Indigenous and Northern Affairs Committee on Oct. 24th, 2016

[The Chair, Liberal, Andy Fillmore]

We'll come to order.

Good afternoon. Welcome, everyone.

This is the House of Commons Standing Committee on Indigenous and Northern Affairs. We are today continuing our study of suicide among indigenous peoples in communities.

I'll just note to members that we're not broadcasting video today, but we are streaming audio.

Today we are hearing in the first hour from two individuals in the first panel. First is Dr. Amy Bombay, assistant professor in the Department of Psychiatry at a very august east coast institution called Dalhousie University, where I myself was once a faculty member. Joining her is Dr. John Haggarty, professor and chief of psychiatry at Northern Ontario School of Medicine.

Welcome to you both, and thank you for making time for us. We're very grateful.

I am happy to offer you each 10 minutes as we proceed.

Dr. Bombay, you have the floor.

[Dr. Amy Bombay, Assistant Professor, Department of Psychiatry, As an Individual]

Thank you so much for the opportunity to speak today. I'll be speaking mainly about the research I've been doing over the past 10 years looking at health inequities among indigenous peoples and at some of the pathways that contribute to the health inequities we see, particularly in relation to mental health.

Some of our research has focused on documenting the health inequities related to mental health. We really don't have a lot of data documenting these inequities across time, and so we don't really know, across different groups, how much worse or better this has become. From the data we have, we see that issues related to psychological distress, suicidal thoughts, and suicidal attempts are getting slightly worse over time and not necessarily getting better.

We compared non-indigenous peoples to first nations on and off reserve, Métis, and Inuit, and we see that first nations living on reserve present more than double the proportion of adults who are reporting suicidal thoughts. The rate is also higher in all of the other indigenous groups. We also note that within these groups, rates of suicide vary significantly across communities and across regions within Canada.

Some of our other research looks at documenting the long-term effects of certain collective traumas faced by indigenous peoples. Much of our work has looked at the long-term effects of Indian residential schools in relation to mental health outcomes.

Here I am showing you a graph representing the proportion of adults who report medium or high levels of psychological distress, based just on a self-reporting questionnaire. This is one of the few questionnaires that measure mental health across these different groups within national surveys that allow us to make some comparisons.

When we looked at this, we found that in the total Canadian population—which actually includes indigenous peoples, so that this number may be elevated a little—about one-third reported moderate or high levels of distress. We compared those findings with results for first nations adults living on reserve according to whether they or their families were affected by the Indian residential school system, and we found that all of those individuals who had a parent or at least one grandparent who attended, or who attended themselves, were at increased risk for psychological distress compared with first nations adults whose families were not affected. This is just to show that the schools affected not only those who attended but also their children and grandchildren.

We looked at that situation across a number of different studies, within both national representative samples and our own data, which we collected on and off reserve. Again we show that those who had at least one parent who went to residential school are at greater risk for reporting high levels of depressive symptoms. In the lower graph on this slide, we show that this was also the case for first nations youth living on reserve.

Already among youth aged 12 to 17 we see that these intergenerational effects of past collective traumas continue to put them at risk for these negative mental health outcomes.

Another goal of our research was to document and explore the pathways that contribute to this increased risk among those whose families have been affected by these major collective traumas. One of the major—and, I think, most intuitive—factors that contribute to this intergenerational trauma is the greater exposure to childhood adversities.

We found that those who had a parent who went to residential school were more likely to report a higher score when we were looking at cumulative exposure to various types of childhood neglect, various types of trauma, and various types of household dysfunction.

The greater risk for childhood adversities in turn put them at risk for experiencing more stress throughout their life. In the literature, this is referred to as a process called “stress proliferation”, where early-life trauma and trauma faced by one's parents continue to put someone at risk for more stress and more trauma throughout their life.

In addition to adult traumas, we found that those affected by residential schools also perceive higher levels of discrimination. Our research in this and other work points to the real negative effects of racism and discrimination on mental health outcomes among indigenous peoples, and not only in general interpersonal day-to-day experiences. There's also a lot of research showing that experiencing racism within the service-provider context in the health care system and within other systems can have even double the negative effects.

Another one of our major findings was that these past collective effects can actually accumulate across generations, so really, if we do nothing to address these intergenerational cycles, we can expect that the effects are only going to get worse.

We did a comparison as shown. These are all first nations adults living on reserve, again from a representative sample, and we compared those whose families had not been affected by residential schools to those who had a parent or a grandparent who attended and to those with a parent and also a grandparent who attended, so two previous generations. We showed that with each additional generation of a family that attended residential school, there was an increased risk of negative mental health outcomes.

