All-Party Committee Report — mentalhealth

pdfs_allpartycommittereport-mentalhealth

Newfoundland and Labrador — Committees

March 2017 Towards Recovery: A Report by the All-Party Committee on Mental Health and Addictions A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador

Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador

1 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Letter to Newfoundlanders and Labradorians The All-Party Committee on Mental Health and Addictions is pleased to present Towards Recovery: A Vision for a Renewed Mental Health and Addictions System.

The first of its kind to address mental health and addictions in Newfoundland and Labrador, the All-Party Committee was established in January 2015, as a result of a private member’s motion passed unanimously in the House of Assembly. The Committee is comprised of Honourable members from all parties elected to the House of Assembly. Towards Recovery is the culmination of consultation, review, analysis and collaboration by the All-Party Committee.

We heard from people throughout Newfoundland and Labrador who have experienced mental illness and addictions, their loved ones, advocates, community agencies, Indigenous communities, regional health authorities, health care providers and the public. We learned about the difficulties people face as they try to navigate the mental health and addictions system. People throughout our province are struggling to find safe and affordable housing. Long wait lists are keeping people from accessing the help they need in a timely manner.

It was particularly distressing to hear about the challenges faced by young people, aged 16 to 25, as they move from the child mental health system into the adult mental health system. Parents of adult children with a mental illness, such as schizophrenia, or a developmental disability, such as autism spectrum disorder, shared their worries with us about what will happen to their children when they can no longer look after them. Although the perspectives shared with us were often unique, the common message we heard was that having the conversation is not enough.

Action is needed now in order to better meet the needs of people in the province. We hope this report will be the impetus for transformation of the mental health and addictions system in Newfoundland and Labrador. With valuable assistance from the Newfoundland and Labrador Centre for Health Information, we recognized that what we heard fell into five common themes: • Need for improved mental health promotion and mental illness and addiction prevention;

2 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador • Better access to more services; • Better quality of care; • Need for improved policy and programming; and, • Need for strengthened community supports. Early intervention is essential. We must all have access to the right care, at the right time, in the right place.

System transformation will require the combined effort of all of government, working closely with the regional health authorities, health care providers, individuals with lived experience, their families and community agencies. Our vision, as described in this report, will take some time to achieve. However, we firmly believe that steady, incremental change will result in a better system to support improved mental health and well-being for Newfoundlanders and Labradorians.

We offer our sincere gratitude to each and every person who attended meetings, wrote to us, shared personal stories, identified problems, or suggested improvements. Your collective input has been invaluable. Respectfully, Hon. John Haggie Chair Ms. Gerry Rogers Mr. Steve Kent Hon. Sherry Gambin-Walsh Alternate Chair Mr. Bernard Davis Mr. Paul Davis Ms. Lisa Dempster Mr. John Finn Ms. Lorraine Michael Mr. Barry Petten

3 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Table of Contents

Summary of Recommendations ............................................................................4 Introduction ..........................................................................................................12 The All-Party Committee Review ........................................................................ 14 Vision and Values .................................................................................................15 Provincial Mental Health and Addictions System at a Glance .............................. 16 Areas for Change .................................................................................................19 Promotion, Prevention and Early Intervention .................................................19 Access to Services .........................................................................................26 Quality of Care ................................................................................................36 Policy and Programming .................................................................................40 Community Supports .....................................................................................49 Accountability and Performance Monitoring ........................................................51 Conclusion ...........................................................................................................52 Appendix A: All-Party Committee Membership ...................................................53 Appendix B: Expert Presentations .......................................................................55 Glossary of Terms ................................................................................................56

4 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador

Summary of Recommendations Promotion, Prevention and Early Intervention 1. Provide all young families with access to programs that focus on: • Parental coping skills to increase resiliency; • Parenting skills and child development; and, • Social and emotional competence of children. 2.

Develop and implement a comprehensive school health and wellness framework that includes evidence-based mental health promotion, prevention and integrated, early intervention programs in schools, which: • Focus on social and emotional learning; • Are embedded in curriculum at every grade; • Help students identify, understand and deal effectively with stress and anxiety; and, • Include content on diversity, social inclusion, social determinants of health and stigma reduction. 3.

