reflection, analysis, and expression. While remaining very close to the concerns of the targeted readership, the publications are also guided by national and international thinking.

Mental Health Services l Volume 3, Number 3 Qmentum Quarterly: Quality in Health Care is an avenue for sharing expertise, innovation, and leading practices across Canada. The publication provides a forum for health and social services organizations that are committed to learning about and improving quality and patient safety.
Alan Stevenson, Bruce H. Swan,
Darien Thira and Delena Tikk
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Contributors to this edition Qmentum Quarterly's content cannot Louise Beauvais, David Bérubé,
be reproduced, in whole or in part, Louise Bradley, Danielle Corbeil,
without the written permission of Coleen Flynn, Nicky Gitlin,
the publisher.
Karen J. Kiely, Kevin Kok,
Concept and Layout Patti Lauzon, Bernadette MacDonald,
Printed on Chorus Art, a chlorine-free Joane MacDonald, Ian Manion,
paper containing 50% recycled content, Wendy Nicklin, Marg Petty,
25% of which is post-consumer waste, Llana Phillips, Marc Pineault,
FSC certified.
President and Chief Executive Officer Accreditation Canada Breaking Down Invisible Walls Dialogue about mental health illness has changed and monitoring interventions is the only way to garner long- significantly in recent years. This is largely the lasting change in this area.
result of mental health care providers and consumers having strongly advocated for a reduction in the Joanne MacDonald and Coleen Flynn have worked on an stigma and social exclusion associated with mental illness. They educational resource that addresses women's mental health have also promoted treatment that is focused on recovery and issues, particularly those affecting new mothers. Their toolkit that is community-based, so patients can access appropriate targets frontline social service workers who are in regular care more easily and with less fear of encountering stigma or contact with women whose mental health issues may not yet other invisible barriers to care. As a result, we are hopeful that be diagnosed.
more people are seeking the help they need to combat mental Delena Tikk and Darien Thira's work at a healing centre enables us to consider a mental health treatment program Governments have also begun to focus on mental health as an that combines Western and traditional Aboriginal healing integral part of the health care continuum. Many services that techniques.
were once part of a fractured mental health care system are being connected in a way that makes sense for patients, Alan Stevenson and Patti Lauzon present an innovative funders, and health care providers. Mental health is finally community-based discharge planning service that has beginning to receive the attention it deserves.
significantly reduced their hospital's readmission rates for mental health patients.
In this issue of Qmentum Quarterly, Bruce Swan describes the steps his team took in developing a systems approach to service Louise Bradley of the Mental Health Commission of Canada delivery, by moving toward an integrated mental health system challenges us to think about how to transform Canada's to improve access and reduce wait time to service.
current mental health services into a recovery-oriented Danielle Corbeil, David Bérubé, Louise Beauvais, and Marc Pineault offer us a view of their hospital's program, which And finally, Kevin Kok, Marg Petty, Liana Philips, and Nicky is aimed at preventing aggressive behavior and violence by Gitlin remind us of the need to attend to the physical as well mental health patients.
as the mental health needs of individuals with psychotic Given the current emphasis on treating mental illnesses outside of institutions, it was apparent to Accreditation As the achievements of these authors suggests, Canadian Canada that there was a need to strengthen the emphasis health services are moving in new directions in order to on the community aspect of mental health services in its provide more relevant and timely access to appropriate Qmentum accreditation program. Karen Kieley therefore services for loved ones who are coping with mental health discusses Accreditation Canada's new Community-Based conditions. I congratulate the authors on their efforts and thank Mental Health Services and Supports Standards, and helps us them for sharing their inspiring practices! understand their key elements.
Ian Manion provides us with insight into youth mental illness and suicide. This subject has received media attention in recent months, but as Ian reminds us, changing the system Ian ManIon
Preventing Youth Suicide Through Comprehensive Mental Health Care I n Canada, we have reached a tipping Given the high personal costs to victims, point where mental health – survivors, and taxpayers, it is crucial that particularly among children and prevention and intervention strategies be youth – has emerged as a priority that implemented in Canada to help young young people suffer requires public attention, careful planning, people get off – and stay off – a path and appropriate resourcing. A sobering in silence until their that ends in suicide. Attention to the indicator of our collective success at pain is beyond their full continuum of mental health care is meeting the mental health needs of essential if we are to succeed at enacting ability to cope. children and youth is the rate of suicide positive change in the mental health of our among young Canadians (CIHI, 2011). children and youth. This must include: n Concerted efforts to promote mental wellness.
Suicide is the second leading cause of death for young people in Canada.
n Early identification of mental health problems. Suicide accounts for nearly one quarter of deaths n Effective interventions for acute and chronic mental among youth each year.
The suicide rate among children aged 5 to 14 years is Our success will also be determined by our ability to fill 1.1 per 100,000.
our knowledge gaps. With quality research and evaluation activities, we can monitor our progress and make evidence- The suicide rate among youth aged 15 to 24 years is informed revisions to our strategies.
13 per 100,000.
It is also important to acknowledge that stigma and the fear For every young person lost to suicide, there are of discrimination can prevent people from seeking help; some approximately 400 documented and undocumented patients face unwelcoming service environments when they suicide attempts.
seek treatment. Our success in reducing suicide depends on our ability to decrease – and eventually erase – the stigma that Approximately one quarter of Canadian youth aged permeates our society and some systems of care. 13 to 18 years have seriously contemplated suicide.
While it can be easy to focus on the negative impact of mental Mental illness has been documented in up to 90 per illness, we must also be passionate supporters of mental cent of suicides.
wellness – particularly among children and youth, where the potential for long-term benefit is greatest. The promotion The financial cost of a single suicide attempt ranges of mental health and well-being before suicidal thoughts from $30,000 to $300,000.
or plans emerge is fundamental to prevention. Fostering positive developmental trajectories to stave off youth suicide is Each year, suicide and associated behaviours represent something that should begin at a very early age. Mental health a $2.2-billion burden to the Canadian economy.
promotion can equip young people with skills that will help them cope when they experience acute distress. It should be Up to 40 per cent of youth say that they would not tell as ingrained in our collective psyche as active lifestyles (e.g., anyone, even a friend, if they were suicidal.
healthy eating, exercise) and injury prevention (e.g., helmet and seat belt use). This could be accomplished through adult role modelling, the inclusion of mental health information in educational curriculums, and by making it part of our general Youth suicide in Canada represents a tremendous social and public awareness.
economic burden, but it is also a symptom of our historic failure to provide a full continuum of effective mental health services Given the strong link between mental illness and suicide to children and youth who need them. Although youth suicide in youth, early identification and effective treatment of such is a complex issue that is multi-determined, pre-existing illness is essential for effective prevention. Arguably, an increase mental illness contributes to nearly all cases of youth suicide, in mental health literacy can help someone understand when suggesting that the tragic outcome can be prevented with an they might be facing mental health problems and where help evidence-informed and collaborative effort to address the root can be found. Similarly, a general increase in mental health of the problem.
literacy allows natural helpers (e.g., parents, friends, coaches) as well as those with potential gatekeeper roles (e.g., teachers, care often presents a barrier to getting the right kind of help at family physicians, other care providers), to better identify the right time. Challenges to the timely and efficient sharing someone at risk. Schools represent an important setting of information among care providers further complicates for both increasing literacy and early identification. Despite the provision of seamless services, especially in the case a significant increase in attention for school-based mental of chronic suicidal risk. Although technological solutions health and the emergence of many promising practices, to information sharing may exist, systematic strategies to efforts remain mostly non-standardized and poorly coordinated. ethically communicate relevant information across sectors Current efforts by the Mental Health Commission of Canada and among providers lag well behind. In the case of suicide, and the School-Based Mental Health and Substance Abuse negative attitudes by care providers – possibly reflecting Consortium (Manion, Short & Ferguson, 2011) are providing frustration and a sense of helplessness – can further complicate leadership in identifying effective practices and sharing that the picture (Piacentini, 1993; Stewart, Manion & Davidson, information more broadly.
Accessible and effective community-based and specialized An effective and non-stigmatizing emergency room response mental health services must be available to young people to youth suicide is still viewed as an important link in the with mental health needs, including those with suicidal risk. continuum of care. Guidelines are available (American Unfortunately, a fragmented and under-resourced system of Academy of Child and Adolescent Psychiatry, 2000; Royal College of Psychiatrists, 1998; Kennedy, Baraff, Suddath, their impact. The acceptability and accessibility of all efforts & Asarnow, 2004) although evidence is still lacking for the can also be ensured by engaging young people and their effective implementation of such strategies (Stewart, Manion, families in program development and evaluation. Q & Davidson, 2002; Newton et al., 2010). Such guidelines must include effective follow-up and comprehensive after-care Ian Manion, PhD, C.Psych., is a clinical psychologist and
upon discharge from the emergency department or hospital. scientist-practitioner. He is the Executive Director for the Ontario It is critical that we learn to appreciate that recurring suicidal Centre of Excellence for Child and Youth Mental Health and thoughts and behaviours are often symptomatic of a chronic a clinical professor in the School of Psychology at the University mental illness that should be viewed and treated with the same of Ottawa. He is Co-Chair of the National Infant, Child and level of care and sensitivity as any chronic illness.
Youth Mental Health Consortium, Co-Chair of the Canadian Child and Youth Health Coalition, and the Lead for the National It would also be valuable to identify and evaluate the systemic School-Based Mental Health and Substance Use Consortium. changes needed for us to adequately promote mental health, identify mental illness at its earliest appearance, meet the urgent needs of those in acute distress, and address the short American Academy of Child and Adolescent Psychiatry. (2000). and long-term intervention needs of young people with Practice Parameters for the Assessment and Treatment of Children and significant mental health concerns. Ongoing investigation Adolescents with Suicidal Behavior. Washington, DC: Author.
will help us understand how to establish and maintain seamless linkages across the continuum of care. Significant Armstrong, L., Manion I. (2006). Suicidal ideation in young males living in rural communities: distance from school as a risk factor, research networks have already been established in Canada youth engagement as a protective factor. Vulnerable children and youth regarding youth suicide and related issues, and many have a studies, 1,102-113. particular focus on identifying and tracking what will become our systemic indicators of success (Newton et al., 2010; Rhodes Canadian Institute for Health Information. (2011). Health Indicators et al., 2011).
