Indigenous and Northern Affairs Committee on June 14th, 2016

[Dr. Cornelia Wieman]

Yes, I would agree with you. I think one of the major issues I have is that I have gone up to Sioux Lookout a couple of times for trips and have seen adolescents being flown out of the communities from the Sioux Lookout zone to come to see me in a clinic. Some of them have never been seen by a psychiatrist before, or if they have, they have not been reassessed for the last two to four years. They are grossly underserved compared to someone, for example, whom I now see at CAMH on a weekly basis, or even on a monthly basis. There are people who were started on medications years ago and their dosage has never been adjusted—or even changed if it's not effective. That's a huge frustration.

When I was talking about the lack of mental health resources, we have some psychiatrists in the country who are willing to provide services to these communities, and they should be congratulated, but we need so many more. We can also take advantage of technology, like telepsychiatry. I used to work in telepsychiatry at the Centre for Addiction and Mental Health. It's a big commitment for a psychiatrist to travel regularly up to a community, but there are some who do.

I think psychiatry programs—this is maybe another national initiative—really need to look at having a separate stream, perhaps similar to specializing in child and adolescent psychiatry, or similar to being a geriatric psychiatrist, or of being a remote or rural psychiatrist, or even an aboriginal stream of training people to work in communities and to travel to these communities if possible. I recognize the difficulty. I've done it myself. I used to be a fly-in psychiatrist. It takes a terrible toll on you personally and on your family. However, I'll say strongly that it is shameful the level of care that people receive in our communities, by and large.

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

Thank you for that.

We had an extraordinary group of young people from Treaty 9 at our meeting yesterday and they said they don't have mental health workers in many of the communities. Randall Crowe, an extraordinary young 26-year-old at Deer Lake, is one of the only mental health workers. He has received no training. He's been doing it since he was 19.

I want to focus on that because when we talk about the suicide crisis in places like Neskantaga, Fort Hope, Pikangikum, and Attawapiskat, it's always described in terms of dollars, that if we put in this amount of money or hire one more worker, that will make the crisis go away. I never hear it framed in that way when we deal with suicide in non-aboriginal communities. In their regard, it's seen as a public health issue and everybody rallies and the resources will be there.

Do you think there's a particular frame that's discriminatory in how governments respond to a crisis when it's indigenous youth, as opposed to non-indigenous youth?

[Dr. Cornelia Wieman]

I would agree with that. We talk about fostering youth identity and resilience in some of our recommendations, because I think that as the aboriginal youth suicide gets talked about as a phenomenon across the country—and yes, definitely, there are crisis spots—the youth start to believe they are only youth in crisis. They don't understand that they can be good students, good musicians, or whatever. I think there are some organizations across the country that are trying to do that. For example, there's the Indspire Foundation. I sat on its board of directors for something like six or seven years. They do a tremendous amount.

I've always had the idea, but never carried it out, of trying to promote the individuals who have been the recipients of the health career scholarships, trying to portray more positive role models for the young people so they can see that it's possible. Whenever I have visited remote communities, I have kids running up to me saying “Oh my gosh, I didn't even know people could be a doctor, that I could even be a doctor.” Young people are not going to see themselves doing something if they can't even imagine themselves doing it. I think that's a part of mental health care that's not about writing a prescription, but something that can be very meaningful and helpful to people's overall mental health and their health holistically.

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

Thank you very much.

[The Chair, Liberal, Andy Fillmore]

Thank you both for that.

The next question is from Rémi Massé, please.

[Rémi Massé, Liberal, Avignon—La Mitis—Matane—Matapédia, QC]

Good afternoon, Dr. Wieman.

I am very pleased that you are able to share your expertise with us today. You directed my attention to several important points, one in particular. You pointed out that almost all of the specialists and mental health interveners were not from the first nations, aside from six of them.

What would you recommend to specialists and others who intervene in the communities so that they can work more effectively?

You said that as opposed to what is normally done, it is important to work at the speed of aboriginal communities. I wonder if you could make some other suggestions that would help those who intervene with the affected communities.

[Dr. Cornelia Wieman]

To start, one of the major issues in working with people in communities is trust. There have been decades upon decades of mistrust between indigenous people and all types of other folks in this country of Canada, but specifically involving health providers.

This is my area of expertise. People may have had previous poor experiences with health care providers when they felt their needs weren't listened to, or they may have been as far out on the spectrum as being overtly mistreated by health care providers. One only has to look at the example of Brian Sinclair, the man who came to the emergency department at the Winnipeg Health Sciences Centre. He was an aboriginal man. He sat in the emergency room for 34 hours and died without even being seen. Trust is a major issue.

