Indigenous and Northern Affairs Committee on June 14th, 2016

[The Chair, Liberal, Andy Fillmore]

Good afternoon, everyone. We'll come to order. Thank you all for being here.

Members, what I would like to do today is to spend the first hour with our witness Dr. Cornelia Wieman, a consultant psychiatrist who joining us by teleconference from Toronto for our first hour. We'll then move into our second topic, on web-based engagement. I'm going to keep 15 minutes at the end between 5:15 and 5:30 for some committee business, if that suits everyone.

I would like to start by acknowledging that we're meeting today on unceded Algonquin territory, for which we're very grateful. On a more personal note for us, this is where our committee held its first meeting, so it's nice to be back to our humble beginnings here today.

Without any further discussion, Dr. Wieman, I would like to welcome you and thank you very much for joining us today. I'm happy to offer you 10 minutes. We'll see how this works by video conference.

Dr. Wieman, thank you very much. You have the floor.

[Dr. Cornelia Wieman, Consultant Psychiatrist, As an Individual]

Bonjour. Good afternoon, everyone.

Thank you very much to the members of this committee for giving me the opportunity to share my experience with you.

I want to quickly introduce myself. You've already heard my name, Cornelia Wieman. I'm originally a member of the Little Grand Rapids First Nation in Manitoba. I'm also a survivor of the sixties scoop. In 1998, I finished my training in psychiatry, and at that time I was the first woman to become an aboriginal psychiatrist in Canada.

The discussion that I hope we're going to have today will be partly based on my experience and the areas I've worked in over the past 20 years or so in the areas of mental health and health generally.

I spent eight years working as a psychiatrist in a community-based mental health clinic on the Six Nations of the Grand River territory. Then I moved to Toronto and spent about seven years in research at the University of Toronto. I co-directed the indigenous health research development program at the University of Toronto, and also the national Network for Aboriginal Mental Health Research, based out of McGill University.

From 2001 to 2002, I was a member of the suicide prevention advisory group. This is one of the key things I want to present to you with this afternoon. This was a group of individuals representing Canada nationally. We examined the issue of first nations youth suicide very comprehensively and released a report entitled “Acting On What We Know: Preventing Youth Suicide in First Nations”.

If you haven't seen a copy of that report, I can send the clerk the link to the pdf. It was a joint project between Health Canada's first nations and Inuit health branch and the Assembly of First Nations.

Since that time, I've moved back into the clinical realm. This time I have had quite a bit of experience working with urban aboriginal populations, mainly in Toronto, providing mental health services through the YWCA Elm Centre, which is a housing first model. This means that they will take women who are homeless or vulnerably housed, 50 aboriginal women suffering from mental health and addictions, and 100 other women who are not aboriginal. I was part of a mental health support team that worked with those women to try to improve their mental health but also maintain their housing in that building.

I've been working at the Centre for Addiction and Mental Health in Toronto since March of 2013. As part of our programming here at CAMH, we have an aboriginal services program. We serve people with mental health and/or addictions. We offer in-patient residential substance abuse treatment, outpatient substance abuse treatment, and outpatient psychiatric care.

In January of this year, I took a position at McMaster University one day a week to work as a faculty adviser to the aboriginal students health sciences program. The major goal of that program is to increase the number of aboriginal health professionals gaining entry into and graduating from McMaster University, which is very relevant to some of the recommendations from Canada's Truth and Reconciliation Commission that I've also included in my handout.

I know I have to be brief. I will talk mainly about the recommendations that came out of the suicide prevention advisory group, which were grouped into four major areas.

The first area was called “Putting Forward an Evidence-Based Approach to Prevention” of suicide. That advocated for continued support for research initiatives around the country, both in aboriginal communities and in partnership with aboriginal communities and academic institutions, such as universities, to increase what we know about indigenous suicide and work on solutions.

I know that previously at this committee, you heard a presentation from Alain Beaudet, who is the president of the Canadian Institutes of Health Research, and the Institute of Aboriginal Peoples' Health, whose scientific director is Malcolm King. I won't go into too much detail, except to say that when we talk about evidence-based approaches, we don't just mean a western framework for doing research. This can also include community-based initiatives and de-colonized approaches to understanding suicide. A lot of the time, there's difficulty obtaining funding for suicide research that communities want to do because, for whatever reason, it doesn't meet the academic standard that's put forward in a western framework.

The second major area was entitled “Toward Effective, Integrated Health Care at the National, Provincial and Regional Levels”. I suppose this is the area where I have the most experience. We need to learn about the best practices and models for delivering exemplary health care to aboriginal communities. I had the great fortune of working in the Six Nations of the Grand River, which you may or may not know is the largest first nations community in the country. When I worked there, it had a population of 11,000 to 12,000 people living on reserve, and almost the same number living off reserve.

