Thank you. I too would like to thank you very much for the opportunity to appear before this committee.
CAMH, the Centre for Addiction and Mental Health, is the largest mental health and addictions facility in Canada. We're a teaching hospital fully affiliated with the University of Toronto, with central clinical and research facilities. We also have 26 locations around the province. We serve 20,000 unique individuals annually and we have a staff of about 2,700 people including 200 full-time psychiatrists.
CAMH operates in-patient facilities in downtown Toronto. About 30% of our beds—170 in total—are forensic mental health beds. We house clients within our forensic mental health program who have been referred to CAMH for psychiatric assessment, and some are on pre-trial treatment orders. The majority of the forensic mental health clients are people who the courts have concluded cannot be held criminally responsible on account of their mental disorder or are unfit to stand trial under part XX.1 of the Criminal Code.
These clients fall under the jurisdiction of the Ontario Review Board. Most of CAMH's review board clients live in the community, but we're responsible for monitoring and treating them according to the terms of the review board orders.
Stigma is a huge barrier to treatment and support. The vast majority of incarcerated individuals with mental illness or addiction are in federal or provincial correctional facilities, not in the forensic mental health system. Your committee has already heard testimony about the prevalence of mental illness and addiction within federal correctional facilities, as well as estimates of those who are able to access treatment and those who aren't.
I won't repeat those numbers, but it's important for the committee to know that all across Canada, across settings as diverse as prisons, schools, workplaces, and city streets, a large percentage of people who need treatment and support for their mental health or substance use problems don't get the help they need.
As is the case in federal correctional facilities, there's no single explanation for this gap in service. We know people often don't seek help or choose not to accept help that's offered, but we also know there's an overall lack of system capacity. Both of my co-presenters today have spoken to that.
While mental health and addictions account for roughly 13% of death, disability, and illness, it receives only 5% of Canadian public health care expenditure. All of these problems have their roots in stigma. We continue to see mental health and addiction problems as frightening, threatening, and shameful.
CAMH has addressed stigma in various ways, but the Mental Health Commission of Canada is very committed to addressing stigma. The commission has done extensive research on how best to confront stigma, and this research has led them to launch some highly targeted initiatives customized to particular audiences and settings.
There are anti-stigma initiatives that have been evaluated and proven to have an impact. One of those is offered by my own organization. I encourage your committee to connect with the work of the Mental Health Commission and explore the most effective ways to address stigma in the correctional culture among both staff and prisoners.
Mental health and substance use problems are complex. The roots of these problems defy simple explanation and the paths to recovery are diverse. These problems are, above all, health problems. And our focus must be on finding the most effective treatment and support to help individuals to heal, to take greater control over their lives, and ultimately, to be successfully integrated or reintegrated into the community.
The groundbreaking 2006 report of the Senate, Out of the Shadows at Last, recommended that the standard of care for mental health within correctional institutions should be raised to the equivalent of non-offenders in the community. This is a worthy objective and one that your committee may want to endorse.
The best treatment within correctional facilities must be rooted in the lives and experiences of the individual. For CAMH and many other addiction providers, this means that we offer health services and supports to people with substance use problems who are still using drugs, including illegal drugs.
Health interventions that do not require cessation of use as a precondition are sometimes referred to as harm reduction, and those interventions often generate considerable controversy. But I would say that the single most important test that harm reduction measures must meet is whether they make people healthier.
Initiatives such as needle exchange programs have been evaluated and proven to reduce the transmission of infectious disease. I believe that the decision about needle exchange programs should be based on the best available evidence about its impact on the health of the prison population.
Connecting to community resources post-incarceration is also important. Regardless of the type of treatment, connecting to community resources upon release from prison can be challenging. Federal inmates who are released on parole continue to receive services funded by Correctional Service Canada, often through community agencies providing contractual services. CAMH has a small program of this type, funded by CSC.
There is no question that continuity of care—particularly once the warrant has expired—is a challenge. Like everyone else, people released from custody must navigate a system of care that can be confusing and is often poorly coordinated, but they carry the additional disadvantage of an extra label. Ontario, and likely other provincial-territorial jurisdictions, struggle to develop the most effective way of connecting people to services. We know that effective, responsive case management can help solve this problem. But case management requires system capacity. Simply put, you have to have services that the case manager can connect to.
In its draft national strategy document, the Mental Health Commission reports that only one-third of people living with a mental health problem or illness get access to services and supports, and that the situation is worse for populations in rural and remote communities. One of the commission's recommendations is that there be “robust and well-coordinated monitoring of mental health status and measuring of performance”. Federal and provincial governments should be working together to monitor the ability of those leaving correctional facilities to gain access to appropriate treatments and supports.
In conclusion, I would say that the Mental Health Commission is developing a national strategy on mental health. A broad-based group that was convened by the Canadian Centre on Substance Abuse--of which I was part as a member of the Canadian Executive Council on Addictions, and which CAMH participated in--has developed recommendations for a national addictions strategy. One of the messages of both plans is the need for services to be seamlessly integrated across institutions, sectors, and settings to meet the needs of individuals.
This is a challenge for all of us who work in mental health and addictions care. It is of course particularly challenging for people emerging from correctional facilities who are likely to have both serious problems and inadequate connection to communities and the services they offer.
We have much work to do to develop services in correctional facilities that meet the needs of prisoners and that offer the continuum of care that we know can work. Canadians across all sectors must find ways to meet the growing demands of people with mental health and addiction problems. The growing demand for mental health and addiction services can be celebrated as testimony to lower levels of stigma and a far greater awareness of the impact of these problems. Meeting this demand will require both greater investment and greater integration of mental health and addictions supports and services with all health services.
Thank you for your attention. I’d be happy to answer questions.