Even with a cohesive system of care and a holistic approach to Davidson, M., Manion, I., Davidson, S.D., Brandon, S. (2006). For youth youth suicide prevention, stigma remains a significant barrier by youth: Innovative mental health promotion at Youth Net / Réseau Ado. Vulnerable Children and Youth Studies, 1, 269-273.
to accessing services when they are often most needed. Too many young people suffer in silence until their pain is beyond Kennedy, S.P., Baraff, L.J., Suddath, R.L., Asarnow, J.R. (2004). their ability to cope. Effective suicide prevention must include Emergency management of suicidal adolescents. Annals of Emergency stigma reduction at the community level as well as within our Medicine, 452–460. systems of care. By engaging young people in the dialogue Manion, I., Short, K., Ferguson, B. (2011). Using Engagement about youth suicide, we will gain a fuller understanding of to Bridge Research and Practice in School Mental Health: A National how to approach them in a protective manner, without Initiative. Paper presented at the 25th Annual Children's Mental making them feel stigmatized.
Health Research and Policy Conference, Tampa, Florida.
Newton, A., Hamm, M., Bethell, J., Rhodes, A., Bryan, C.J., Tjosvold, Youth Net/Réseau Ado is a for-youth and by-youth mental M., Ali, S., Logue, E., Manion, I.G. (2010). Pediatric suicide-related health promotion and suicide prevention program. Young presentations: A systematic review of mental health care in the people have guided the development and evolution of this emergency department. Annals of Emergency Medicine, 56, 649-659.
community-based approach to care (Davidson, Manion & Piacentini, E.S. (1993). Evaluating adolescent suicide attempters: Davidson, 2006). The risk of suicide decreases when young what emergency nurses need to know. Journal of Emergency Nursing, people are engaged in this type of program (Armstrong & Manion, 2006) and their participation can change our dialogue Rhodes, A.E., Boyle, M.H., Tonmyr, L., Wekerle, C., Goodman, D., so that mental health and suicide can be addressed directly in Leslie B., Mironova, P., Bethell, J., Manion, I. (2011). Sex Differences an open and protective fashion.
in Childhood Sexual Abuse and Suicide-Related Behaviors. Suicide and Life Threatening Behavavior, 41, 235-254.
Youth suicide remains a complex issue without easy solutions. Royal College of Psychiatrists. (1998). Managing Deliberate Self-Harm in The role of mental illness in youth suicide is clear and must Young People. Council Report CR64. London, UK: Author. be addressed. Effective efforts at addressing youth suicide must include interventions across the full continuum of care. Stewart, S.E., Manion, I.G., Davidson, S. (2001). Suicidal children Such efforts need to be coordinated and multi-systemic (e.g., and adolescents with first emergency room presentations: predictors of six-month outcome. Journal of the American Academy of Child through health, education, primary care, recreation). We must & Adolescent Psychiatry, 40, 580-587.
conduct ongoing evaluations of these efforts in order to assess Preventing Aggressive Behaviour in Mental Health An Integrated Violence against employees, visitors, and patients Mental Health Action Plan
in health care facilities is often ignored, but With the goal of improving access to a variety of mental health breaking the silence surrounding violence is services in Quebec, the Ministère de la Santé et des Services critical. An open conversation about violence Sociaux (MSSS) (Ministry of Health and Social Services) and its consequences will help us end this behaviour.
created an action plan that makes mental health a provincial priority. It was the "Plan d'action en santé mentale 2005-2010 In 2011, Accreditation Canada implemented a new Required - La force des liens," and it called for the development of Organizational Practice (ROP) for preventing workplace community-based primary care services in order to provide violence. Its client organizations across Canada must now the entire population with timely access to mental health address the violence that is much more common than one services. This was also expected to clear congestion in might suspect (Accreditation Canada, 2011).
secondary and tertiary care services, and to ensure that the right services were delivered by the right professional at Mental Health at St. Mary's Hospital Centre
the right time. In the past few years, the St. Mary's Mental Health Program has been reorganized to align with the values St. Mary's Hospital Centre is a 271-bed university-affiliated set out in La force des liens (MSSS, 2005).
community hospital in Montreal. It provides primary and secondary care in eight clinical programs: Surgery, Geriatrics, Indicators
Medicine, Family Medicine, Maternal Child Care, Cancer Following the introduction of La force des liens, the mental Care, Ambulatory Care, and Mental Health. The hospital health team began to regularly review indicators for various meets the needs of regional mental health clients via services. By doing this, they aimed to track changes in the emergency, hospital, and outpatient services.
profile of clients served by their Mental Health Program.
Data analysis confirmed the impact that du travail, secteur affaires sociales (ASST- was being felt by the psychiatric emergency SAS) (Occupational Health and Safety department and the inpatient unit. This Association, Social Affairs Sector)].
impact was particularly notable in the now intervene sooner volume of activity (the number of beds The Interdisciplinary Committee on grew from 29 to 32 in the past year), and Preventing and Managing Violent in the increase in the length of stay, which Behaviour aims to: has effectively generated more disruptive and violent behaviour among clients. The techniques learned Improve the safety and quality of length of stay has also increased dramatically care by implementing strategies to because of a lack of specialized housing prevent and manage violent behaviour services that would enable patients to by patients, families, and visitors continue their treatment while living outside the hospital.
n Develop a concerted professional approach to violent behaviour Aggressive Behaviour in the Inpatient Unit
In recent years, staff members have observed an increase n Manage complex cases in incidents involving aggressive behaviour that requires intervention by the code white team – a team trained to n Involve patients, families, and visitors in safety and respond to violent or potentially violent situations. This increase preventing violent behaviour resulted from the greater complexity of cases.
transitioning to a Culture of Safety and Quality Care
For example, our statistics for 2010-2011 show an increase in emergency room visits and hospitalizations for diagnoses of Training
toxic psychosis induced by substance abuse. The benchmark Awareness about intervening in violent situations has MacArthur study notes that alcohol abuse is a trigger factor been raised throughout the facility via Omega training, for violence; it is the diagnosis most associated with a risk of which teaches a safe approach to preventing and managing violence in general psychiatry (Monahan, 2001).
aggressive behaviour. Professionals in the psychiatric unit have also attended conferences pertaining to violence and In addition, there has been an increase in the length of stay have shared their knowledge with colleagues.
for hospitalized patients with judicial problems, and in the number of patients requiring confinement and/or treatment Staff members now intervene sooner to de-escalate violence, orders. As reported by Quanbeck, et al. (2007), the limitations using pacification techniques learned in their Omega training. that the institutional environment places on these clients can Table 1 provides examples of the techniques staff members trigger violent behaviours.
use to reduce reliance on physical restraint and seclusion Interdisciplinary Committee on Preventing and Managing Violent
Although a Workplace Violence Prevention Committee has been in place at St. Mary's Hospital Centre since 1995, committee members did not have the clinical expertise to address aggressive behaviour issues specific to the Mental Health Program. Therefore, the Interdisciplinary Committee on Preventing and Managing Violent Behaviour in the Mental Health Program was established in April 2009. It aimed to implement organizational, structural, and professional strategies required for safe and high-quality care in the Mental Health Program. A link exists between the two violence prevention committees through cross-membership. Ad hoc representatives also participate by invitation on the Interdisciplinary Committee on Preventing and Managing Violent Behaviour in the Mental Health Program to analyze complex cases requiring specialized expertise [e.g., representatives from the Association pour la santé et la sécurité table 1. Potential Dangerousness Grid
n Measure the degree of dangerousness demonstrated by a client n Guide the choice of an appropriate intervention n Have a common language among service providers Description
intervention (anticipate / observe / Gauge)
8 exceptional threat
Gain time, negotiate, secure the area,
threat with a weapon.
limit space, tactical team, call 911 or
local code.
7 Serious assault
Gestures that could cripple or prove
Gestures made to stop the action with
the level of force considered necessary.
6 Physical assault
Humiliating or painful physical contact Physical crisis management,
(e.g., shove, slap, pinch, claw).
disengagement and/or control
5 active resistance
Directed opposition to the act, not the
Progressive gestural
4 Psychological intimidation
Dominant attitudes (e.g., gestures,
Defuse, re-evaluate, refocus,
throws or breaks objects.
Priority of protecting people,
limiting the source of objects.
3 resistant
"no, no, no." refuses to listen, ignores
Clear instructions, remind of
and apply consequences.
2 Conditional collaboration
evaluate the argument, favour
1 emotional tension
anxiety, weeping, withdrawal.
The person taken hostage must remain calm and, if they can, speak, negotiate, and establish a link. Note: This table was inspired by the scale produced by Robert Arbour for IPN (Omega training). The risk of a patient becoming violent toward themself table 2. Decreased Hours
or others is evaluated during the initial nurse assessment upon intake. Nurses also provide daily updates for patients St. Mary's
admitted to hospital, so that all health professionals can Hospital Center 2008
quickly read their chart, understand their violence profile, and use an appropriate approach. These assessments can also (Mental Health
highlight the need for new medication(s) or the readjustment of medication(s) for a patient who is not responding to Sitter and
security agents'
Other approaches have included structured, interdisciplinary activity programs for patients, as units with predictable, repetitive routines have lower rates of violence (Katz, 1990).