Create regional interdisciplinary teams, reporting to the regional health authorities, to provide timely mental health and addictions assessment and treatment for students in schools. 4. Recommend the Premier’s Task Force on Improving Educational Outcomes review the roles of guidance counsellors, educational psychologists, social workers and instructional resource teachers (IRTs) to determine the best way to meet the mental health and addictions needs of students in the school setting and the resources required to do so. 5.

Encourage post-secondary institutions to provide evidence-based mental health promotion, prevention and early intervention programs for students during orientation and at various points throughout their programs. 6. Encourage community leaders to form coalitions to promote mental wellness, encourage people to seek help and prevent suicide.

5 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador 7. Eliminate the stigma and discrimination associated with mental illness and addiction in health care settings, schools, workplaces and communities.

This can be achieved through: • Providing contact-based education programs that involve people with personal experience telling stories of recovery and are supported with rigorous evaluation and sustained funding; and, • Encouraging increased uptake of Mental Health First Aid and expanding availability of this program throughout the province. 8. Some families with complex needs receive services from multiple government departments. Service managers at the regional level must be encouraged to develop mechanisms to work together to better meet the needs of these families. 9.

Prioritize supporting programs that use a housing-first approach to provide the required services to help people to stay well in their homes. 10. Amend the Residential Tenancies Act to provide authority to effectively deal with inadequate rental properties, including boarding and rooming houses. 11. Utilize e-mental health and technology-based interventions with a special focus on promoting wellness and early intervention for mild to moderate mental health problems. Access to Services 12. The Waterford Hospital must be replaced as an urgent priority.

While it is recognized that some type of infrastructure and in-patient services are needed, having them all located in one psychiatric hospital is not the answer. The Provincial Government must investigate options for replacing the existing hospital with in-patient services as well as more services provided in community and closer to home. These in-patient and community services should be identified in a plan within the first year of this report’s release. Services delivered at the Waterford Hospital must continue until new service options are in place. 13.

The Provincial Government must immediately ensure the reduction of wait lists and wait times in mental health for everyone by: • Immediately directing the chief executive officer of each regional health authority to reduce the wait list and wait times for mental health and addictions services,

6 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador including for psychiatrists (wait times not currently available for psychiatrists) within one year of the release of this report; • Developing a wait time reduction action plan, which will include a plan to address no-show rates to better accommodate the challenges faced by some individuals in attending appointments; • Adopting a standardized methodology for collecting and reporting wait times in all regional health authorities; and, • Providing provincial oversight and regular public reporting on wait times and wait time reduction progress. 14.

Through a stepped-care approach, develop and offer a range of mental health and addictions services integrated, wherever possible, within existing community and primary health care services throughout the province, including: • Self-management programs for mental wellness, anxiety and depression; • Counselling services; • Strongest Families Program for children, youth and their families; • Therapist-assisted, online, cognitive behavioural therapy for depression, anxiety and addictions; • Peer support; • Provincial Warm Line; • 24/7 access to medical withdrawal management; • Day treatment programs; • Access to in-patient services for eating disorders; • Single session walk-in clinics; • Assertive community treatment (ACT) teams; • Mobile crisis intervention teams; • Dedicated mental health services for first responders, including ambulance personnel, firefighters, police officers and correctional staff; and, • Support for families and caregivers of people living with mental illness and addiction. 15.

Provide access to evidence-based services via technology (telehealth, telephone, online, text, virtual reality and social media). 16. Increase access to counselling services for inmates in correctional facilities. 17. Assign responsibility for the provision of health services in prisons and the associated funding to the health and community services system, to improve mental health and addictions services and supports for inmates.

7 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador 18. The physical state of Her Majesty’s Penitentiary is negatively impacting the mental health of inmates and staff. The building design and physical space are not conducive to providing quality mental health and addictions programs and services. Therefore, government must prioritize the completion of a new facility to replace Her Majesty’s Penitentiary. 19.

Review the eligibility criteria for community support services and increase access to interventions with proven effectiveness for the treatment of autism spectrum disorder and other developmental disabilities. 20. Ensure primary health care providers have access to mental health and addictions consultation and specialized services for their patients. 21. Provide online information about the mental health and addictions services and how to navigate them. 22.

Conduct a review of the benefit status, special authorization criteria and process under the NLPDP for both attention deficit hyperactivity disorder and neuroleptic medications to determine if changes are required to ensure appropriate and timely access. 23. Advocate for better health insurance programs from personal and employer-funded health insurance providers to align the plan’s provisions with the individual’s needs. Quality of Care 24.