We also wanted to see if that effect seemed to transfer to other types of collective trauma. We focused on the residential school system because it was really the only kind of major collectively experienced trauma that we have data on, and we could look at the negative outcomes. The large removal of indigenous children into the foster care systems is another major collectively experienced phenomenon that today contributes to negative outcomes in the same way that the residential school system does.

We showed that the more generations there are in your family that went to residential school, the greater the risk you're at for being removed into foster care at some point in your life. When we looked at the pathways that accounted for these increased risks, we found a kind of sequential relationship, where having a parent who went to residential school put those children at risk of growing up in a household with low economic stability and living in poverty. In turn, that low economic stability put them at risk of just not having a generally stable household. Even if it wasn't about abuse, it was about providing a stable household, which these parents just really couldn't do because of their familial residential school history. In turn, those people were more at risk for being taken into foster care, again really demonstrating the intergenerational nature of all of these environmental and collectively experienced traumas.

Our research looking at this has also found that same effect among youth living on reserve in relation to suicidal ideation and suicidal attempts. What we found is really interesting. When we split the groups up into those aged 12 to 14 and those aged 15 to17, we found that this effect was particularly evident in the younger age group, those aged 12 to 14, which suggests to us the extreme importance of early intervention. When we looked at adults in terms of those who reported suicidal ideation in childhood and youth, it was these individuals who continued to have mental health problems throughout their lives. We know that's also the case in the mainstream population and in the mainstream literature. Those with early onset of any type of mental health disorders are at risk for chronic problems throughout their lives, which really emphasizes the importance of addressing these early on.

In addition to identifying the risk factors that put those affected by residential schools at greater risk, we were also really interested in looking at the protective factors that can protect, because not all of those affected by residential schools do have depressive symptoms or other health problems.

I wanted to share some quotes from subjects in some of our studies in which we have done some qualitative research, just to hear in their own words what has been protective for them. This is from someone whose parent went to residential school.

She said:

I was ashamed growing up but I have since reclaimed my identity.... Now that I am on my own, I have more pride and I am learning to love my identity. I gave my son a traditional Ojibwe name and I vow to raise him to be proud of who he is.

In a lot of our research we constantly heard stories of cultural pride being a really important protective factor. When we looked at that in our quantitative data, we also found that cultural pride was really protective.

In this graph we looked at the negative effects of discrimination in relation to depressive symptoms among first nation adults, and we found a strong relationship. “In-group affect” is just the academic term for cultural pride. When we see those who have high in-group affect, so high pride, we see that those individuals are protected against the negative effects of discrimination. Their depressive symptoms don't shoot up when they perceive these high levels of discrimination. There's other evidence out there showing these protective effects of cultural pride and cultural engagement.

Our research has also really pointed to the importance of learning about historical trauma and learning about residential schools and learning about the foster care system, and how all of these things have affected indigenous peoples. I just want to share another quote on how continued learning about this is needed, because people are still just learning about how this has affected their families.

This person shared the following:

I found out when I was 27 that my father attended residential school, my sister told me. My father has never spoken to me about it. I read his court statements without his knowledge... and this is where I learnt about the sexual, physical, emotional, and cultural abuse he endured. I was deeply saddened, but it gave me an understanding of why my father behaves the way he does. lt helped me understand the cycle of abuse, because in turn he abused my mother and I. He learnt these behaviours in Residential School and could not cope so he turned to alcohol and so did I... but at the moment I am in treatment and dealing with these issues. I CAN break the cycle.

This is just a quick graph from, again, a representative sample of first nation adults. It points to the importance of traditional healers in dealing with mental health issues. Even though traditional healers are typically not part of the mainstream health system, about one in five adults still reports using traditional healers more often than other types of healers.

This graph shows the number of community projects aimed at healing as a result of the residential school system, and how, as the Aboriginal Healing Foundation was shut down, the availability of these services decreased over time. When we look at that compared to the proportion of adults affected by residential schools on reserve, we see that doesn't match up. We see that the proportion that has been affected themselves, either by attending or by having a parent or grandparent who attended, has not decreased since 2002, and that today our most recent data shows that more than half have been affected intergenerationally by residential schools.

[The Chair, Liberal, Andy Fillmore]

Dr. Bombay, we're not going to get through all of your slides.

[Dr. Amy Bombay]

That's okay.