Since its creation, this committee has implemented important As a result of these measures, our reliance on hired private changes to the inpatient unit and it continues to support agencies to monitor patients has also declined, as shown quality improvement initiatives there.
in Table 2. This finding may also reflect a greater quality of care delivered by our staff.
particularly in the Nursing Directorate at the Douglas Mental Health University Institute. She has practised in psychosocial rehabilitation n Reviewed team functioning and extended and community care. She is currently the co-researcher on a project on knowledge development in mental health. Description
intervention (anticipate / observe / Gauge)
Trained staff on the Omega approach developed by Marc Pineault, MHA, is the Quality and Risk Management
Coordinator at St. Mary's Hospital Centre. He worked for 10 years n Refined the staff orientation process as a research assistant and coordinator in public health, and then worked at the Planning and Strategic Planning Office of the McGill Structural Strategies University Health Centre. For the past seven years, he has worked in quality and risk management at the Douglas Mental Health n Evaluated and then acquired resources (human, University Institute, at the Montreal Heart Institute, and at material, and financial) to improve the work St. Mary's Hospital Centre. He is a member of the Executive Committee on Human Factors Related to Patient Safety at the Ministry of Health in Quebec. n Constructed a seclusion room David Bérubé, RN, MA, is the Head Nurse for the Mental
Professional Strategies Health Program at St. Mary's Hospital Centre. He heads the facility's code white team and the employees' Omega training, which n Standardized aggressive behavior evaluation tools in develops skills that ensure the safety of workers and others involved order to have a common language among staff members in violent situations. He and his collaborators have also developed a policy and procedure to standardize code white team approaches, n Ensured the completion of a monitoring sheet for from the perspective of continuing quality improvement. patients who require monitoring Louise Beauvais, RN, MSc(N), has been the Nursing Practice
n Ensured the use of the Omega board on the inpatient Consultant for the Mental Health Program at St. Mary's Hospital Centre for two years. She co-authored the In-Hospital Suicidal Behaviour Prevention and Management Program developed by the n Held weekly meetings with staff and patients to share Directors of Nursing in psychiatric hospitals in Quebec (2006). information about safety and risky situations She is co-researcher for a project on the "therapeutic relationship" in foster homes, and has been involved in a research project on violence in psychiatric care units. The organization's leadership is responsible for ensuring a safe, high-quality, therapeutic setting for patients and a safe work environment for employees. Concerted action to address Accreditation Canada. 2011. Required Organizational Practices. workplace violence is essential at various levels. This should Retrieved from http://www.accreditation.ca/uploadedFiles/ROP% include specialized training on safety, addictions, and therapeutic relationships. A proactive approach should ASSTSAS. (2003). Omega Training, Participant's Workbook. provide mechanisms for clinicians to improve the monitoring Bibliothèque Nationale de Québec 1998, revised edition, 2003.
of clinical cases with a high risk of violence.
Katz, P., Kirkland, F.R. (1990). Violence and social structure on The Interdisciplinary Committee on Preventing and mental hospital wards. Psychiatry, 53:262-277.
Managing Violent Behaviour for the Mental Health Program Ministère de la Santé et des Services Sociaux (MSSS). (2005). Plan enabled a concerted approach to workplace violence d'action en santé mentale 2005-2010 : La force des liens. (Author).
at St. Mary's Hospital Centre. The committee has unified staff in implementing best practices to improve patient and Monahan, J., et al. (2001). Rethinking Risk Assessment: The MacArthur Study of Mental Disorder and Violence. New York, NY: employee safety and the quality of care. Q Oxford University Press.
Danielle Corbeil, RN, MSc(N), MPA, is the Program Manager
Quanbeck, D.C., McDermott, B.E., Lam, J., Eisenstark, H., Sokolov, G., Scott, C.L. (2007). Categorization of Aggressive Acts Committed of the Mental Health Program at St. Mary's Hospital Centre and by Chronically Assaultive State Hospital Patients. Psychiatric Services, has been a surveyor with Accreditation Canada since 2006. In her career, she has held various clinical and administrative positions, Karen J. Kieley
Accrediting Community-Based Mental Health Services One in five Canadians will Health Commission of Canada's experience a mental illness at Framework for a Mental Health Strategy some point in their lives (CMHA, for Canada: 2011), making mental health services a critical component of health care. frequency, mental health "…in a transformed mental health While historically, mental health services system, programs, treatments, services, services are being meant in-hospital care, over the past and supports must also, to the greatest offered in community- 10 years, we have begun to move away from possible extent, be available in the this model. With increasing frequency, based settings.
community, and oriented to supporting mental health services are being offered people to live meaningful lives in the in community-based settings, in locations community of their choice" (Mental of clients' choosing, such as clinics, Health Commission of Canada, 2009).
workplaces, schools, or clients' homes. accreditation of Mental Health Services
In 2003, a WHO-commissioned team noted that "there are no persuasive arguments or data to support a hospital-only The accreditation of mental health services has been a approach" to mental health services (Thornicroft & Tansella, component of Accreditation Canada's programs for many 2003). Their research indicated that both professional opinion years, although the previous mental health standards focused and current literature supported the concept of "balanced care," primarily on in-hospital client care. Having noted significant in which core services are delivered via community-based care, changes in the delivery of mental health services (which and in-hospital care remains an important means of support. were corroborated by client feedback), Accreditation Canada The team's findings were later supported by the Mental undertook the development of new standards for community- based mental health services in 2009.
The standards were developed with the support of a working consultation. Four organizations pilot tested the standards group comprising directors, program leaders, managers, and accreditation process in the fall of 2010. As part of and quality managers from mental health service delivery this pilot testing, surveyors visited the organizations and organizations across Canada. During discussions, the group conducted on-site tracer activities, client and staff interviews, members emphasized the importance of encouraging and debriefing sessions. Concurrent with the pilot testing, comprehensive and integrated mental health services that are the standards were distributed nationally to over 500 both person-centred and focused on recovery and well-being. Accreditation Canada client organizations, surveyors, These areas are included in Accreditation Canada's new government officials, and field experts in order to gather Community-Based Mental Health Services and Supports their feedback. The Community-Based Mental Health Standards, which also address organizations' roles in Services and Supports Standards were well-received by the combatting stigma regarding mental illness, and promoting pilot organizations and others who responded during the optimal mental health in their community. The standards follow the format of the existing Qmentum Following the evaluation phase in late 2010, the standards Service Excellence Standards, which are built around five key were released in February 2011, and were immediately made elements: clinical leadership, people, process, information, available for accreditation surveys. and performance. As noted below, organizations enrolled in the Qmentum program are expected to: Invest in Community-Based Mental Health Services and Supports Accreditation Canada is committed to continuous quality - Collect information about the community and clients improvement in its own programs, and welcomes feedback on all of the standards, including the Community-Based Mental - Align mental health services with the organization's Health Services and Supports Standards. If you have feedback, mission and vision or require further information, please contact - Set goals and objectives for mental health services Engage Competent and Proactive Staff and Service Providers Karen J. Kieley, MHSA, is an Accreditation Product
- Have an interdisciplinary team of qualified and diverse Development Specialist at Accreditation Canada. She is the lead Product Development Specialist for the Mental Health Services - Promote positive worklife and Community-Based Mental Health Services and Supports standards. In addition to her work on mental health, her projects Provide Safe and Appropriate Services and Supports include home care and home support services, long-term care, - Ensure quick access to appropriate services retirement homes, senior populations, and small and rural - Facilitate access to other services in the community hospitals. She holds a Master of Health Services Administration - Assess individuals' needs from Dalhousie University and a Bachelor of Arts (Psychology and - Develop a service plan Business) from Memorial University. - Transition patients to other services Maintain Accessible and Efficient Information Systems - Maintain client records - Provide staff and service providers with access to Canadian Mental Health Association. (2011). Mental Health is information technology Everyone's Concern – Fact Sheet. Ottawa, Canada: Canadian Mental Health Association. Retrieved from http://www.mentalhealthweek.ca/ Monitor Quality and Achieve Positive Outcomes - Address safety and risk concerns Mental Health Commission of Canada. (2009). Toward Recovery - Use research, evidence-based guidelines, and leading & Well-being: A Framework for a Mental Health Strategy for Canada. practice information Calgary, Canada: Mental Health Commission of Canada. Retrieved - Create on-going quality initiatives within the organization/ Thornicroft, G., Tansella, M. (2003). What are the arguments for community-based mental health care? Copenhagen, Denmark: WHO Regional Office for Europe. Retrieved from http://www.euro.who.int/ Following nine months of development, the standards were evaluated using a pilot survey method and a national web-based Bruce H. Swan
A Systems Approach to Mental Health Service Integration Mental illness ranks first as the Calgary Health Region was responsible cause of disability in the United for tertiary, secondary, and community States, Canada, and Western Establishing parameters hospital mental health as well as community Europe, according to a study outreach programs.
by the World Health Organization. This decisions remains study found that mental illnesses including The coalition consisted of 41 partner depression, bipolar disorder, and schizophrenia a significant part organizations that provided mental health account for 25 per cent of all disability of building trusting services to people in Calgary and the across major industrialized countries (World surrounding area. The partners were from Health Organization, 2001). The economic education, supportive housing, health loss of productively from mental illness promotion, self help groups, hospitals, is staggering – the United States loses $63 medical clinics, and industry. The billion annually to mental health illness (Rice & Miller, 1996). primary funders of the service system were the Ministry of In Alberta, the team that authored A Framework for Reform: Health through the Calgary Health Region and the Alberta Report of the Premier's Advisory Council on Health (known as Mental Health Board.
the Mazankowski report) concluded that "Mental health is not well integrated with the health system" (Abdurahman, Our first task was to answer the question "Who do we Bryan, Cranston, et al., 2002).
serve?" This led us to numerous conversations with clients, stakeholders, and service providers. Their responses As the Executive Director of Mental Health Services for ranged from a narrow definition of serving the severely and Calgary, I had the privilege of leading a team that mapped a persistently mentally ill, to a systems approach that successful, integrated, mental health system by establishing a considered mental health from a population health perspective. coalition of partners. I held a joint appointment of the Alberta The team therefore developed a new vision of "A mentally Mental Health Board and the Calgary Health Region from healthy population," and a new mission, "To boldly build a 2002-05. The Alberta Mental Health Board was a provincially comprehensive responsive network of mental health services run organization that was responsible for 75 community with innovative stakeholder partnerships." The vision gave clinics, the provincial psychiatric hospitals, and the provincial the team members focus and the mission gave them a mental health programs, including forensic psychiatry. The purpose.
Figure 1. THe MenTaL HeaLTH cOnTInuuM OF care
An integrated and seamless system of settings, service providers, and service levels with an increased focus on relationships and partnerships.
Prevention &
Basic Treatment (Focused core Services)
ACH Consultation PCU 2I FMC Strathmore Clinic Behavioural Clinic Adolescent Urgent Treatment Service Eastside/Westside Collaborative Care Geriatric Mental Diversity Service Exceptional Needs Treatment Service Exceptional Needs/ Regional Suicide High River Clinic Bridging the Gap Bow Valley Crisis Foothills School W. Cluster Mental Victims Services* Secure Treatment Lasting lmpressions Community Claresholm Clinic Outpatient Mental Assessment Clinic/ Women's Shelter)* Services - urban/ Foothills Regional Victims Services* Learning Resources green = geriatric Suicide Services Outpatient Service black = more than one age group served underline = contracted Victims Services* Treatment Service Services - NE/NW/ Crisis Partnership (Distress Centre)* Supporting the continuum of care is Information, evaluation & Training
By taking a population health perspective and a system-or Treatment (Tertiary), Rehabilitation, and Sustain and Support ented approach to mental health, the team used Accreditation services (see Figure 1). This mapping exercise helped us Canada's definition of "continuum of care" to build a gain participant buy-in. The continuum of care covered platform for the new mental health system. "An integrated all age groups (infants, children, youth, adult, seniors, and seamless system of settings, services, service providers and geriatrics) and an Information and Evaluation unit tracked and service levels to meet the needs of clients or defined the impact of change on the system. We also mapped the populations. Elements of the continuum are: self-care, various service providers to demonstrate each partner's role in prevention and promotion, short-term care and service, the process; this step highlighted overlap and duplication.
continuing care and service, rehabilitation and support" (Canadian Council on Health Services Accreditation, 2002).
