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Looking Back: Reflections on Community Mental Health in Ontario

By Diana Ballon

Sixty years ago, mental health “patients” were being warehoused in asylums, with no voice to express their own thoughts and feelings. No safe space. No belief in any kind of future. Now people with similar mental health problems are integrally involved in managing their own treatment plans, they have access to a greater range of treatment and supports, and a shared sense — with their health-care providers — that recovery is possible.

Stigma persists and discrimination against people with mental health problems continues, particularly for those who are most marginalized and who suffer the most debilitating forms of mental illness. But progress has been made. Looking back over the history of community mental health in Ontario, we have much to celebrate.

The Canadian Mental Health Association (CMHA) was founded as a national organization in 1918 and federally incorporated in 1926. The Ontario Division of CMHA received its provincial charter in 1952. In 1963, CMHA released its landmark policy document, More for the Mind, with 57 recommendations concerning mental health care in Canada. More for the Mind advocated for deinstitutionalization and the development of appropriate forms of community care. Recommended changes included the need to integrate mental health services within general health services; to decentralize psychiatric services from the provincial government to regional agencies; and to coordinate psychiatric services for patients through all phases of their illness. Every subsequent review of psychiatric services in Canada has reflected these principles.

Deinstitutionalization in the 1950s and 60s led to the closure of almost 80 percent of beds in psychiatric hospitals. However, it took about 20 years to recognize that without the necessary community services in place, deinstitutionalization was a disaster, says Ed Pomeroy, a clinical/community psychologist in the Niagara region and professor emeritus at Brock University. Not only were there not the funds in place to support people with serious mental illness, but mental health providers “maintained a vision that didn’t take into account the realities of people with serious mental illness in the community.”

In the hospital, people didn’t have to worry about food. Even if it was lousy, it was still food. “But out in the community — will people eat?” Pomeroy asks rhetorically. Poor nutrition, access to legal and illegal drugs and abysmal housing moved people with serious mental illness “from back wards to back alleys,” says Pomeroy.

The push to physically move people out of hospital was not accompanied by a corresponding shift in attitude. Pomeroy describes the process in his 1992 article “Citizens Shaping Policy: The Canadian Mental Health Association’s Framework for Support Project,” co-authored with John Trainer and Bonnie Pape. Mental health providers maintained an often patriarchal, controlling attitude still embedded in a medical approach to caring for the mentally “ill.” And consumers and their families were understandably angry, frustrated and hurt. Instead of being respected as experts in their own care, they were viewed as disabled, and seen as without agency or ability to provide input into their own recovery.

Gradually, change began to occur. Building Community Support for People: A Plan for Mental Health in Ontario (1988) — known colloquially as The Graham Report — marked the most important shift away from a medical model towards a community-based approach to delivering mental health services in this province, recalls Mike Petrenko, executive director of CMHA London.

The report led to Putting People First (1993), the first provincial policy document to outline a 10-year plan for community mental health reform. It committed to prioritizing the needs of people with serious mental illness, and recommended that, by 2003, the Ministry of Health and Long-Term Care commit 60 percent of mental health funding to community services and the remaining 40 percent to hospital care. That split represented the reverse of how funding was allocated at the time.

As District Health Councils and mental health committees emerged, there was a major thrust to invest in community-based services. “For the first time in every community across the province, the providers were all at the same table,” Petrenko says. Previously, hospital programs and community programs had been in competition, but now they began to plan collaboratively as partnerships, continues Petrenko. Unfortunately, not much has changed on the financial front: hospitals still receive the majority of funding.

Working with clients — or consumer/survivors, as they called themselves — marked another type of partnership for community mental health agencies, where clients were recognized as experts on their experience, to be consulted with, listened to and respected for their perspective. The experience of family members was also valued. No longer could doctors be seen as the sole “authority” on people’s mental illness. And clients could set goals for their own recovery.

The idea of recovery is hardly new, says Vicky Huehn, executive director of Frontenac Community Mental Health Services in Kingston. “Respect, dignity and choice” have been central to the psychosocial rehabilitation movement for over 30 years, Huehn says. Staff members encourage people to talk about their aims and aspirations as part of their recovery journey: the individual with mental illness is the decision-maker, and the staff member is there as a partner.