[The Chair, Liberal, Andy Fillmore]

Do you want to hit the conclusion, and then we can draw out during the questioning whatever we've missed?

[Dr. Amy Bombay]

For sure.

That was pretty much it. I just wanted to end by sharing this graph showing that we really need a holistic approach to dealing with these issues. That's going to be different in different communities. It needs to address youth, but also the community, and supporting children and youth into the future.

Thanks.

[The Chair, Liberal, Andy Fillmore]

Okay, thank you so much.

Dr. Haggarty, let's move right into your presentation. Thank you.

[Dr. John Haggarty, Professor / Chief of Psychiatry, Northern Ontario School Medicine / St. Joseph's Care group, As an Individual]

Good afternoon. It's a pleasure to have a chance to meet with you and to be invited to participate in the discussion that has been under way for many years and will continue for some time.

I come to you both as a clinician and as part of now more active health care planning in northwestern Ontario. My clinical work with first nations dates back to the late 1980s and the early 1990s in Labrador, and subsequently as a resident in psychiatry and a researcher in Baffin Island and later Nunavut.

I also now work as a clinician in a collaborative care mental health service model. This is a model of care that I will speak to a little later on in regard to bringing specialty care to primary care locations, which is where much of mental health service gets delivered.

I've been involved with research in the area of indigenous suicide since the early 1990s, and there are a couple of points I want to highlight from both the work I've been involved in and Amy's presentation. These include some challenges to the traditional ideas of suicide and suicidal behaviour in first nation and Inuit communities.

Something that complements what Amy said is that in one study we undertook, we found traditional language maintenance to have a protective effect. There was clearly a difference, as was already pointed out in the data, in that when a community is able to maintain traditional language at a higher rate, there appears to be a lower rate of suicidal ideation and attempts and behaviour.

The other thing that's a bit of a counter to what I'd call a mainstream suicide study is that the presence of common mental disorders explains only a small percentage of variation in suicidal behaviour. In a study I undertook, we looked at two communities in the far north, and we found that although there was a very high incidence of suicidal ideation, less than 20% of it could be explained by the presence of common mental disorders that we were also looking at, such as depression, anxiety, and alcohol abuse.

This is a subtle but important consideration. It means that there are probably other factors in communities that could account for suicidal behaviour. Amy has spoken of this, and I'm sure Dr. Kirmayer will speak of it later. This is important, because when it comes to delivering clinical services, as clinicians we certainly know that mental disorders are a part of the suicide picture, but we have to clearly bear in mind that the social determinants of mental health and the social determinants of health are critical to understanding it. Some of these have been touched on.

I want to emphasize, without getting into the details, the work of Chandler and Lalonde, who published a number of articles on cultural continuity, which has been touched on already. As well, the adverse childhood events study by Felitti is, I think, important. These are highlighted in a number of places and it would be worthwhile for this committee to have as good a grasp of these as possible.

Amy touched on a number of issues, one of which is how generations pass on these effects. I'm not sure, but there may be a few biologists in the room here. The study of epigenetics is increasingly showing that there are biological reasons as to why the trauma that happens to a grandfather or grandparents may be passed on genetically through methylation of the key genetic coding within our own cellular structure.

This is an important phenomenon that is gaining in understanding. It was very gratifying to go to Fort Frances and be asked to talk about passing on trauma, and to then go to a talk, at the American Psychiatric Association meeting, about how the genome project has allowed us to understand many aspects of this. This is important for us to grasp. It's early days, but there is some understanding of what has been touched on. It's very powerful.

I won't touch on the Nunavut suicide strategy or the Pikangikum coroner's report, but I think these are important to have a full grasp of, because the advice is all there, and many of us would be repeating what has come from very bright people preceding us.

In the last few minutes that Andy lets me speak, as a program planner, a chief of psychiatry, and someone who has been involved in the determination of service modelling, I want to touch something on.

I gave a presentation a couple of Fridays ago in Thunder Bay to the Ontario Psychiatric Outreach Program and shared the idea of how we can create specialty service access in places like the Pikangikum nursing station or Pond Inlet. As we evolve the technology of service delivery, I think there are really creative opportunities that are low-intensity and potentially low-cost that we are certainly trying to look at and optimize.

Part of this arises out of the Auditor General's report on nursing stations, which talks about the need for specialist access, not just by having someone fly in but by having someone who can be contacted or having on-site resources that can be developed. I proposed possibilities to increase those, and I'll touch on those in a minute.