In order for the mapping process to work, it was important for each participant to know that their funding, profile, and Using this platform, the team designed a mental health ability to provide service was secure, and not threatened continuum of care that included Prevention and Promotion, in any way by their participation in the project. The team Early Intervention, Crisis Intervention, Acute Inpatient, approached the task with the understanding that we were Basic Treatment (focused Core Services), Specialized all invested in health care reform and we were prepared to Figure 1. continued
Specialized Treatment
Sustain and Support
ACH Mental Health Regional Housing - Specialty Clinics Rehabilitation Centre Approved Homes.
Forensic Community Personal Care Homes Addiction Network & Independent Living Assertive Community Northwest Outpatient Treatment Service Schizophrenia Service Community Extension IlS/Family Support Southern Alberta Competency Assess- Forensic Psychiatric Peer Support Outreach Centre (Bow River) (Clubhouse Calgary)* Creative Community Diversion Service Arnika Centre (VRRI Geriatric Mental Living Activities Eating Disorder Day (Clubhouse Calgary)* Resource Activity Rehabilitation & Clubhouse Society* High Needs Complex Career Links (Calsary Under 65 Long-Term Forensic Adolescent Vocational Services)* Horizon West/Horizon Community Supports/ Forensic Assessment Hunter/Miner House Supporting the continuum of care is Information, evaluation & Training
establish new ways to reduce wait times and increase access As a result of mapping, it became evident to partners that to services. We recognized that each organization contributed more financial resources should be allocated to this to the mental health continuum of care and that their roles initiative. might shift over time as innovation and integration developed. The fact that funding was not threatened by these changes Thanks to the dedication of our coalition partners, we were helped to build the trust that was needed to move forward. eventually successful in tabling a new mental health operating budget that was agreed to by all of the partners. The majority Results: Realigning Services
of new funding requests were made for community agencies During our mapping process, we noted duplication and and support programs described in the continuum. To inefficiency in our intake processes. A central intake for produce the budget, the coalition partners considered systems mental health services was therefore developed as a result issues and made these a priority. This approach reduced the of this collaborative. Child and adolescent mental health competitiveness around funding because everyone involved in services were transformed from 12 intake points to one and the system began to see where the greatest needs were; they adult mental health services went from 30 intake points to saw that resources could be better allocated. We were thus able one. This incredible realignment enabled service providers to to address wait times and increase system capacity. redirect their resources and better serve their clients in other areas. Wait times for mental health services were reduced and "Until I saw the Association of Self Help plotted on capacity in most services areas increased. the continuum of service template, I was sceptical of the integration process. Now I believe our association is part In another example – a shared care approach to family of the continuum. We feel we are part of the Planning practice – a mental health team supported family physicians for the future in Calgary. [There has been] A shift in who continued as the primary service provider for their management thinking and practice as the Continuum of mental health patients. The team consisted of social Mental Health Care has caused managers and leaders to workers, mental health nurse practitioners, psychologists, think systemically, to recognize they are not in Mental and psychiatrists. Under this shared care model, there was a Health Service delivery alone, that there are other 50 per cent reduction in referrals from shared care family elements along this continuum that provide care and physicians' offices to hospital. This initiative was in its initial service to clients. Increased communication among stages prior to the continuum of service mapping process. stakeholders internally and externally to the Calgary Figure 2. calgary Health region: Mental Health & Psychiatric Services continuum of care
Original Operation Funding Proposed Operation Additional Original Operating $ 82,229,578 Additional Operating $ 74,605,610 Total Operating Funds $ 156,835,188 Health Region is what is working best with the model" Coaching, a facilitator of the LEADS in a Caring Environment (Swan, 2004). Marion McGrath, Executive Director, Capabilities Framework, and a surveyor for Accreditation Canada. Calgary Association of Self Help It takes time to build trust among coalition and network partners. Establishing parameters around funding decisions remains a significant part of building trusting relationships. Abdurahman, M., Bryan, L., Cranston, L., et al. (2002). A Framework Transparency is the key to moving forward, and it is vital for Reform, Report of the Premier's Advisory Council on Health. Calgary, Alberta: Ministry of Health.
to attaining agreement on how funding decisions are made. Mapping the funding allocations for the continuum of service Adair, C.E., McDougall, G.M., Beckiem, A., Joyce, A., Mitton, C., Wild, helped to clarify where investments were being made (see C.T. (2003). History and measurement of continuity of care in mental Figure 2). It also helped the coalition partners think about health services and evidence of its role in outcomes. Psychiatric Services where funding allocations should be made.
Canadian Council on Health Services Accreditation. (2002). Achieving Granted, it is easier to discuss these changes than to implement Improved Measurement (AIM): Glossary. 2nd Ed. Ottawa: Canada.
them – putting them into practice can pose significant Rice, D. P., Miller, L. S. (1996). The economic burden of schizophrenia: challenges. For our coalition, however, a systems approach to Conceptual and methodological issues and cost estimates. In: Moscarelli, service delivery meant that patients and their families were M., Rupp, A., Sartorius, N. (Eds.). Schizophrenia. Chichester, UK: Wiley. able to receive appropriate services in a coordinated way Swan, B.H. (2004). Descriptive Thesis: A model Structure utilizing the Continuum of Mental Health Service to promote integration, build new Bruce H. Swan, B. Comm. (hons), DHA, FCCHSE, CEC,
partnerships and collaborative practices for Mental Health Service Delivery. PCC, is the President of B.H. Swan and Associates, a network Ottawa, Canada: Canadian College of Health Service Executives. of consultants and professional coaches. He facilitates working sessions on shifting organizational culture and teaches the "Coach World Health Organization. (2001). The World Health Report 2001 - Approach to Leadership," which introduces leaders to the best Mental Health: New Understanding, New Hope. Geneva, Switzerland: practices in coaching. He is a certified Executive Coach with the World Health Organization.
International Coach Federation, an Associate of Essential Impact Coleen Flynn
Reproductive Mental Health Services in Atlantic Canada T he Reproductive Mental Health Therefore, several years ago, the RMHS Service (RMHS) at the Izaak team began creating public educational Walton Killam (IWK) Health materials about mental health issues Training participants Centre in Halifax has the only surrounding pregnancy and early parenting. verified the stigma, interdisciplinary specialty mental health This was done with the help of a small team in the Atlantic region that provides self-esteem issues, start-up grant from the Mental Health expertise in maternal mental health and barriers to access that Foundation of Nova Scotia, the Capital education and evidence-based treatments. District Health Authority, and IWK many vulnerable mothers The RMHS program provides consultations and assessments to women throughout face when dealing with Atlantic Canada, as well as treatment and mental health issues.
Soon after that, the RMHS team began primary mental health care to mothers looking for opportunities to partner with within Nova Scotia. It offers a variety of other communities of practice serving treatments to women struggling with a women at risk for mental health mental health issue during pregnancy or in the first year after problems during their pregnancy and in the early stages of their child's birth. Treatments include medication, evidence- their parenting. The RMHS team began working with the based individual therapy, and/or group therapy. Psychiatrists, staff at the Dartmouth Family Resource Centre (known as the social workers, and nurses comprise the RMHS team, Dartmouth Family Centre – DFC). The DFC is a non-profit and referrals are received from family practitioners in the organization that provides preventative programs, services, and support to families primarily in Dartmouth North, Nova Scotia. The DFC's mission is to provide a safe and welcoming place where all community members feel accepted and valued, and where families can be involved in activities that address We know that social support has a direct impact on outcomes pre and postnatal support, childhood development, parent- in mood disturbance and adjustments in the peripartum child interactions, and parenting education and support.
period (Hinden, et. al., 2006). Appropriate support from family, friends, and the broader community can only happen The Mothers' Mental Health Toolkit
when people are educated about the mental health challenges regarding mothering (Solchany, 2009).
The RMHS team and DFC staff members collaborated on a PHAC-funded grant to create a "Mothers' Mental Health Toolkit." The RMHS team's modest aspirations to create public education materials expanded into a comprehensive Toolkit directed at frontline staff. The Toolkit was created for widespread distribution to frontline community support service providers. It includes educational, interactive exercises on wellness and preventive practices, understanding risk, early symptom recognition, illness support, and important aspects of intervention and recovery in the spectrum of maternal mental illness. Most of the Toolkit materials (which include client handouts and service provider information) are intended for frontline community service staff who may not have prior education on mental health issues, but who have considerable experience working with women suffering from mental health problems. Frontline staff members often see women who have not yet received formal treatment, so the project aimed to increase the knowledge and capacity of these service providers. We wanted them to be able to work within the scope of their field (support and advocacy), and also represent the first step in a continuum of mental health care for the general population, which needs to access specialized treatment services like those at the RMHS. In this sense, our hospital- based program aspired to extend its reach beyond the hos- Pre and post-testing of the Toolkit and related training affirmed the benefits of covering the entire spectrum of mental health care. In the Toolkit, information is provided on specific topics like wellness, risk recognition, and illness presentation, as well as broad approaches to intervention, recovery, and the return to wellness. Training participants verified the stigma, self-esteem issues, and barriers to access that many vulnerable mothers face when dealing with mental health issues. The training enhanced workers' ability to see how the Toolkit materials could be used to introduce conversations about support, readiness for change, and eventually a mental health assessment. A 6-month follow-up review of the Family Resource Centre's experience with the Toolkit began in June 2011. We have been collecting data on the Toolkit's ease- of-use from selected Family Resource Centre workers.