In the 1980s and 90s, services were gradually developing for and sometimes by consumers: self-help/mutual aid and support groups, consumer-run drop-in centres, clubhouses, 24-hour crisis lines and Assertive Community Treatment (ACT) teams, among other initiatives.

Rather than simply “treating” mental illness, mental health providers also began to recognize the need to consider determinants of health: the fact that income, work, education and housing were also crucial to people’s well-being and were conditions that had to be supported.

Housing was the first priority: originally, there were four categories or levels of support in the provincial funding assigned to supported housing. This tiered approach was “absolutely offensive,” says Huehn. The fixed levels didn’t acknowledge that people’s need for support can fluctuate; instead, they implied that people had to “graduate” to move from one level or stage to the next, and that if they went back to hospital they had failed.

Along with a focus on housing was a push toward supported employment. In the late 1980s and early 90s, vocational employment programs were established to enable people with serious mental illness to integrate or reintegrate into a regular workplace. Unlike sheltered workshops that had previously been the norm, these new programs helped people to find “regular jobs”: an employment officer would look at a person’s skills, aptitudes and abilities (sometimes with vocational testing), help to find the person a job, and then support him or her through the initial adjustments and other difficult periods, as needed. “It’s a great support system that continues today,” says Petrenko.

Programs continue to become more complex. There’s a “maturation of the system,” says Huehn. Mental health services established in Ontario have been able to draw on Canadian as well as international research, from such countries as New Zealand, England and Australia, to learn about successful approaches to community care.

“We now have the genesis of best practice in terms of services and supports,” observes Petrenko. Supported employment has paved the way for consumer-run businesses. People can now get mental health accommodations in both the workplace and post-secondary education. Crisis lines have matured from chat lines to provide mobile capacity with mental health and addiction supports. In the last six or seven years, court support and diversion programs have emerged, to help divert people with serious mental illness in the criminal justice system out of prison cells and psychiatric hospitals into safe bed programs and other types of housing and community support, says Huehn.

Unfortunately, many of our services have reached capacity. “We’re stalled,” Petrenko says. Pomeroy concurs: there were many ideals post-deinstitutionalization, but today there is “by no means consensus that a lot of progress has been made.” The consumer movement has lost momentum, he says. “With the removal of District Health Councils and the huge mandates of the Local Health Integration Networks, we have moved further away from these ideals and more toward professional interests.” Even the idea of “recovery” that came out of the consumer movement has now been appropriated by professionals, he says.

The biggest tragedy is “that the consumer voice got lost so easily.” It takes work to stay in touch with the needs of the seriously mentally ill, says Pomeroy.

“So where is the optimism?” I ask.

“That we’re having this conversation, that we can use words like consumer, survivor, empower, recovery, accommodations… that there are islands of people working really, really hard and really, really well.”

Petrenko also sees a positive future for community mental health. “We’re on the cusp of transition to a significant emphasis on prevention and mental health promotion,” he says, referring to the 10-year strategy for mental health and addictions outlined by the Ministry of Health and Long-Term Care in their 2009 discussion paper “Every Door is the Right Door.”

“We’ve focused on mental illness. We’re now shifting our focus to mental health and mental illness,” Petrenko says. The strategy is moving towards preventing mental health problems, maintaining positive mental and physical health, and intervening early to treat the onset of mental illness.

People are now talking about mental health problems in a way they never were before.

Diana Ballon is a Toronto writer and editor specializing in mental health issues.

The Long and Winding Road: Reports, Recommendations and Plans for Mental Health Reform

Mental health policy in Ontario has moved from an emphasis on institutionalization of people with mental illness to a system that depends on effective and accessible services delivered in the community. This redirection in policy is frequently referred to as mental health reform.

Many reports concerning mental health reform have been published in Ontario in the last 30 years. All reports have strongly endorsed the principle of moving mental health care from psychiatric hospitals into the community, where people with mental illness can receive the services they need when they need them.

1983 – Towards a Blueprint for Change: A Mental Health Policy and Program Perspective (Heseltine Report)
The primary goal of this report was to provide support for the development of a continuum of service delivery, while ensuring that people with mental illness can receive appropriate help in their own communities.

1988 – Building Community Support for People: A Plan for Mental Health in Ontario (Graham Report)
This report followed a series of consultations and recommended that priority should be given to services for people with serious mental illness. The report proposed a plan for the development and implementation of a comprehensive community mental health system.