Prioritize the transition to recovery-focused, person-centered care for all mental health and addictions services and staff by: • Continuing to support the already established Recovery Network, a group of almost 200 staff, physicians and individuals with lived experience throughout the province, and ensuring the network helps guide the direction of recovery for the mental health and addictions and correctional systems; • Incorporating the ongoing workshops in recovery, that are taking place across the province, into required training for new and existing staff in both the health and correctional systems; • Addressing compassion fatigue, stress and burnout in staff; and, • Involving staff and individuals with lived experience of mental illness and addictions, and incarceration, in the development, implementation, monitoring and evaluation of guidelines for a recovery-focused approach for all mental health and addictions and correctional services staff.

8 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador 25. Support the implementation of the Choosing Wisely Guidelines for prescribing psychiatric medication in the province. 26.

Encourage and provide opportunities for health care, correctional staff and police to avail of existing education and training modules in mental health and addictions, and implement new ones where needed, that include opportunities for networking, mentoring and skill building. 27. Require professional regulatory bodies to mandate ongoing mental health and addictions continuing education requirements for their members. 28.

Recommend, as part of the provincial Personal Health Information Act Statutory Review, that consideration be given to amending the legislation to ensure family members and caregivers providing support to, and often living with, an individual with a mental illness or addiction, have access to the appropriate personal health information necessary to provide that support. 29. Develop standards and guidelines, which recognize the critical role of families and caregivers, and provide guidance to staff on how to support families and caregivers, and include them, wherever possible, in treatment decisions. 30.

Provide web-based information on education, self-care and self-management for families and caregivers. 31. Ensure primary health care providers have improved access to information about programs and services to share with families. 32.

Increase the number of physicians and nurse practitioners involved in addictions medicine by: • Encouraging Memorial University’s Faculty of Medicine to create a Clinical Program Director of Addictions Medicine within the Discipline of Family Practice; and, • Encouraging the development of a network of physicians and nurse practitioners to provide opportunities for continuing medical education, consultation and mentorship in addictions medicine.

9 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Policy and Programming 33. Adopt harm reduction as a foundational approach to the provision of mental health and addictions services. 34. Support Indigenous people to achieve their mental wellness goals by providing resources to assist with sustained land-based programming. 35. Ensure psychiatrists provide regular visits to Labrador coastal communities, as needed. 36.

Establish four to six dedicated mental health beds in Labrador, which will include services that are inclusive and culturally appropriate for all Labradorians. 37. Prioritize the recruitment of two permanent full-time psychiatrists (while establishing a sustained commitment for regular locum coverage) to ensure psychiatric coverage for: • New mental health beds in Labrador; • Emergency departments in the Labrador Health Centre and Labrador West Health Centre; and, • Out-patient clinics for Labrador West and Happy Valley-Goose Bay. 38.

Provide general education to community leaders and policy makers, with a specific focus on seniors’ mental health to increase understanding of aging and mental health, stigma and ageism. 39. Provide specialized training for people who work one on one with seniors. This must include family physicians; nurses; ambulance personnel; counsellors; and, individuals who work in the areas of primary health care, mental health and addictions and long- term care and supportive services. 40. Develop standards, policies and programs specifically to address mental health and addictions gender-based needs. 41.

Provide general education to community leaders and policy makers, with a specific focus on LGBTQ2S youth, to increase understanding of sexual orientation, gender identity and mental health concerns. 42. Provide specialized training for people who work one on one with LGBTQ2S individuals. This must include physicians, nurses, community and school-based psychologists, teachers, counsellors and social workers.

10 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador 43. Continue to support the implementation and evolution of the provincial Opioid Action Plan. 44. Increase provincial mental health and addictions spending from approximately 5.7 per cent of the total annual health care budget to nine per cent in five years (by April 2022), to better align with the recommended national average. 45.

Develop a comprehensive, government-wide inclusion policy to be applied to all mental health and addictions services to ensure the diverse needs of all populations are recognized and addressed. 46. Establish standards for youth transitioning into adulthood (16-25 years old) that include a requirement for collaboration and evidence-based practices so that programs and services are geared to young people’s needs wherever they live. 47.