There has been strong community and expert support for the project to date. The Toolkit was the result of specialty and frontline staff members from varied spectrums of care working together to create contextually appropriate materials. This has encouraged us to create further partnerships that take our treatment teams beyond their clinical silos and their traditional spectrum of care. Q Coleen Flynn, MSW, RSW, is the Team Leader and Clinical
pital walls to participate actively in early intervention and Social Worker for the IWK's Reproductive Mental Health Service. community support models.
Coleen has also worked as a sessional professor in the Faculty of Social Work at Dalhousie University. Having worked for 15 The Toolkit's development was supported by an Atlantic years with women and their families, Coleen's expertise focuses on Canadian Advisory Board representing Family Resource "vulnerable families," which includes those who struggle with social Centre staff in all four provinces, from urban and rural determinants such as poverty, discrimination, and a lack of settings. These communities' perspectives were an important resources. She also has an interest in group facilitation. base for the RMHS/DFC collaboration. Everyone's primary interest was supporting the emotional development of Joanne MacDonald, MD, FRCPC, is the Clinical Leader
mothers with mental health issues in our region. The project and Senior Psychiatrist with the IWK's Reproductive Mental team at RMHS worked to promote the visibility and Health Service. She is also an Assistant Professor of Psychiatry at importance of mothers' mental health, to reduce the known Dalhousie University. Joanne is interested in holistic care for impact of mothers' mental health issues on their young mothers and advocacy around collaborative care for mothers and children's emotional, behavioral, and cognitive development, their young children. Her clinical and academic work has included and to broaden the capacity of community members to rural community mental health, a private psychotherapy practice, recognize women at risk for mental health issues.
eating disorders multidisciplinary care, and leadership of the psychiatric consultation-liaison service to medical and surgical The project had four phases: 1) Research into existing community resources and a literature review 2) Consultation and data collection to determine the needs of resource workers and the mothers they Hinden, B.R., Biebel, K., Henry, A., Katz-Leavy, J. (2006). A survey of programs for parents with mental illness and their families: Identifying 3) The development of accessible and relevant Toolkit common elements to build the evidence base. Journal of Behavioral Health Services & Research, 33(1):21-38.
materials for vulnerable women 4) A Toolkit training series for staff at the Community Solchany, J.E.(2001). Promoting Maternal Mental Health during Pregnancy: Action Program for Children and the Canada Prenatal Theory, Practice & Intervention. Seattle, WA: NCAST Publications Nutrition Program Kevin KoK
Marg Petty
A Collaborative Fitness Pilot Project for Clozapine-Treated Patients Marg Petty
nicKy gitLin
T here is a gap in mental health Health Rehab Services (the Clozapine Clinic), services when it comes to and the University of Saskatchewan's addressing the physical health College of Kinesiology and the College needs of individuals with are significant for of Medicine (Dept. of Psychiatry). The schizophrenia and other psychotic disorders psychosocial treatments project aims to fulfill a recognized service (Everett et al., 2007). For more than a need for high risk Clozapine-treated among individuals century, we have known about the increased patients. It also aims to show that Clozapine prevalence of diabetes in schizophrenic treatment efficacy can be positively patients (McIntyre et al., 2005). A number influenced by a fitness program and dietary of factors, including negative symptoms such as amotivation, social withdrawal, anhedonia, and a lack of spontaneity, mean that many Fun 2 Move's health care providers include a psychiatrist, a individuals with schizophrenia are leading increasingly fourth year kinesiology student, a registered nurse, a registered sedentary lives. And yet, we often treat their mental health dietitian, a recreational therapist/certified exercise physiologist, needs while ignoring the prevalent physical repercussions of and additional consultations from the patients' primary health their illnesses.
care providers. All activities take place at the university campus at the College of Kinesiology's Physical Activity Changing physical activity and dietary behaviours can have Complex (PAC). The PAC has a walking track, a dance studio, an impact on chronic disease management and reduce risk change rooms, and fitness equipment. It also provides a social factors. Although nutritional and physical activity programs atmosphere of support and community integration and uses a are available, it is sometimes difficult to attract or retain non-traditional (i.e., non-clinical) setting. The PAC was made individuals with psychotic conditions. Dropout rates are available at no cost for the Fun 2 Move program.
significant for psychosocial treatments among individuals with psychotic conditions (Hassapidou et al., 2011; Villeneuve, The program's participants all take Clozapine to lessen the Potvin, Lesage, & Nicole, 2010). Accordingly, a strategy is symptoms of their schizophrenia and their risk for metabolic required that offers adequate support and encouragement to syndrome. The group consists of a maximum of 12 male and engage individuals with psychotic conditions in the physical female patients who are registered with the Clozapine Clinic. and psychosocial aspects of recovery. This strategy should Participants are screened for program eligibility by the include monitoring the potentially harmful effects associated psychiatric nurse and the attending psychiatrist.
with medications such as Clozapine that are associated with dramatic weight gain, higher rates of obesity, and the potential the intervention
onset of diabetes.
The program offers two fitness sessions per week for 10 weeks. Clozapine is an established treatment option for patients The sessions include several cardio-aerobic activities that with psychotic conditions, such as schizophrenia, who have enhance cardiovascular endurance and respiratory capacity. failed to respond to other standard medications; this applies to These include a spin bike, step class, dance and music-based approximately 20-30 per cent of all patients with psychotic games, track walking, exercise ball and yoga for improving disorders (Kerwin, 2005; Miller, 2000; Taylor, 2000; balance, yoga for resistance and strength training, tubing Wahlbeck et al., 1999). However, Clozapine has serious side bands, hand weights, and other fitness equipment. Guided effects (NAMI, 2010) that can include tachycardia, blood imagery, breathing exercises, and music are used to promote pressure changes, orthostatic hypotension, a lowered seizure relaxation.
threshold, sedation, constipation, weight gain, and an increased risk for metabolic syndrome. The latter is often The program also addresses the dietary needs of Clozapine- characterized by adverse serum lipid levels, hypertension, treated patients by encouraging healthy eating in accordance central obesity, and type 2 diabetes (Leadbetter et al., 1992).
with the Canada Food Guide (Health Canada, 2010). A physical activity record and progress notes are written after Fun 2 Move
each session and kept in each participant's file.
Fun 2 Move is a collaboratively run fitness management Measures
pilot project delivered to Clozapine-treated patients by an interdisciplinary treatment team in Saskatoon. Partners Participants are screened into the program using five include the Saskatoon Health Region Mental Health and assessment tools to determine their suitability for the program. Addiction Services (MHAS) Adult Community Mental Their motivation to partake in physical activity is assessed in the winter), and anxiety about being among university table 1. Quality of Life and satisfaction
students. All of the participants acknowledged that they were Mean scores
challenged by the program's demands, particularly activities requiring balance and flexibility, and the visual relaxation Q-LES-Q domains
strategies. Nevertheless, it was encouraging that the participants' views of the program were largely favourable. The location was described as clean and very bright. Participants Subjective feelings were especially enthusiastic about accessing the gym equipment and some requested "more in-gym exercise" and Social relations heavy weights. Eight participants said they would definitely General QOL index come back to the program.
One participant, who was unable to complete the Cooper with the Physical Activity Stages of Change Questionnaire Institute Health and Fitness 1-Mile Walk Test during the pre- (Marcus & Simkin, 1993), which is a four-item self-report program test, did complete it within the average performance questionnaire that categorizes individuals into one of five stages time during the post-program test. Three others were absent of change for physical activity behaviour.
for the post-program test. Of the remaining six participants whose performance was measured before and after the All participants also receive a baseline screening for medical program, five improved their time, maintaining a good to risk with the Physical Activity Readiness Questionnaire average performance during the post-program test.
(PAR-Q) and a subsequent Physical Activity Readiness Medical Examination (Par-Med X) (Canadian Society for With respect to dietary education and consumption, all Exercise Physiology, 2002). To assess ongoing physical risk, participants self-reported an increased awareness of food the Par-Med X is re-administered every six months or sooner groups and the need to modify their eating habits, including if medical conditions worsen.
reducing their intake of caffeine, fats, and calories.
The Cooper Institute Health and Fitness 1-Mile Walk Test On the Q-LES-Q-18, 9 of 10 participants completed both the measures aerobic (cardiovascular) fitness levels and is based pre and post-program tests. Results on the Q-LES-Q-18 Index on how quickly individuals are able to walk one mile within a Score are presented in Table 1. As shown, there is a positive moderate range of exercise intensity. Their test scores are based change from pre to post-program tests from 3.73 to 4.08. (A upon age-adjusted standards (in minutes) for men and women score of 4 is typical of a generally healthy person.) The physical (Cooper Institute, American Council on Exercise, 2003).
health post-program test score was 3.54, an increase from 3.39, but it was still not within the average range. The other The Quality of Life Enjoyment and Satisfaction Questionnaire domains were above the expected normative range. For (Q-LES-Q-18) (Ritsner et al., 2005) is a brief, self- example, the post-program subjective feelings test had an administered questionnaire intended to aid in monitoring average score of 4.26, the leisure test had a score of 4.08, and quality of life outcomes for patients with schizophrenia, the social relations test scored an average of 4.29.
schizoaffective disorder, and mood disorders. The Q-LES-Q-18 is comprised of a general index score as well as a score for: conclusion
a) physical health, b) subjective feelings, c) leisure time activities and d) social relationships. We had hoped that Fun 2 Move would allow us to track changes in the quality of life when Clozapine- treated patients A Client Satisfaction Questionnaire (Larsen, Attkisson, are involved in fitness activities. We also wanted to support Hargreaves, & Nguyen, 1979) and a nutritional evaluation are a treatment model that includes both the physical and administered at the end of the program.
psychosocial aspects of recovery. Although evaluation of this project is in the preliminary stages, the results seem promising evidence of success
insofar as the participants reported improved life satisfaction and enjoyment, as well as satisfaction with the program.
Preliminary results for this fitness pilot project show clear benefits for Clozapine-treated patients.