The Sachigo Lake study of first aid skills is an example, in our region of northwestern Ontario, of how you can develop a specialized skill in an areas such as crisis assessment and then capacity-build. The issue is how to sustain it, how to deliver it, and how to ensure that the nurse practitioners and RNs in these communities have these skills. I think these are critical.

I have one final point on policy and resources before I move on to a model of care. I sit on the Ontario child and youth mental health funding review committee. I think you folks are placed where this can really have an impact. The social determinants of health are highly impacted by the ability of policy and funding to drive change and create what has been called “equity plus”. That term comes out of a book, and it describes the idea that we are not just looking for fairness or equality but we are looking at, probably for some time, an enhanced funding formula that will need to give consideration to distribution of resources. I really think the social determinants of health highlight the importance. It's not just about health care delivery; it's about improving job opportunities and addressing poverty and housing.

I'll close with a couple of comments and highlight a few key things. I've had the opportunity to try to steal from across the country and from outside of the country some of the best service-delivery models. The conceptual draft model I am now entertaining with our local health integration network includes a few conceptual ideas that build upon a stable primary care system. Any discussion about enhancing health care has to be built on a stable primary care system, whether that's family doctors, nurse practitioners, or good nurses with solid skills.

In primary care, I think we are underperforming in a lot of avenues: in the development of a basic understanding of crisis assessment, in the skills to deal with suicidal ideation and in the skills to deal with basic depression and anxiety. Things like the CBIS model, which is a cognitive behavioural therapy model out of British Columbia, and DBT, which is an enhanced cognitive behavioural therapy model, deserve some community and cultural adaptation. I have had discussions with Dr. Mushquash in Thunder Bay about this, and maybe you've heard about it as well.

The RACE model in British Columbia—rapid access to consultative expertise—offers a model of care across a number of specialties. Someone calls and says, “I need to talk to someone who is a primary care provider in two hours to two days. Who do I call, and how do I do that?” It's possible. It has worked in British Columbia.

With regard to access, we are moving into the health care system delivery model. It started out of a cardiology and a family practice unit in Vancouver that said, “Why can I live next door to specialists who are 200 feet away and I can't call anybody?” It's something that is translatable anywhere in Canada, no matter how rural and remote.

The Ottawa e-consultation model is another model that says, if a family doctor or nurse practitioner doesn't need to speak to someone in two hours to two days but could do so maybe in the next three to seven days. It is looking at province-wide implementation in Ontario, and I think it should be given some consideration. It has been strongly piloted, with somewhere around 6,000 consultations in the four years it's been running in Ottawa. It is being piloted in our area of northwestern Ontario, and I look forward to seeing that happen.

As a primary care provider, if I don't need to speak to a specialist, how can I get assistance for someone with common mental disorders such as depression and anxiety that is adaptable to settings such as nursing stations. The case consultation or the ECHO mental health model, which is coming out of the Centre for Addiction and Mental Health, is an additional model.

What you are hearing me describe is a progressive pyramid of innovations that add to what exists currently, which is, for someone who is in a crisis and needs to be in a crisis bed at a hospital, either a “Form 1” or an elective consultation.

We don't seem to have a lot in between. We have an adaptation of e-consultations, rapid assessment, and the ECHO mental health program, which is an intensive mental health training program that is available for any primary care provider. Last, there is case consultation, which we've integrated across a number of NP clinics that I've been working with. I'd be glad to further discuss this model of psychiatric access, which I'd like to see implemented, that optimizes a lot of service-delivery innovations.

The last thing I want to talk about is PCVC. Anyone with a computer, as long as it has a little camera on it, can link up anywhere in the country that has WiFi to access a specialist on an encrypted network. I think this allows turning down some of the steam on a nurse practitioner sitting in an outlying community that has no road access, who can say I'm not sure how to manage this but I can put the patient in front of you if you'd like to help. We have a chance of having that with the available technologies, which are an enhancement of the telepsychiatry model that currently exists.

I'll pause there. Sorry for going over.

[The Chair, Liberal, Andy Fillmore]

That's okay.

Thank you for that, Doctors Haggarty and Bombay.

We're going to move right into a round of seven-minute questions. That includes asking the question and answering it. I would urge the committee members to come to their point as quickly as possible so we can hear from you.

The first question is from Mike Bossio.

[Mike Bossio, Liberal, Hastings—Lennox and Addington, ON]

We got a lot of information from both of you.

I want to talk to some of the cultural imperatives that seem to be coming out of a lot of discussions on mental health and the impact those can have toward giving individuals pride and hope.