Develop specific provincial action plans for: • Alcohol abuse, which would include a focus on promotion and prevention, as well as screening, brief intervention and referral; and, • Suicide prevention, with the aim of reducing stigma and empowering communities to build resilience and inclusiveness. 48. The Provincial Government must adopt a health-in-all-policies approach to ensure health impact considerations are built into all policy decisions. Community Supports 49.

Regional health authorities and community agencies must work more closely together to ensure smooth service delivery for individuals by: • Strengthening existing partnerships (and creating ones where they do not formally exist) through regular communication, meetings and sharing education, strategic planning and other opportunities for engagement; and, • Using change management principles to set the expectation that community agencies and regional health authorities share non-confidential information and consult each other on the evolving needs of individuals and how best to meet them. 50.

Develop adequate multi-year funding models for community agencies.

11 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Accountability and Performance Monitoring 51. Develop and publicly release an implementation plan for the recommendations in this report by June 30, 2017. 52. Establish an accountability and performance monitoring framework to track results of the implementation plan. 53. The Minister of Health and Community Services must report publicly on the implementation of the report’s recommendations.

The first report must be released 6 months after the release of this report, with subsequent reports released at 12 and 24 months. 54. Revise the mandate of the Provincial Mental Health and Addictions Advisory Council to include oversight for the implementation of the recommendations in this report.

12 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Introduction Mental illness or addiction touches almost everybody in Newfoundland and Labrador either directly or through family, friends or co-workers. In any given year, one in five people will experience a mental illness or addiction. The chance of developing a mental disorder over the life span is close to 50 per cent.

Anxiety disorders affect about 12 per cent of Canadians in any given year –––––– Anxiety disorder and major depressive disorder are the most common forms of mental illness. Depression will be the second leading cause of disability by 2020. Other mental illnesses, such as post-traumatic stress disorder (PTSD), eating disorders and borderline personality disorder have become part of public discourse as people with these disorders talk about their difficulty getting help. Canada is currently facing an opioid crisis. The Provincial Government has responded by implementing an Opioid Action Plan.

While prescription drug abuse is a real concern, alcohol dependence remains the most common form of addiction. In 2014, Newfoundland and Labrador exceeded the national rate of heavy drinking, with the third highest heavy drinking rates in the country, exceeded only by Yukon and Northwest Territories. The 2014-15 Canadian Student Tobacco, Alcohol and Drugs Survey reported that in the previous 12 months, 44.6 per cent of students, Grades 7 to 12, in Newfoundland and Labrador drank and 30.1 per cent reported binge drinking.

The Federal Government is preparing to introduce legislation in spring 2017 to legalize cannabis. Significant education and awareness efforts will be required to ensure that people, and particularly young people, are aware of the consequences and health concerns associated with cannabis use. Only about 40 per cent of people affected by mental illness and addiction seek help. This is largely due to the stigma surrounding mental illness and addiction.

A 2014 Mental Health and Addictions Anti-Stigma Survey indicated that while between 67 and 79 per cent of Newfoundlanders and Labradorians would be very likely to discuss a physical illness, only between 44 to 54 per cent would be very likely to discuss a mental illness or addiction.

13 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador People not seeking help may also be attributed, in part, to long wait lists and difficulty finding services in a complex health care system. As efforts to reduce stigma, raise awareness and improve system navigation occur, the demand for services continues to grow.

About 500 times each year in Newfoundland and Labrador, a person with a mental illness is detained against her or his will and brought to a psychiatric facility. On about 175 of those occasions, he or she is hospitalized involuntarily under the Mental Health Care and Treatment Act and given psychiatric treatment without consent. Involuntary psychiatric hospitalization is coercive and usually includes detention in a locked facility. A small number of individuals who have been detained involuntarily will be placed on a community treatment order, which mandates treatment within the community.

Given the restrictive nature of such orders, it is imperative that they are rigorously monitored to ensure the individual’s rights, as outlined in the legislation, are protected. Although there have been significant efforts made in recent years to enhance the provincial mental health and addictions system, there is still much more work to be done. Specifically, there is a need for increased mental health and addictions promotion and prevention and early intervention efforts; better access to more services and supports; better quality of care; improved policy and programming; and, strengthened community supports.

The mental health and addictions system must offer a broad range of services to provide the best possible opportunities for recovery. Transforming current services into an integrated, person-centered and recovery-focused system is not a simple task. However, it is possible. Collaboration between Provincial Government departments, staff in regional health authorities, other health care providers, community agencies and people with lived experience and their families will be critical. Redesign of the system to prioritize peoples’ needs is essential.