Ultimately, the key to this project was the strong partnership between the interdisciplinary team at the University of Fun 2 Move was well attended – 10 out of 12 participants Saskatoon (psychiatry and kinesiology programs and the completed the program. Barriers to completing it included PAC) and the Saskatoon Health Region Mental Health and difficulties with transportation, cold weather (it took place Addiction Services (the Clozapine Clinic, community mental health rehab, and recreational therapy programs). This project with the College of Medicine at the University of Saskatchewan. created an empowering environment that allowed participants For the past six years, he has been a consultant with MHAS. He to develop a sense of well-being; it was an exceptionally is the principal investigator for a number of clinical drug trials, well-coordinated service provided to an otherwise underserved primarily about schizophrenia. He also serves on a number of and at-risk psychiatric population. It represents an important quality assurance committees including a provincial addictions step toward better quality of care for these patients. Q medical advisory committee. The authors would like to thank Dr. Adam Baxter Jones, Marg Petty, BSPE, CEP, earned her degree in 1982 from
Acting Dean of the College of Kinesiology at the University of the University of Saskatchewan and has been a member of the Saskatchewan, Professor Bart Arnold at the College of Kinesiology, Canadian Society of Exercise Physiologists since 1997. She has and Mr. Roger Moskaluke, the Facility Manager of the Physical worked for 24 years within MHAS and has won many awards; she Activity Complex at the University of Saskatchewan for is the co-recipient of awards for collaborative programs, including collaboration in this effort. The authors are also grateful to the the SHEA Award, Bravo Awards, and honourable mention for the students who dedicated their time to this project. SAHO Green Ribbon Award for unique program development and a multidisciplinary approach to patient care. Llana Phillips, MA, joined MHAS in 1991 to work in program
evaluation. She assisted in a 2-year study on the quality of life Nicky Gitlin, RDB Sc. (Nutr.), obtained her degree in 2006
following psychiatric day treatment rehabilitation and a 3-year from the University of Saskatchewan and a certificate in Disordered study on the efficacy of a community based program in treating Eating Prevention and Management from Douglas College in individuals with co-occurring disorders. She was seconded to MHAS British Columbia. She is a Registered Dietitian with MHAS and is Administration in 2007 to assist in the development of quality also a Bravo Award recipient. She is a member and past chair of the performance indicators and the MHAS Performance Dashboard. eating disorder interagency committee, SWADE (Saskatoon Weight Attitudes and Disordered Eating), and a member of the Academy Kevin Kok, MD, FRCPC, is a Clinical Director in the Department for Eating Disorders.
of Psychiatry in Saskatoon and is a Clinical Associate Professor REFERENCESCanadian Society for Exercise Physiology. (2002). ParMed-X Physical Marcus, B.H., Simkin, L.R. (1993). The stages of exercise behavior. Journal Activity Readiness Examination. Retrieved from http://www.csep.ca/cmfiles/ of Sports Medicine & Physical Fitness, 33, 83-88.
McIntyre, R., Leiter, L., Yale, J., Lau, D., Stip, E., Ur, E., et al. (2005). Canadian Society for Exercise Physiology. (2002). Par Q Physical Activity Schizophrenia, Glycemia and Antipsychotic Medications: An Expert Readiness Questionnaire. Retrieved from http://www.csep.ca/cmfiles/ Consensus Review. Canadian Journal of Diabetes, 29(2), 113-121.
Miller, D.D. (2000). Review and Management of Clozapine Side Effects. Everett, A., Mahler, J., Biblin, J., Ganguli, R., Mauer, B. (2007, September). Journal of Clinical Psychiatry, 61(S8), 14-17.
Improving the Health of Mental Health Consumers. Symposium conducted at the National Wellness Summit to Reduce Co-morbidity and Early Mortality National Alliance on Mental Illness. Fact Sheet on Clozaril. Retrieved from of People with Mental Illness, Rockville, Maryland.
Hassapidou, M., Papadimitriou, K., Athanasiadou, N., Tokmakidou, V., Pagkalos, G., Tsofliou, F. (2011). Changes in body weight, body composition and cardiovascular risk factors after long-term nutritional intervention in Ritsner, M., Kurs, R., Gibel, A., Ratner, Y., Endicott, J. (2005). Validity of patients with severe mental illness: an observational study. BMC Psychiatry, an abbreviated Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q-18) for schizophrenia, schizoaffective, and mood disorder patients. Quality of Life Research, 14, 1693-1703.
Health Canada. Eating Well with Canada's Food Guide: A Resource for Educators and Communicators. Retrieved from http://www.hc-sc.gc.ca/fn-an/ Taylor, D. (2000). Clozapine – a Survey of Patient Perceptions. Psychiatric Bulletin, 24, 450-452.
Kerwin, R.W., Bolonna, A. (2005). Management of clozapine-resistant The Cooper Institute. 2011. The 1-Mile Walking Test. Retrieved from schizophrenia. Advances in Psychiatric Treatment, 11, 101-106.
Larsen, L.D., Attkisson, C.C., Hargreaves, A.W., Nguyen, D.T. (1979). Villeneuve, K., Potvin, S., Lesage A., Nicole, L. (2010). Meta-analysis of Assessment of Client/Patient Satisfaction: Development of a General rates of drop-out from psychosocial treatment among persons with Scale. Evaluation and Program Planning, 2, 197-207.
schizophrenia spectrum disorder. Schizophrenia Research, 121(1-3), 266-70.
Leadbetter, R., Shutty, M., Pavalonis, D., Vieweg, D., Higgins, P., Downs, Wahlbeck, K., Cheine, M., Essali, A., Adams, C. (1999). Evidence of Clozapine's M. (1992). Clozapine-induced weight gain: prevalence and clinical Effectiveness in Schizophrenia: A Systematic Review and Meta-Analysis of relevance. American Journal of Psychiatry, 149, 68-72.
Randomized Trials. American Journal of Psychiatry, 156, 990–999.
PAtti lAuzon
Improving Mental Health Outcomes One Connection N avigating the health system The Canadian Mental Health Association and community services can Lambton Kent (CMHA-LK) recognized be a challenge. For people the importance of establishing strong with a serious mental illness, connections between mental health connecting with the appropriate health We have witnessed consumers and community services, and community services can be a daunting a tremendous drop in especially at the point when mental and overwhelming experience.
health care consumers are discharged re-admission rates.
from hospital. The CMHA-LK also believes Mental health patients' ability to navigate in collaborating with community partners.
these systems is such a point of a concern that the Mental Health Commission In Ontario at that time, there were of Canada has identified "improving numerous reports and research study pathways to recovery and well-being" as one of its seven goals recommendations that recognized the importance of for a transformed mental health system.
establishing better connections between community agencies and mental health patients who were about to be discharged from hospital.
After hospitalization, mental health clients are often Therefore, in 2002 the CMHA-LK began to work regularly discharged with few community connections to support with the local hospital, Bluewater Health, to establish better their recovery. A November 2006 report from the Canadian connections with mental health services across the continuum Institute for Health Information noted that "over one in three of care. The two organizations recognized a gap in health care patients (37 per cent) discharged from a general hospital with a services for mental health patients, and soon partnered to diagnosis of mental illness were readmitted within one year of create a community-based discharge planning service.
their discharge. In comparison, 27 per cent of all other patients admitted to a general hospital were readmitted within a year" "The plan really was born out of the shift in the province (CIHI, 2006).
from providing hospital-based care to community-based care," explains CMHA-LK Chief Executive Officer, Alan Stevenson. "These recommendations came out of the Making it Happen document produced by the Ontario Ministry of Health and Long-Term Care in 1999" (OMHLTC, 1999).
Stevenson also stated that the publication The Time is Now (2002) from the Mental Health Reform Implementation Task Force of the Ontario Ministry of Health and Long-Term Care, also noted the need for integrated and seamless care for mental health consumers being discharged from hospital. "It is so important for mental health consumers to have consistent care that identifies their individual needs, making their care client-focused," says Stevenson.
In 2002 the In-Reach Discharge Planning Program was created. An expert Community Case Manager from the CMHA-LK at Bluewater Health acts as a Discharge Planner, connecting mental health patients with community resources. This Discharge Planner ultimately serves as a consistent support person for patients transitioning from the hospital back into their community. The resources they might access are varied and include housing, financial assistance, counselling, medication management, and case management from the CMHA.
Although only one case manager works on the program at this time, preliminary reactions and results have been excellent. "We have had very positive feedback from clients," "We have witnessed a tremendous drop in re-admission rates," says the CMHA-LK Community Case Manager, Sarah explains Denise Armstrong, a social worker at CMHA-LK. Aberhart. "Navigating the system can be overwhelming "Those numbers are significant." and people are happy to have someone help them with this navigation." The CMHA-LK Community Case Manager evaluation
works directly at the hospital to link community and hospital services, so they can work together to benefit clients and their Armstrong helped to formally evaluate the program in 2010, with a team of experts, and as she explains, the feedback from clients has been positive. "They tell us they are happy Aberhart also takes part in case conferences at the outset of to be connected to ongoing services." The evaluation of the a patient's care at the hospital. This helps bring more holistic program also confirmed the belief of staff at the CMHA-LK care to the In-Reach Discharge Planning Program, as she is in that the model met client needs.
contact with patients from the outset of their care.
It was noted that "…basing discharge planning services with "It definitely helped that the doctors were on board with this the same agency that also provides housing advocacy, case plan from the beginning. It was challenging at first but we have management, and other community-based mental health an excellent relationship with the hospital and it has worked services offers clients a direct connection to these services out well," says Aberhart. Although some administrative at discharge" (Jensen, 2010). This connection has resulted changes were necessary during the program's implementation, in more clients securing aid, such as housing and financial a seamless process was eventually put in place.
support once they are out of hospital.