That speaks to a lot of what you spoke about, Amy.

I'd like to know the level of importance cultural heritage and cultural connection have in indicating that where it's strong, the suicide rate is here, and where it's not strong, the suicide rate is there. Are you seeing a correlation there in different studies?

[Dr. Amy Bombay]

Across the different studies, culture can be measured in a lot of different ways. Language is one measure. That's been shown to be protective in relation to suicide and in relation to educational outcomes and other outcomes. That said, not all communities have their language, yet they have other strengths. Different aspects of culture will be protective for different communities.

For example, in northwestern Ontario some of the communities are trying to go back to their culture, and they have their own ways of doing that in line with their own cultural traditions, whereas some other communities aren't keen to go back to their cultural traditions as they've held on to their Christian religions. Even though these communities are pretty close together, the same kind of cultural approach is not going to work in both of them.

[Mike Bossio, Liberal, Hastings—Lennox and Addington, ON]

Are you seeing a correlation between those that have made that connection and lower rates of suicide?

[Dr. Amy Bombay]

It's going to be different across different communities. In some communities, you're going to see the strong link between language and positive outcomes. In other communities, you might not see that. Other aspects of their culture might be protective. Typically, various aspects of culture do seem to be protective according to the empirical literature.

[Mike Bossio, Liberal, Hastings—Lennox and Addington, ON]

Some may be land-based, or some may be art-based, as is the case in Haida Gwaii.

[Dr. Amy Bombay]

Exactly. Some have to do with political involvement. Some have to do with collective activism. People can try to enhance their cultural pride in various ways.

[Mike Bossio, Liberal, Hastings—Lennox and Addington, ON]

Have you seen that cultural connection in a lot of communities? In a lot of cases, they also have more empowerment, or self-government, in that they have a model of longer-term, stable funding associated with that, so they establish their priorities.

[Dr. Amy Bombay]

That's right. I think that's another aspect of the Chandler and Lalonde studies. There's been some question as to what they were actually measuring in those studies. Some of them were measuring cultural factors. Some of the others were more about having systems in place in self-government and self-run policing and self-run firefighting. Those aspects are just as important if not more important and they also act as a source of pride for communities when they're running them themselves in their own way.

[Mike Bossio, Liberal, Hastings—Lennox and Addington, ON]

John, I don't know if you want to comment at all on any of those points.

[Dr. John Haggarty]

No, I think that Amy summarized it well. Again, that early work was by Lalonde, and I think it would certainly be worth understanding what the categories were.

In one study we did in northwestern Ontario, we actually took his findings and made a checklist to say, “Okay, in communities A, B, and C, which ones match?” and we did a comparison. His findings were consistent with what we found in our part of the world, in our communities, with regard to the ability of communities to be in distress or to show signs of distress.

[Mike Bossio, Liberal, Hastings—Lennox and Addington, ON]

You'd also talked about early onset to make sure that you bring in therapies or consultations very early on in the process. Can you give us some particular examples as to what that might look like?

[Dr. Amy Bombay]

I think that's going to look very different in different communities, and it will be based on what they feel is going to be protective.

That graph shows increased risk among 12- to 14-year-olds, but we also know from the epigenetic research that intervening at times such as when the mother is pregnant, is important. Taking a developmental life course perspective and trying to intervene at some of those key developmental stages is really important. That starts with the mother at preconception and continues. I think that education has to do with just working with a community to see what particular issues are affecting it and working with it to find the answers.

[Mike Bossio, Liberal, Hastings—Lennox and Addington, ON]

John, you proposed numerous models around the social determinants of health and mental health, such as RACE, PCVC, ECHO mental health, and the Ottawa e-consultation. Do you think it's imperative that a lot of those be driven by indigenous communities to establish an indigenous presence, or counsellors, or local representation to really be effective?

[Dr. John Haggarty]

I don't think there can be any success without it becoming embedded within the community environment that's there. I think there has to be flexibility and there has to be some invitation to participate, but like anything that's been successful...no community that I've ever visited has said, “We're going to start totally from scratch, and we have no interest in dialogue and what works elsewhere”. Often it's “Talk to us about what you've done and what's worked, and find a way to make sure that it has cultural sensitivity and respect, and we'll make it our own or adapt it as we need to.”

[Mike Bossio, Liberal, Hastings—Lennox and Addington, ON]

And so—

[The Chair, Liberal, Andy Fillmore]

We will now move to Cathy McLeod.

Go ahead, please.