Silos must be broken and everyone has to work together to create an environment that will encourage innovation to address system gaps and find creative solutions to problems. “To continue to rely on crisis response systems means we will be paying the highest cost for the poorest outcomes and, consequently, we can expect to face exponentially higher costs in the future.” Provincial Mental Health and Addictions Advisory Council

14 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador The All-Party Committee Review The All-Party Committee’s (the Committee) mandate was to conduct a full review of the provincial mental health and addictions system to identify gaps in services and areas for improvement. Please refer to Appendix A for a full list of current and former committee members.

The Committee heard from 69 mental health and addictions community-based groups, received 70 public presentations from individuals, families and organizations and held round- table sessions with 292 participants. In addition, the Committee received approximately 120 online and written submissions. Information and input received from the public consultation sessions can be viewed online at www.BeHeardNL.ca.

Meetings were held throughout the province with: • Community groups, health care providers, advocates and individuals and families with lived experience of mental illness and addiction; • Indigenous communities; • Local and national mental health and addictions experts; and, • Senior leadership and staff in the four regional health authorities and correctional system. Consultation sessions took place in Clarenville, Corner Brook, Grand Falls-Windsor, Happy Valley-Goose Bay, Labrador City, Marystown, Nain, Sheshatshiu and St. John’s.

The sessions were well attended and provided an important opportunity for people to share their personal experiences and perspectives. The Committee met with senior leadership teams and mental health and addictions staff in each of the regional health authorities, as well as correctional staff and police agencies. Members learned about what is working well and some of the systemic challenges faced by staff in both the mental health and addictions and correctional systems.

Committee members toured health care facilities, residential treatment centres, Her Majesty’s Penitentiary (HMP) and the Newfoundland and Labrador Correctional Centre for Women. The Committee heard from the Miawpukek First Nation in Conne River, as well as residents and members of the Nunatsiavut Government, Innu Nation and NunatuKavut Community Council in Labrador.

15 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Meetings were also held with the Newfoundland and Labrador Centre for Health Information (NLCHI), the Mental Health Commission of Canada, the Canadian Centre on Substance Abuse and Memorial University’s Faculty of Medicine. For a detailed list of expert presenters and topics, please refer to Appendix B.

Vision and Values The recommendations in this report support the implementation of an integrated, person- centered and recovery-focused system that provides the right care, at the right time and in the right place. The following vision and values should guide both the implementation of the recommendations and the delivery of mental health and addictions services in the province. Vision A province that promotes positive mental well-being and resilience and supports individuals and families with lived experience of mental illness and addiction to live full and rewarding lives.

Values Respectful Service delivery must be sensitive, compassionate and free from stigma and discrimination. Person-centered Priority in the delivery of services and treatment must be given to services that meet the person’s needs. People must be encouraged and allowed to be partners in planning their own care. Accessible Appropriate services must be available when needed and as close to home as possible. Recovery-focused Programs and services must instill hope and empower people to seek mental health and well-being.

16 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Collaborative Government, community agencies, health care providers and individuals and families share responsibility for improving service delivery. Effective and Efficient Service delivery must be evidence-based and sustainable. Services must be regularly monitored and evaluated to ensure the best possible health outcomes with the best use of resources.

Responsive Appropriate screening and assessment must be accessible at the first sign of a mental health or addictions issue. Provincial Mental Health and Addictions System at a Glance In Newfoundland and Labrador, 37 per cent of the total 2015-16 provincial budget was allocated to health care. The regional health authorities spent 5.7 per cent ($135.9 million) of their total expenditures on mental health and addictions in that timeframe. This does not include other public expenditures, such as MCP and prescription drugs.

The national average for public health care spending on mental health and addictions is approximately seven per cent. In 2012, the Mental Health Commission of Canada called for Canadian health systems to increase the amount spent on mental health to nine per cent of health spending over 10 years. The annual economic cost of mental health and addictions-related issues in Canada is $51 billion –––––– Newfoundland and Labrador has four regional health authorities that provide direct services for individuals who experience mental health and addictions challenges.