The formal evaluation in 2010 also referred to a variety of research studies that verified the need for a community- One of the main program goals was to lower re-admission rates based discharge planning program for mental health clients. at the hospital. The results speak for themselves – the overall Among others, Durbin, et al. (2004) demonstrated the need readmission rate was an incredible 40 per cent lower in the for solid connections between mental health consumers and year after the program was implemented.
service providers. "When clients have good relationships with providers, feel their providers are responsive, and are confident Although the program has been successful thus far, there is the team is working together on their behalf, continuity is always room for evaluation and improvement. Aberhart says that ultimately, she would like to see every mental health patient able to access the program; at present, her clients must In another project, Forchuk (1998) reported that "The be referred by the hospital. Perhaps this will happen in the provision of continued support from familiar in-patient staff future, but in the meantime, the program will continue to with peer support, assisted clients with chronic mental illness provide seamless care for some fortunate mental health clients to successfully return to the community." in the Lambton region. Q Moving Forward
Alan Stevenson, BSW, MSW, is the CEO of the Canadian
Mental Health Association, Lambton Kent Branch, and has served The program is now viewed as a leading practice by as the Chair of the CMHA Ontario Executive Directors Network. Accreditation Canada. At present, Aberhart says she is He was an expert panellist on the Ontario MOHLTC case working with 17 to 20 clients per month and the greatest management and crisis response standards development teams areas of concern for most clients continue to be housing, and has served on numerous DHC, MOHLTC, and LHIN family counselling or marital breakdown, and financial planning groups and committees. Alan has also held positions with support. "The two issues (housing and finance) are usually the Lambton District Health Council, CMHA Windsor-Essex the ones we see with clients upon discharge," she explains. County Branch, CMHA Lambton, and the YMCA of Windsor "We connect consumers with so many of the services that Essex. they will require when discharged. These are ongoing services that they will need and they get connected through just one Patti Lauzon, APR, CFRE, is the Integrated Director of
Communications and Community Engagement for the Canadian Mental Health Association Lambton Kent Branch. She studied Connecting with one professional as a support advocate Journalism at St. Clair College and holds a BA from the is one of the fundamental approaches used by the program. University of Windsor. In 2004, Patti obtained her CFRE Mental health consumers and their families have long voiced designation, and in 2010 she successfully obtained her APR title. their concerns about the inconsistency of mental health care; She also holds the position of Director of Advancement at the they often have to tell difficult and personal stories many times CMHA Windsor-Essex County Branch where she has worked for before they receive the service(s) they require.
five years. Connecting with one planner to access community services and a partnership between the CMHA and Bluewater Health are the cornerstones of the In-Reach Discharge Planning Durbin.J., Goering, P., Streiner, D.L., Pink, G. (2004). Program structure Program. These are important aspects in providing optimum and continuity of mental health care. Canadian Journal of Nursing care for mental health consumers in the Lambton region.
Forchuk, C., Martin, M., Chan, Y.L., Jensen, E. (1998). Bridging the Discharge Process. The Canadian Nurse, 94(3):22-26.
Jensen, E., Chapman, P., Forchuk, C., Seymour, B., Witcher, P., Armstrong, D. (2010). An Evaluation of Community-Based Discharge Planning in Acute Mental Health Care. Canadian Journal of Community Mental Health, 29(S5):111-124.
Canadian Institute for Health Information (CIHI). 2006. More than one in three patients hospitalized for mental illness are readmitted within one year of their discharge. Retrieved from http://www.cmha.ca/bins/content_page.
Ontario Ministry of Health and Long-Term Care (OMHLTC). (2002). The time is now: Themes and recommendations for mental health reform in Ontario. Government of Ontario, Toronto: Canada.
Ontario Ministry of Health and Long-Term Care (OMHLTC). (1999). Making it Happen: Operational framework for the delivery of mental health services and supports. Author. Government of Ontario, Toronto: Canada.
Transforming the Mental Health I n its report on the state of the mental a Person-Centered and
health and addiction system in recovery-oriented Mental
Canada (2006), the Standing Senate People who require Committee on Social Affairs, Science, hospital-based services and Technology affirmed that "the status Too often, people living with mental health should be able to access quo is not an option." As part of its plan problems and illnesses are incorrectly told them promptly and must to transform the mental health system, the that they cannot hope to improve their Committee recommended the creation of always know that services quality of life, or function better in society. a mental health commission. Established will be provided in the However, the hope of recovery – understood in March 2007 as a national non-profit as "a way of living a satisfying, hopeful, and least intrusive and least organization, the Mental Health Commission contributing life even with the limitations of Canada (MHCC) has worked with restrictive way possible.
caused by illness" (Anthony, 1993) – is stakeholders to change attitudes toward in fact available to all. The starting point mental health problems and to make sure for building a mental health system that that people who experience mental health issues have access consistently provides quality treatments, services, and support to a range of treatments, services, and support.
is to recognize that people living with mental health problems and illnesses can, in this sense, recover, without necessarily In "Toward Recovery & Well-Being: A Framework for a being "cured." Mental Health Strategy for Canada" (MHCC, 2009), the Commission set out seven goals designed to transform A mental health system that is recovery-oriented necessitates Canada's mental health system. The revised mental health genuine partnerships among people living with mental system described in the Framework would address quality health problems and illnesses, their families, and their service dimensions by focusing on people's need for an accessible, providers. These relationships enable health providers to share integrated, equitable, and effective system. their knowledge and support people in identifying and selecting treatments, services, and supports that will help them attain the best health and quality of life possible. A person-centred Table 1. seven objectives to Transform the
mental health system would involve people living with Mental Health system
mental health problems and illnesses and their families in the delivery, organization, and evaluation of services at all levels 1. People of all ages living with mental disorders or mental using various mechanisms such as the creation of patient illness are actively engaged and supported throughout their councils, representation on Boards and participation in recovery process and the reestablishment of their well-being.
2. Mental health promotion is fostered and mental disorders, A recovery-oriented system would also use recovery principles as well as mental illnesses, are prevented when possible.
across a person's lifespan. We should ensure that children and youths are given every opportunity to become resilient against 3. The mental health system meets the different needs of all mental health problems and illnesses, and that we support people living in Canada.
older adults in meeting needs associated with aging. Such a system would make it possible to draw on and integrate natural 4. The role of families in wellness promotion and service supports (families, peers, and broader circles of support) that delivery is recognized, and their needs are taken into help people form links with their community, heritage, and 5. People have equitable and timely access to programs, Timely and equitable access
treatments, services, and supports that are appropriate, effective, well integrated, and take their needs into account.
Today, two out of three adults, and three out of four children will not receive the help they need to deal with their mental 6. Actions are founded on diverse knowledge sources and health concerns (Statistics Canada, 2003; Waddell, 2005). As evidence-based data; results are measured and research the Framework insists, a mental health system that delivers quality implies timely and equitable access to integrated services, regardless of an ability to pay. No matter where people 7. People living with mental disorders or mental illness first seek help, they should be connected appropriately to the are wholly integrated as members of society.
system, and the services they access should be coordinated to ensure continuity of care.
Programs, treatment, services, and supports should enable professionals in Canada have already recognized these people to live meaningful lives in their communities. Research principles as core competencies (MHCC, 2009), we must still shows that people living with mental health problems and put them into practice. Professional organizations can help illnesses achieve better outcomes when the proper services make this happen by ensuring that health professionals have and supports are provided in their own community, rather than the training and skills to meet the diverse needs of people from in an institutional setting (Davidson, et al., 2005). varied backgrounds and cultures. It will also be important to support communities in assessing their own needs, building on Primary health care is often the first point of contact for people local strengths, and taking ownership of local problems.
living with mental health problems and illnesses (Macfarlane, 2005). Collaborative models involving primary health care and A mental health system that is designed to address quality other mental health services, including peer support workers, cannot avoid confronting stigma and discrimination. As the can offer more holistic care, contribute to stigma reduction, Framework states, "stigma and discrimination have a huge and improve communication between various service providers negative impact on people living with mental health problems (Pautler, 2005). People who require hospital-based services and illnesses, affecting all aspects and stages of their lives – should be able to access them promptly and must always know dealings with friends, family, communities, educators, employers, that services will be provided in the least intrusive and least mental health service providers, and the justice and health restrictive way possible.
care systems" (MHCC, 2009).
addressing disparities and Confronting stigma Discrimination occurs within the mental health and broader
and discrimination
health care systems, and can contribute to long wait times and inappropriate treatment in the emergency room and other Disparities in employment, education, housing, and income departments. Moreover, stigma and discrimination are often have a massive impact on mental health outcomes in Canada anticipated by people living with mental health problems and and around the world (Ontario Legal Clinics, 2010). Service illnesses, and constitute a barrier that keeps them from seeking providers must respect people's traditions and values, and work help. The many initiatives already underway across Canada to to make culturally appropriate mental health services and address stigma and discrimination must be expanded if we are supports widely available. While many mental health care going to fully address these pervasive problems.
an effective Mental Health system
and discrimination, takes into account the diverse needs of people across Canada, and is based on varied sources of Developing an effective mental health system involves knowledge and evidence. In short, achieving quality and translating the best available knowledge into practice. Research transforming the mental health system go hand in hand. Q has led to important advances in understanding the brain. We now know more about the impact of genetics, This article was authored with the assistance of Louise Lapierre, MA, psychological and behavioural factors, and the influence of Policy & Research Analyst and Francophone Stakeholder Relations at the social environments on mental health and well-being. Still, it MHCC, and Dr. Howard Chodos, PhD, Special Advisor, Mental Health takes far too long for this knowledge to have a real impact on Strategy at the MHCC. the front lines of service delivery.
Louise Bradley, MS, RN, CHE, has an extensive background
Overall, funding for mental health research is not in health care, most of which has been focused on mental health commensurate with the impact of mental illness on society; in Canada. She is the President and Chief Executive Officer of funding needs to be increased so we can address the full the Mental Health Commission of Canada, a not-for-profit spectrum of mental health determinants. Given the complexity organization that has a mandate to help improve the lives of people of mental health, multiple methods and sources of knowledge living with mental illness in Canada. need to be mobilized. Peer research – led by people with actual experience with mental health issues – must be encouraged as must research that draws on traditional sources of knowledge.
It is only with a strong commitment to developing, Anthony, W.A. (1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990s. Psychosocial disseminating, and using the best available knowledge Rehabilitation Journal, 16, 11-23.
that Canada will be able to provide the most effective and appropriate treatments, services, and supports to all Davidson, L., Harding, C., Spanoil, L. (2005). Recovery from severe mental illnesses: Research evidence and implications for practice. Boston: Boston University: Author.
Macfarlane, D. (2005). Current state of collaborative mental health care. Mississauga, ON: Canadian Collaborative Mental Health Initiative. Achieving the transformed mental health system presented Retrieved from http://www.ccmhi.ca/en/products/documents/12_ by the MHCC in the Framework requires us to rethink and address many dimensions of quality. A transformed mental Mental Health Commission of Canada. (2009). Toward recovery & health system is people-centered and ensures equitable and Wellbeing: A framework for a mental health strategy for Canada. Calgary, timely access to programs, treatments, and services that are AB: Mental Health Commission of Canada. Retrieved from integrated, efficient, and coordinated. It is focused on people and their families and is recovery-oriented. It addresses stigma Pautler, K., Gagné M.A. (2005). Annotated bibliography of collaborative mental health care. Mississauga, ON: The Canadian Collaborative Mental Health Initiative. Retrieved from www.ccmhi.ca Statistics Canada. (2003). Canadian Community Health Survey: Mental health and well-being. Ottawa, ON: Statistics Canada. Retrieved from Ontario Legal Clinics. (2010). Presentations to representatives of the Mental Health Commission of Canada. Toronto, Canada. The Standing Senate Committee on Social Affairs, Science and Technology. (2006). Out of the shadows at last: Transforming mental health, mental illness and addiction services in Canada. Ottawa, ON: Government of Canada. Retrieved from http://www.parl.gc.ca/Content/ Waddell, C., McEwan, K., Shepherd, C.A., Offord, D.R., Hua, J.M. (2005). A public health strategy to improve the mental health of Canadian children. Canadian Journal of Psychiatry, 50(4):226-233.