I can't speak on behalf of the Six Nations community, but I do know that through the care that we delivered, our goal was always to try to provide services that would be equivalent to, or exceed, what someone would be able to obtain at a community mental health clinic in any urban or rural clinic, anywhere across the country. I believe we did that.

They have much more data on outcomes and things like that. I cannot speak to that because I don't work there anymore and they own their own data. I do know that, generally, people's outcomes were much better for being in contact with our service and being followed. We had lower rates of admission to hospital and lower rates of suicide than what you would expect when you look at first nation suicide rates across the country, which are generally thought to be two to four or five times the Canadian national average.

A major issue in mental health care is providing sustainable funding for mental health services and healing centres, on reserve, in rural areas, and in urban areas. Again, some of the recommendations from the Truth and Reconciliation Commission also speak to this.

For example, when you look at the budget for non-insured health benefits for the year 2013-14, the total expenditures for the entire budget were just over $1 billion. Pharmacare takes up 40.5% of that budget. There's a lot of money that's spent on pharmacare, as well as medical transportation to get people to and from their appointments. “Other health care” only accounts for 1.4% of that budget, which amounts to about $14.2 million. That other health care is deemed for short-term crisis intervention and mental health counselling benefits to address at-risk situations.

I know from checking the meeting schedule of this committee that you've already heard from the first nations and Inuit health branch. I believe you heard from Keith Conn around that.

There's been a long-standing issue of insufficient funding for both western-trained mental-health professionals, and traditional healing, which typically isn't reimbursed in the way that say, physicians, social workers, or psychologists are reimbursed. That, in itself, is an issue as well, because traditional healers spend a lot of time working with people in their communities, and a lot of the time, the work that they do is on a volunteer basis.

In its recommendations, the Truth and Reconciliation Commission also stressed the value of aboriginal traditional healing practices. Because I am aboriginal by background, I think I've had a natural tendency to be open to including traditional healing practices in the patients that I see, but other psychiatrists may not be.

That leads me into talking briefly about a health and human resources issue across the country. I checked the data from the Canadian Psychiatric Association. There are 4,770 psychiatrists across the country. I know of three other aboriginal psychiatrists who are practising in the country. There have been four of us for some time. I know of two aboriginal psychiatry residents who are in the process of completing their training, which brings us to a grand total of six. When you divide six by 4,770 you get 0.01%.

The reality is that virtually all psychiatric care across this country to aboriginal people is provided by non-aboriginal psychiatrists and other health professionals. I have questions about why we're training aboriginal family physicians, but why psychiatry, in and of itself, is seeming to be an unattractive specialty to attract aboriginal medical students to choose upon graduation.

In my work at McMaster in trying to recruit aboriginal students into the medical program, for example, we would really like to continue this pattern. Again, this is another major recommendation of the Truth and Reconciliation Commission. Because the majority of care is provided by non-aboriginal health professionals, there's a great need to train health professionals in cultural safety, so that they're providing culturally relevant care.

I'll end there and hope we have a really good discussion.

Thanks.

[The Chair, Liberal, Andy Fillmore]

Thanks so much, Dr. Wieman, for that. It's much appreciated.

We're going to move into a series of seven-minute questions from members. We'll use the same cards as we have just now.

The first question is from Michael McLeod, please.

[Michael McLeod, Liberal, Northwest Territories, NT]

Thank you for the presentation. They were very interesting points. It sounded as if you had more to add, but timing became the challenge.

I really was interested to hear more about the traditional healers. We have the concern in a lot of communities that.... First of all, in most parts of the north, where I come from in the Northwest Territories, we don't have professional care at all. In most cases when we do, it's certainly not by aboriginal people. A lot of our communities have worked hard to try to engage our elders in working with youth or people who are in situations of crisis. It's been very difficult. First of all, they're not compensated properly, if at all. When they are compensated, our tax laws claw it back. They are really reluctant to accept any money, but at the same time, it's not fair for them to be doing a lot of this work on their own.

We heard from many organizations and people over the last while on what works well. I wanted you to expand a little bit on the role that aboriginal culture could play in developing positive identities. I've asked this question many times on the role that delivery agents, such as the friendship centres and aboriginal head start, could make in dealing with some of these issues that are challenging us socially.

[Dr. Cornelia Wieman]

Thank you.