Regional health authority services are supplemented by other health care providers, including fee-for-service physicians, psychologists, social workers, pharmacists and community agencies. There are over 900 dedicated and highly-skilled mental health and addictions staff in the province. In communities where there is no psychiatrist, access to a psychiatrist is available through telehealth.

17 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador While provincial mental health and addictions services span a full continuum, from promotion and prevention, to early intervention, treatment and aftercare, gaps in services exist.

An ideal continuum would include a variety of the following programs and services offered in person or electronically (online, by telephone, or video conference/telehealth): • Promotion, prevention and early intervention, including counselling, self-help and peer support for mental health and addictions; • Screening, assessment and early intervention; • Emergency services; • Acute, in-patient psychiatric services; • Specialized services, including assertive community treatment (ACT) teams, forensic mental health services and opioid addiction treatment; • Adult and youth residential treatment centres; and, • Programs and supports specifically for youth, women and seniors.

Mental health and addictions referrals are steadily increasing in each of the four regional health authorities. On average, there are 20,000 referrals yearly; approximately 12,000 calls placed to the 24/7 provincial Mental Health Crisis Line; and, about 3,000 admissions to in-patient mental health and addictions services, 15 per cent of which are for treatment of concurrent mental health and addiction disorders. The Mental Health Crisis Line is a confidential and free telephone-based helpline for people experiencing mental health problems.

It is available to anyone in the province 24-hours-a- day, 7-days-a-week by calling toll-free 1-888-737-4668. As our understanding of mental illness continues to evolve and the mental health and addictions issues facing the population continue to change, so must the mental health and addictions service delivery system. Significant efforts have been made over the last few years to improve access to specialized mental health and addictions services for the most seriously ill.

While this is still important, new treatment methods and best practices, nationally and internationally, now go beyond traditional, office-based counselling and admission to psychiatric units. Ultimately, there will need to be a heightened focus on a community-based system that places strong emphasis on health promotion and prevention, as well as treatment, recovery and peer support, delivered through an integrated primary health care model.

18 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador What’s Working Well People praised the work of community groups, such as the U-Turn Centre, Stella’s Circle, CHANNAL, Turnings and Narcotics Anonymous; as well as regional health authority services, such as Blomidon Place in Corner Brook, the day treatment program at St. Clare’s and the Hope Valley youth treatment centre in Grand Falls-Windsor.

The Committee heard that the assertive community treatment (ACT) teams provide an important service. Many people expressed their appreciation for the compassionate and skilled staff they had met. People spoke favourably about the increased public awareness of the importance of mental health, aided by various public campaigns in recent years. “The Summit Program is so supportive to my son and less pressure and worry to me as a caregiver.” Participant People also indicated they believed stigma had been reduced but needs to be eliminated.

Mental Health First Aid was provided as an example in almost every meeting as a program that reduces stigma and empowers people with the ability to recognize and respond to an individual in a mental health crisis. Individuals were also readily able to acknowledge programs and services that are working well and regional health authority and community agency staff who have made a positive difference in their lives. “Humberwood Treatment Centre is very helpful and the group sessions there have been helpful. Very compassionate and caring.” Participant “There is a peer support group here in Labrador.

It’s offered through the Salvation Army. Important to hear from individuals who have experienced it.” Participant

19 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Areas for Change The recommendations that follow are reflective of what the Committee heard during the consultations. Some of the recommendations are new, others build on work already being done and all are actionable and measurable. Promotion, Prevention and Early Intervention Mental health is not just the absence of mental illness. It is how a person thinks, feels and interacts with others.

It is as important as, and strongly linked to, physical health. Research shows that poor mental health is a significant risk factor for chronic physical conditions. Likewise, people with chronic physical conditions are at a higher risk of experiencing mental health problems, including addiction. “There is no health without mental health.” World Health Organization The social determinants of health, such as income, social status, education and social support networks, significantly influence mental health.

Income is one of the strongest social determinants as it influences the quality of other determinants, including housing, food security, education, physical activity and tobacco and alcohol use. A growing body of evidence strongly suggests that higher social and economic status is associated with better health. As income rises, health care needs generally decrease. Taking action to improve the social determinants is essential to promote mental health and well-being and prevent mental illness and addiction.

Homelessness, poverty, unemployment and low literacy put people at much greater risk for developing mental health and addictions issues. Likewise, mental illness and addictions can negatively influence an individual’s ability to find safe and stable housing, gain employment and earn adequate income. The Provincial Mental Health and Addictions Advisory Council emphasized to the Committee the importance of ensuring that issues associated with low income and poverty be considered in all government decision-making.