1993 – Putting People First: The Reform of Mental Health Services in Ontario
This report endorsed the Graham Report (1988) and proposed a 10-year plan for mental health reform in Ontario based on common vision and values.

1994 – Implementation Planning Guidelines for Mental Health Reform
This report set out clear expectations for District Health Councils and their role in mental health reform.

1996 – District Health Council Recommendations
Based on Putting People First (1993), District Health Councils recommended that community mental health services be coordinated through strategies such as joint networks, lead agencies, joint protocols, assessment tools, and tracking with a clear point of access into the system, that models of delivery be based on best practices and that a continuum of services are offered, including case management.

1998 – 2000 and Beyond: Strengthening Ontario’s Mental Health System
Based on a consultation led by Dan Newman, MPP, who was Parliamentary Assistant to the Minister of Health and Long-Term Care, this report endorsed the principle of community-focused care set out in Putting People First (1993) but noted that at the five-year mark, funding had not yet been allocated to implement needed reform.

1999 – Building a Community Mental Health System in Ontario: Report of the Health Services Restructuring Commission
The HSRC recommended that the Ministry of Health and Long-Term Care (MOHLTC) should divest Ontario’s nine provincial psychiatric hospitals to the public hospitals. It also recommended transitional funding so that services could be established before the beds were closed.

1999 – Making It Happen: Implementation Plan for Mental Health Reform
This report outlines the MOHLTC’S strategy “to increase the capacity of the system for comprehensive and integrated treatment, rehabilitative and support services while focusing on community alternatives wherever possible.” It was also intended to guide strategic investments over the next three years and committed to protecting mental health funding.

2000 – Mental Health: The Next Steps: Strengthening Ontario’s Mental Health System
This short report on the consultation process on legislative changes to the Mental Health Act and the Health Care Consent Act states that the proposed legislative changes will “ensure people with serious mental illness get the care and treatment they need in a community-based mental health system.”

2000 – Making It Work: Policy Framework for Employment Supports for People with Serious Mental Illness
This report elaborates on the issue of employment supports, providing additional recommendations on issues not adequately addressed in the initial 10-year plan set out in Putting People First (1993). The goal was to develop a coordinated response at both the federal and provincial levels to income and employment supports and the business sector.

2001 – Making It Happen: Operational Framework for the Delivery of Mental Health Services and Supports
This document is a companion to Making It Happen: Implementation Plan for Mental Health Reform (1999). It established a framework to reform the mental health system. The report commits to including a continuum of services for persons with mental illness: first line, specialized and intensive. Again, the government re-affirmed its commitment to investment in community mental health care to alleviate pressure resulting from the divestment of psychiatric hospitals.

2002/2003 – Mental Health Implementation Task Force Reports
Nine regional task forces consulted with thousands of people in the field of mental health over a three-year period and submitted nine region-specific reports. A final report of the Provincial Forum of Mental Health Task Force Chairs, The Time is Now, identified 11 key themes for reform.

2010 – Navigating the Journey to Wellness: The Comprehensive Mental Health and Addictions Action Plan for Ontarians
The final report of the Select Committee on Mental Health and Addictions, which included representation from all three political parties. Based on extensive consultations, the report makes 23 recommendations, including the creation of an umbrella organization to design, manage and coordinate the mental health and addictions system. The committee also recommended the consolidation of all mental health and addictions programs and services in the MOHLTC, including those for children and youth.

2010 – Respect, Recovery, Resilience: Recommendations for Ontario’s Mental Health and Addictions Strategy
The final report of the Minister’s Advisory Group (MAG) on Mental Health and Addictions, a group of consumers, family members, health care providers and researchers who were asked to provide the MOHLTC with advice to guide the creation of a 10-year mental health and addictions strategy in Ontario. Five key goals are named: improve mental health and well-being for all Ontarians; stop stigma and discrimination; create healthy, resilient, inclusive communities; identify mental health and addiction problems early and intervene; and provide timely, high quality, integrated, person-directed health and other human services.

Looking Ahead: 2011 and Beyond — Ontario’s 10-Year Mental Health and Addiction Strategy
The Ontario government is developing a new 10-year strategy for mental health and addictions. Two main areas of focus are expected: how to redesign mental health and addiction services to best meet the needs of individuals; and how to create the conditions in communities to help everyone reach optimal mental health and well-being.