Going back to the suicide prevention advisory group report, the fourth major area that I didn't get to was recommendations around strengthening youth identity, resilience, and participation in cultural activities. I've seen a couple of articles on that in the news over the last couple of weeks. I think in the western provinces there have been a couple of studies released that indicate that incorporating traditional and cultural activities into the daily life of a community is helpful for their mental health. Some of you may be familiar with the seminal work that's been presented by Michael Chandler and Christopher Lalonde in British Columbia that talks about lower rates of suicide in communities that have at least one facility dedicated to traditional and cultural practices.

The way I have always operated as a mental health professional is that I have been open to patients or clients participating in both areas if they wish. I would treat them as a psychiatrist, because I'm trained as a psychiatrist; but as a first nations person, I would also be open to sharing the care with a traditional healer. I understand some of the difficulties around traditional healing: engaging them, engaging the elders, and how they're compensated. It's still an issue that needs to be sorted out, and probably individually for each community. When I worked at Six Nations, there was also some controversy around who may call themselves a traditional healer. We relied on respected individuals in the community to point these folks out to us so we could establish a working relationship with them.

Understandably, some traditional healers were very hesitant about working with a western-trained psychiatrist. I think the point to learn is that these types of good collaborative working relationships take time to establish. The western medical model wants to move things quickly, and wants to see someone, assess a person, diagnose them, make a plan, and that's sort of it. I had to relearn a lot of my training when I finished and started working in a community on reserve to learn how to work at that community's pace. It ended up being fruitful in establishing that type of relationship.

Even though it requires effort and commitment on both parts, if there's mutual respect present, then I think it can do nothing but provide optimal care for aboriginal people living in a variety of communities, not just on reserve, but here in downtown Toronto as well. CAMH is progressive in the sense that we have two elders, two traditional healers, who are attached to the aboriginal services program here as well. Someone can see a western-trained psychiatrist, or a social worker, or a nurse, but they can also see a traditional healer for ceremony and counselling if they wish. I haven't visited the site over the last little while, but I believe they're putting a sweat lodge on the grounds of the Centre for Addiction and Mental Health, which would be terrific for the people undergoing the residential treatment.

I don't know if that answers your question. I think we need to appreciate that aboriginal people are asking for this as part of their mental health care. It's up to the health care providers to be open to that. There's a challenge, however. I know in Ontario—I can only speak for the Province of Ontario—without going into too much detail, Ontario's doctors are at odds with the provincial Minister of Health, and there's been a lot of chatter around—

[Michael McLeod, Liberal, Northwest Territories, NT]

Can I just interrupt you? The area I was hoping you would address is the facilities in communities. You mentioned that this is part of your recommendation, and I agree with that recommendation. Communities across the north—and I can only speak to the ones in the north and the isolated communities—in a lot of places don't have restaurants, don't have coffee shops, and don't have places where youth can gather. They don't have friendship centres. They don't have drop-in centres. We need a mechanism or an organization in communities that can deliver youth programs. I like the point that you're making.

I've also heard from the traditional healers, the people in the communities, and the elders that while they like working with youth, they also don't like mixing with people from other.... For example, one community said they don't want to be participating when there are hip hop dancers and all these other motivational types of influences.

[The Chair, Liberal, Andy Fillmore]

Mike, we're out of time.

[Michael McLeod, Liberal, Northwest Territories, NT]

Sorry, but thank you.

[The Chair, Liberal, Andy Fillmore]

The next question is from Cathy McLeod, please.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

Acting on what we know, you talked about four. First was the evidence-based approach. The second was effective integrated care. The fourth is the strength in cultural identity.

Were the third and fourth talking about the resources and allocation, or did we miss the third?

[Dr. Cornelia Wieman]

We did miss the third. The first was research. The second was mental health services. The third I had to skip over, and it was about supporting community-driven approaches.

That can also be inclusive of traditional healing, but we're also talking about other types of activities, like on-the-land activities for youth, youth and elder pairings, community kitchens, and sports facilities, etc.

I know the committee has met with Jack Hicks who used to work up in Nunavut and now is at the University of Saskatchewan, but I recently heard of a small, anecdotal study that came from Nunavut where a community with very high rates of suicide didn't necessarily do anything too extreme in bringing in crisis teams or getting a psychiatrist to visit that community. The community built a skating rink, and the suicide rates in that community went down.

Sometimes I think the answer doesn't always have to be very complicated or, should we say, western and scientific, but sometimes it can be what the community asks for, and how they are supported in making use of it. That can lead to a decrease in the community in the level of distress and suicide. That's really encouraging.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

Your last two are a primary prevention model, a public health model, and the others are more care models.

[Dr. Cornelia Wieman]

Yes.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

I know I have experienced incredible frustration, but with the jurisdictional issues, when you're talking about integrated care, could you narrow down your particular recommendation about integrated care? I ask because I think it's an important area where sometimes things overlap: it's a little about Jordan's principle, but it's also a little about what the province is doing, what Health Canada is doing, what the health authorities are doing.