Delena Tikk anD Darien Thira
Mental Health and Addiction A Blended Reality T he mental health and addictions intensity and safety of a healing centre, program at the Three Voices they would remain lost in their suffering It is vital that the of Healing Society (TVOH) and would continue to harm themselves integrates Western medicine and recovery process and those close to them.
traditional Aboriginal healing techniques. When an individual pursues their own Steps to Healing
clients return to their healing, their wellness becomes a model communities, or they for their community, which transforms The three greatest mental health challenges them from a victim into a contributing will succumb to their in Canada's Aboriginal community are community member.
addiction(s) once more.
anxiety, depression, and rage — all of which are products of individual and community The TVOH program has been able to trauma. These conditions often lead to substantially increase the success of its addiction treatment self-medication with drugs and alcohol, which can result in programs by using what has been referred to as "Western addiction. Meanwhile, depression carries a risk of suicide, and opening with traditional cleansing." Since introducing this rage can lead to violence. These three states affect individuals, combined program, the TVOH's program completion rate has their families, and the entire Aboriginal community. more than doubled and its clients' sobriety rate one year after completing treatment has also increased.
When clients arrive at the TVOH, a mental health assessment is conducted; its aim is twofold. First, it offers participants The TVOH is a non-profit society that owns and operates a the opportunity to delve deeply into their history of personal 12-bed, First Nations, in-patient, accredited, adult alcohol trauma, family distress, and the impact of colonialism on and drug treatment centre in Creston, British Columbia. The their community. This is done with the guidance of a skilled clientele comes from all walks of life in BC, Alberta, and the professional in a manner that allows for the release of their Yukon. The TVOH offers alternating gender-specific programs suffering and the recognition of their personal, social, and that run for six weeks. For its clients, participating in a healing spiritual strengths. These are all pre-requisites for the healing program is an essential step in their recovery. Without the and empowerment necessary to overcome their addiction. Our staff clinician (who has a PhD in clinical psychology) works can be the most important part of a client's recovery journey with clients during the program's third week to help them open (pre and post-treatment). Other recommendations might include up so they can identify and explore their core issues.
making a connection with a narcotics addiction/alcohol addiction home-group, finding a sponsor, seeking a healthy The second objective of the assessment is the creation of a Elder to speak with, and continuing to participate in cultural holistic mental health assessment report. The report is ceremonies or activities. This report offers guidance to the compiled by a mental health clinician and it contains a community-based counsellors who will provide follow-up biopsychosocial history of the client, a description of their support and counselling after the client leaves the TVOH challenges and strengths, a clinical analysis of the client treatment program. As many of the referral workers are not and how they function, and recommendations for follow-up trained to conduct holistic mental health assessments, the actions. Upon completion of the report, the clinician reviews report acts as a map, helping them offer rich therapeutic it with the client to ensure the client understands and agrees interventions. It can also help them make better referrals with the findings. Differences are discussed and the document to formal or informal mental health resources in the client's is amended so that the final version of the document meets community. This enhances the community's capacity to serve the personal and cultural needs of the client and retains the client needs upon their return to the community, thereby clinical findings of the assessor. The result of this approach is increasing the likelihood that clients will continue their a high level of participant buy-in and a willingness to use the healing journey after they leave the TVOH treatment report for further recovery. For many of our clients, this report program. It is vital that the recovery process continues when is the first time their story has been heard and documented. clients return to their communities, or they will succumb to Their story and the clinical analysis of its impacts then their addiction(s) once more.
becomes a firm foundation for further healing work.
The work of our clinician has been very well received by At the end of the six-week treatment period, the report clients, as evidenced by their feedback at the end of the produced by the clinical staff and the psychologist is forwarded program. This is because he understands the mental health to the client's referral worker in their home community. issues facing First Nations' people and he is able to build Recommendations are made to help with the client's a trusting relationship with the participants in a relatively healing journey. For example, depending on what is available short timeframe. His assessment reports have also been valued in the client's community, we strongly recommend one-on-one by the community counsellors who conduct follow-up counseling, as the client and referral worker relationship activities.
The traditional cleansing held by our Elders takes place cent to 80-90 per cent and the sobriety rate at one year after during the second half of the treatment program. After our completing treatment has risen from 10 per cent to 40-60 psychologist works with the clients, they are better able to per cent. We have also noted a reduction in the number of recognize and address traumatic events that were previously clients who need to return for additional treatments programs. suppressed. During week four, our Elders host healing week Demand for our program is so great that we operate above which is a traditional way of cleansing past traumas. It allows the required occupancy rate and maintain a waiting list that our clients to undertake the deep healing they seek via a averages three to six months. Despite this wait time, patients culturally-rooted spiritual cleansing that is facilitated by First refuse referrals to other programs; the positive testimonials Nation Elders (also former addiction counsellors). These of former clients carry tremendous weight in Aboriginal Elders offer their wisdom by sharing stories, and they encourage communities.
collective healing by asking clients to share their life experiences. They also provide ceremonial opportunities for clients to seek We have begun to successfully promote holistic living for First guidance and cleanse themselves of the pain that surfaced in Nation's people. We recognize that, for our clients, addressing the previous week when they remembered and confronted their mental health and addiction issues goes hand-in-hand. past traumas. Our Elders are perceptive, and they work with They are linked, and can only be successfully addressed in a each client in a group setting to expel the feelings associated safe environment, with people who understand the historical with traumas and addictions. At first, clients are often afraid traumas that are unique to First Nations' communities. to participate in this cleansing, as it is extremely emotional The demand for our program demonstrates a real need in and their traumas are often difficult to face. Yet, when the surrounding communities, and a desire to seek treatment that cleansing is complete, the clients are able to see themselves incorporates traditional Aboriginal healing techniques and as the survivors of trauma and addiction, rather than Western treatment programs. Thus far, our model has proven as victims. More than that, they are able to see themselves quite successful. Q as healthy and worthy people who have much to offer their families and communities.
Delena Tikk, hICAS III, is the Executive Director of the Three
Voices of Healing Society's Wellness Centre in Creston, BC. She is The TVOH calls upon the strengths of both Western and also the President of the Association of BC First Nations Treatment traditional Aboriginal healing methods; they are united for Programs. Her background is in business management and the good of clients who have come to pursue their wellness. administration and she is a certified addictions counselor. Of course, our ultimate objective is to have our clients carry this sense of wellness back to their families and communities Darien Thira, PhD, serves as a community development/mental
and to pass it on to other people in their lives. In this way, health consultant for many Aboriginal communities across Canada. clients can become healers as they engage in a life well-lived.
He offers training workshops and clinical consultation related to a variety of communications, trauma, and crisis-related fields. He Since 2006, when we started using this programming in our is an adjunct faculty member at the Adler School of Professional curriculum (Western opening with traditional cleansing), our Psychology. His doctoral dissertation related to Aboriginal suicide, treatment centre's completion rate has risen from 30-40 per resilience, and social activism. Table 1. TVOh Statistics for 1 april 2009 – 31 March 2010
Total number of program applicants: 181 Number admitted to the program: 94 Client Profile at entry
average age (ranging from 25-65)
alcohol as main substance abused
Family history of substance abuse
Previous addictions treatment
Cross addictions (i.e., alcohol and narcotics)
Vice-President, Programs and Services Accreditation Canada In Closing Pursuing Quality Initiatives C anada's mental health system is at a critical point o Ottawa from 8-10 November 2011 in its reform. Several factors have precipitated change in recent years, including shifting public n 4th Annual Medical Device Reprocessing Forum perceptions of mental illnesses and an understanding (in partnership with the CSA) that comprehensive, community-based service delivery is a crucial link for patients. I am grateful to you, our readers, o Mississauga from 4-5 October 2011 for thinking about the innovations that this issue's authors so generously shared! n 1st Annual Infection Prevention and Control In keeping with our focus on mental health, you may be Conference (in partnership with the CSA) interested in joining colleagues from across the country to share o Mississauga, Ontario from 6-7 October 2011 innovative practices that support quality improvement and accreditation in client-centred mental health and addictions services. A session will take place in Winnipeg, Manitoba, n Ethics in Health Care Conference from 20-21 October to consider stigma reduction, client- centred care, recovery models, suicide risk assessment, and o Toronto from 3-4 November 2011 ethics in mental health, among other topics.
If you would like more information about our educational This fall, Accreditation Canada will showcase several knowledge events and conferences, please visit www.accreditation.ca. exchange opportunities in the form of educational sessions and They are a fantastic way to stay up to date on innovations in conferences. They are a great way to participate in knowledge the field.
translation activities with your peers, and to learn about advances in best practices and research. As part of our The December 2011 issue of Qmentum Quarterly will focus on commitment to partnerships and knowledge exchange, you "Innovations in Access." Not surprisingly, most health care will note that some of these events are organized jointly with consumers remain focused on wait times when they think organizations that can offer a complementary perspective in about or discuss health care access. We know that many client the accreditation field.
organizations are working to make creative and effective approaches to service available. In this issue, we hope to Consider taking some time for professional development by facilitate dialogue and knowledge exchange around innovative attending one of the following: ways to help patients access care. I look forward to connecting with you in December.
n Patient Safety Series regional sessions (offered in partnership by Accreditation Canada, ISMP Canada, Together in advancing quality and safety! and the CPSI) o Montreal from 28-30 September 2011 o Halifax from 26-28 October 2011 If you are an Accreditation Canada client or surveyor, please make changes to your Qmentum Quarterly mailing address via the client or surveyor portals. If you would like to change the mailing address for a paid subscription, please contact Sylvie Anne Turgeon, Subscriptions and Customer Service - Les éditions du Point
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