For the folks I worked with on the reserve, it took a lot of time. It took months of my working in that community for people to come forward and feel comfortable in coming to see me because, even though I'm first nations myself, I was presented to the community as “This is going to be our psychiatrist who is working in the community”, and people have a lot of hesitancy about psychiatry. It resonates some of the trauma they may have experienced through the sixties scoop, through being in child protective services, or through the legacy of residential schools, in that psychiatrists have the special ability to involuntarily hospitalize people if necessary, or treat them against their will in very extreme cases, as you know. So because there is that quite vast difference in power, it takes a lot of time and a certain temperament to be able to sit there and be patient and allow the patient to trust you. You have to gain that trust not only through your words but through your actions.

On non-aboriginal health care professionals, for example, I have seen colleagues especially when I was at McMaster University, where there is a psychiatrist whose name is Gary Chaimowitz, who has provided psychiatric services to communities on the west coast of James Bay for something like 20 years. He goes regularly. He is committed to those communities, and the communities know that, so there is trust that has developed.

I'm not saying it has to take 20 years, but psychiatrists who might visit a community are probably not going to function that well in that community if they expect to see 30 people in one day and just get people in a revolving door, every five minutes, and hand them prescriptions. It takes patience.

[Rémi Massé, Liberal, Avignon—La Mitis—Matane—Matapédia, QC]

You say it takes time to establish a bond of trust. How can we accelerate the establishment of that bond of trust? In certain communities there are crisis situations and interventions have to happen.

What would be some potential solutions to accelerate the establishment of a bond of trust so that we may intervene more quickly?

[Dr. Cornelia Wieman]

First of all, I'll just preface by saying that clinical skills cannot necessarily be taught entirely. A lot of it has to do with the clinicians' personality style and whether they seem approachable and friendly. It sounds perhaps like a silly thing, but it's actually quite important. Initially, to establish a quick rapport, especially in crisis situations, the patients, or clients, or community members need to feel that they are going to be heard, that their distress is going to be heard, but also that their ideas about potential solutions are going to be heard.

I have heard time and time again stories of people saying they were depressed and wanted to maybe try a medication but wanted to see a traditional healer, and when they mentioned that to the doctor, he said it was “either my way or the highway”, and they were sent out the door. In a crisis situation, being open to what community members or patients are saying to you about what they think might be helpful for them is a really good point to stress and work with.

[The Chair, Liberal, Andy Fillmore]

One minute, please.

[Rémi Massé, Liberal, Avignon—La Mitis—Matane—Matapédia, QC]

I have one last question.

Given that a large number of specialists may be required to intervene in the communities, in the meantime, what could you recommend to the communities in the more remote areas to help them prevent suicide?

I would like to know, for instance, what lessons learned could help the communities where adequate mental health support cannot provide benefits quickly.

[Dr. Cornelia Wieman]

I think a really good example came out of the recent suicide crisis in Attawapiskat, where the youth got together as a group. They essentially had a focus group and came up with what they thought would be helpful for them and their community, such as having a place to gather, or play pool, or whatever. The point is the youth themselves came up with those solutions, and in many cases that's a concept that health providers are not familiar with, because we like to say what we think would be best for the patient, and it may not match with what the patient sees would be helpful for them. I think that's really the crux of it. It's trying to collaborate together to come up with solutions, both for individuals and specific communities.

[The Chair, Liberal, Andy Fillmore]

We're going to move on now to a round of five-minute questions, and the first question will be from David Yurdiga, please.

[David Yurdiga, Conservative, Fort McMurray—Cold Lake, AB]

Dr. Wieman, thank you for participating in our study today. It's a very important study and we all want to resolve this, but it's not an easy subject to talk about because there are a lot of challenges and a lot of heartache.

My first question, or maybe it's a clarification, is about traditional healing. We heard a lot about traditional healing today. What does that entail? What does that actually mean? What's traditional healing?

[Dr. Cornelia Wieman]

First of all, I'll say I am not a traditional healer myself, but I am open to working with traditional healers. There are different kinds of traditional healers. There are some who do ceremonies, for example. In my culture, in the Anishinaabe culture, there may be ceremonies around smudging; ceremonies that you may or may not have participated in the past, where they pass around the conch shell and you smudge yourself with the smoke. There are other ceremonies like the sweat lodge, which is a cleansing, purifying ceremony, which I won't go into in detail. And there are many other ceremonies that I don't even know that much about myself.

Then there are traditional healers who may offer traditional medicines that are probably mostly herbal in nature. Again, as a psychiatrist, I have to be careful. When I've worked with traditional healers, I'm not opposed to my patients taking traditional medicines per se, but I do monitor people very carefully because sometimes people also want to take a prescription medication. The first principle is the safety of the patients, so we want to monitor them to make sure they're not having any traditional medicine and prescription medicine interactions.