Where did you go with that one?

[Dr. Cornelia Wieman]

It's still an unresolved issue. When I worked on reserve in the province of Ontario my time was paid through the Ministry of Health, i.e., provincially, but the program I worked for was federally funded because it was a mental health program on reserve. Furthermore, the medications that patients received were funded through non-insured health benefits, which again is a national pharmacare program for first nations and Inuit across the country.

It seemed there were always different silos of funding for different aspects of the services for people, and it became very unwieldy to provide services in that manner. It would probably be too much detail today to get into some of the difficulties with the non-insured health benefits program from a practical point of view, but suffice it to say, they exist.

That makes it very hard to deliver care from a practitioner's point of view when you're trying to advocate for your patients, as there are different kinds of ways that things have to get done, because some fall under provincial jurisdiction and some under federal jurisdiction.

In the urban setting, it's not so much of an issue, except that some people may still have coverage for their medications through non-insured health benefits.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

The pharmaceutical approach doesn't work well at all. Can you give us a sense of the lie of the land with significant depression. Where's the latest research?

[Dr. Cornelia Wieman]

I believe strongly, from my 18 years of being a psychiatrist, that there is a role for medications to play for every Canadian with a mental health issue, if necessary, and that includes aboriginal people. I don't think aboriginal people with severe depression who require medication should suffer because they don't have, for example, access to medications in certain circumstances. But I do believe that other non-medication forms of help and assistance should also be available to them.

Medications in many cases are required, but I think one of the issues I had—and this was with the non-insured health benefits program—is that there are different layers. I would often have to try the older versions of medications that, according to the clinical practice guidelines, were out of date, and I would have to have a patient fail on those older medications before they received funding for newer medications that were available on the market. I guess that's a feature of pharmacare programs that serve people on social assistance, people on provincial disability programs, and those receiving support from the first nations and Inuit health branch. It did disturb me when I was working with people—

[The Chair, Liberal, Andy Fillmore]

You have one minute left.

[Dr. Cornelia Wieman]

—when I felt they weren't able to access the same level of care, the same up-to-date level of care, that my patients in downtown Toronto had access to.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

I have time for one more quick question. You talked about the de-colonized approaches. Can you maybe describe those a little better?

[Dr. Cornelia Wieman]

De-colonize, in my understanding, just means not coming from the lens of a western medical model. If somebody in a community decides that they would like to evaluate stories of mental health healing or recovery from trauma, I would say that it would be a meaningful study and a meaningful piece of research for that community to do. Unfortunately, that type of research often doesn't get funded, particularly from pots of money that are governed by western medical model frameworks. It makes it very difficult to determine who's doing the research, who it is for, what its purpose is, and what its value is going to be.

[The Chair, Liberal, Andy Fillmore]

We're out of time there.

The next questions are from Charlie Angus, please.

[Charlie Angus, NDP, Timmins—James Bay, ON]

Thank you, Dr. Wieman, for this excellent presentation.

I want to start on the issue of the non-insured health benefits. You were saying that you are expected to give out-of-date medication to people, and the medications had to fail before they would be upgraded. That sounds to me like a very disturbing interference in the doctor-patient relationship, and we've had evidence of other medical practices that the non-insured health benefits branch has interfered with.

What would you recommend to end this, because it would seem to me discriminatory?

[Dr. Cornelia Wieman]

I felt that it was. For a number of years, I sat on the first nations and Inuit health branch's non-insured health benefits drug utilization evaluation advisory committee—it's a mouthful. I think the major factor that limits the pharmacare program is money. That's the bottom line, but I think when we're talking about treating people in acute levels of distress, if they, for example, have not had any clinical benefit on the first-line treatment, which is usually a certain type of SSRI anti-depressant.... I remember when I practised on reserve that they would have to have, for example, two trials of a medication in that class before we were allowed to apply to have a different class of medications.

It seemed to me very unfair and not up to the standard of care that's recommended according to the guidelines of care that I have to adhere to as a licensed health professional in the province of Ontario.

[Charlie Angus, NDP, Timmins—James Bay, ON]

Thank you for that.

I represent a Treaty 9 region, which has been ground zero of the suicide crisis. We lost a young woman in Moose Factory on Sunday night.

What I've been told time and time again is that requests to have treatment have been overruled as unnecessary because young people have to be medevaced out, or there is nobody to medevac them out to, or there's no healing centre, and the only option then is to let child welfare know, so the young people go to ground because they would actually be taken and put into foster care, which is a social disaster if we're trying to alleviate a suicide crisis.

Has that been your experience in terms of what's happening in isolated regions?