Traditional healing can be the medicines, as I said; ceremonies; and traditional counselling. That may be from an elder, it may be from people whom we call cultural resources, so people who know the stories, etc. It's actually very broad. You'll find some people who really specialize only in the medicines, and some traditional healers who work only with ceremony.

[David Yurdiga, Conservative, Fort McMurray—Cold Lake, AB]

I am curious if by incorporating traditional healing within the western mental health services, you have you noticed a decrease in suicides. Is there a difference from before, using traditional healing versus western medicine, or is it a combination of both?

[Dr. Cornelia Wieman]

I'm not sure if that type of particular study has been done, but I do know from the large surveys that take place every three-to-five years, called the regional health surveys, that the vast majority of first nations across the country want to see traditional healing practices as part of their health care, including their mental health care. We as health professionals have to respond to that. We have to acknowledge that and try our best to be accommodating of that. I think that's the other major piece. Health professionals who are being trained in western academic institutions—meaning nurses, midwives, physiotherapists, occupational therapists, physicians, and psychiatrists—need to know that this is quite possibly going to be part of the person's treatment plan, and be open to that. I don't really know how much of that is being addressed in medical training across the country.

[The Chair, Liberal, Andy Fillmore]

You have one minute left, please.

[David Yurdiga, Conservative, Fort McMurray—Cold Lake, AB]

What are the qualifying factors to become a traditional healer? Obviously, you want somebody who has some background. Are there criteria that you guys follow to incorporate a traditional healer within your programs?

[Dr. Cornelia Wieman]

Again, I can say, as I'm not a traditional healer, so it would never be my place to say what the criteria would be for a traditional healer. I know, generally, that it's either passed down in families. Someone's grandmother or mother might have been one, and the person may be drawn towards traditional healing.

When I worked on a reserve community, we relied very heavily on respected elders in the community to tell us who they thought would be good, traditional healers for us to work with. I mention this because in some communities there are people who are calling themselves traditional healers but don't necessarily have the respect and backup of their communities.

[The Chair, Liberal, Andy Fillmore]

We're out of time.

The next question is from Gary Anandasangaree, please.

[Gary Anandasangaree, Liberal, Scarborough—Rouge Park, ON]

Dr. Wieman, in an article for the Canadian Psychiatry Association in 2007, you mentioned that it would be desirable to have 60 aboriginal physicians by 2020. You indicated today that there will be six, meaning four presently and two in the pipeline now as residents. Is it safe to say that we won't meet that target and, if not, what are the strategies that we need to employ to make sure we have those numbers? Is that number even adequate at this point?

[Dr. Cornelia Wieman]

I think from the point of view of aboriginal people who are trained as psychiatrists, we are almost non-existent. We're one-thousandth of 1% of the number of psychiatrists in Canada. So we're not going to meet any goal anytime soon, but it is an important question. We are graduating across the country a fair number of aboriginal individuals in medicine. We do much better in the western provinces, with British Columbia, Alberta, Saskatchewan, and Manitoba doing a much better job in that respect than the rest of Canada.

We do pretty well in Ontario to a certain extent—better than we did in the past—but by and large, graduates of medical school choose to specialize in family medicine. I'm always curious as to why people don't choose psychiatry, because the mental health needs of our communities are so great. I don't think there has ever been a study done on this. I'd like to do a survey of graduates and find out why it is that they don't pick psychiatry as a choice. It may have something to do with the fact that many aboriginal medical school attendees are mature students with families and family medicine training can be completed in two years following medical school, whereas psychiatry residency takes five years.

I don't know if that's part of it, and I also don't know if, again, it's because of that dynamic where as psychiatrists we can do things that are involuntary. We can hospitalize people against their will. We fill out form 1 certificates to hold people against their will. I don't know whether or not there's a reluctance to engage in that kind of health care where you have that kind of power, so to speak, over your patients and that it seems kind of paternalistic, or whatever it is.

What I would very much like to see as a solution, however, is psychiatry training programs across the country having a sub-specialty in rural and remote mental health care, including delivering services to first nations, Inuit, and Métis communities across this country. I think that may go a long way to attracting some aboriginal graduates of medical school into that form of training, but it also would train a cadre, so to speak, of psychiatrists who upon finishing their residency training would be willing to work in these communities and provide services where they're so desperately needed.

[Gary Anandasangaree, Liberal, Scarborough—Rouge Park, ON]

With respect to the urban indigenous population, do you believe that the current services available in places like Toronto and major cities are adequate and, if not, what additional services would be desirable?

[Dr. Cornelia Wieman]

I would say that the need in many cases outweighs the supports that are available. I myself don't work at the aboriginal mental health centre in downtown Toronto, which is called Anishnawbe Health Toronto, but they have a mental health program there. I think people would probably say—