The need for multiple government agencies, which often serve the same families within the same regions, to work better together was also raised. Among people with the most severe and complex mental health problems and illnesses, unemployment is estimated at between 70 and 90 per cent ––––––

20 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador For some individuals with mental illness and addictions, providing counselling is not enough. Research shows that access to safe and stable housing, social supports and employment significantly improve quality of life.

The Committee heard stories about people who are living in deplorable and unsafe housing and about recipients of income support who have very little money to pay for the necessities of life, such as food and clothing, once rent is paid. One case manager described feelings of hopelessness and despair after dropping a person off to a boarding house and seeing firsthand the living conditions. The Committee also heard from people with mental illness and addictions who are not able to access housing at all, as landlords have refused to rent to them. Hospitalization can disrupt housing arrangements.

People may be placed in shelters, or short-term housing until they have supports in place, such as a case manager, or until they are stabilized on medication. Many times, people with severe mental illness or addiction never find a place to call home and spend most of their lives moving from one temporary housing arrangement to the next.

Improved access to housing and community-based services can improve quality of life and help to keep people living with mental illness and addictions out of hospitals and out of the criminal justice system –––––– The Committee heard about how difficult it is to get well and recover when there is constant worry about finding a comfortable place to live. Many people described situations where a person leaves hospital or a treatment centre to live in a boarding house with no privacy, dilapidated conditions and possibly violence and drug use.

Most programs provide only temporary housing and only when the person is in treatment and doing well. However, research shows better results when barrier-free housing is provided as the first step (known as a housing-first approach), even before individuals are stabilized on medication or in recovery from an addiction. When health services are offered and the housing situation has been stabilized, health outcomes are better. Providing individuals with a place to live first increases their opportunities to get well.

People with safe and stable housing have fewer hospital admissions and emergency room visits. “We are really failing with poverty and housing. These are huge barriers.” Participant People living with mental illness and addictions often face stigma from members of the public, friends, family, coworkers and even from staff in the health care system they look to for help. Stigma and discrimination affect all areas of life, including education, employment

21 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador and housing. Stigma prevents people from seeking help and impedes access to the support networks and treatment needed for recovery. Stigma in the workplace is an issue as individuals are reluctant to disclose a mental illness or addiction for fear of being looked down upon, passed over for a promotion, or losing their job.

Addressing stigma requires more than simply increasing awareness of the problem. The most effective way to reduce stigma is through the delivery of education programs where people with mental illness and addictions share their personal stories of hope and recovery. This is known as contact-based education. Another effective method of reducing unintentional stigma and the resulting discrimination, is to change legislation and policies that are stigmatizing.

People living with mental illness or addiction often say that the stigma is worse than the illness itself. “People who have walked in these shoes can teach and educate others, including health care providers.” Participant Approximately 70 per cent of mental health problems begin in childhood or adolescence. A staggering 1.2 million Canadian children are affected by mental illness. Even more surprising is that less than 20 per cent receive appropriate treatment.

Clearly, it is crucial to build a solid foundation for healthy social and emotional learning and resilience for children and youth in Newfoundland and Labrador. Infants, children and youth are easiest reached at home, daycare or school. It is important for educators to have appropriate training and support to allow them to deliver effective early childhood and school-based promotion, prevention and early intervention programs.

The Newfoundland and Labrador Counsellors’ and Psychologists’ Association strongly advocated to the Committee about the need for more mental health resources in schools, particularly school counsellors and educational psychologists. “We need to be intervening early. It’s critical. Emotional and behavioural responses are formed in the early years. They become more resistant to change.” Participant Only 23 per cent of Canadians would feel comfortable talking to their employer about a mental illness ––––––

22 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador The health and community services and education systems must work together to improve the mental health and wellness of students. While the provision of more resources is likely required, it is important to understand what resources currently exist and how they are being used, to determine where additional resources are required and what resources will best meet the needs of students.

The Committee met with the Premier’s Task Force on Improving Educational Outcomes, which is currently examining the K-12 education system in the province. The Task Force has been directed to consider specific areas, including student mental health and wellness, and is expected to submit a report this spring. “In the school system, we are catching grenades.” Participant Suicide is one of the top 10 causes of death in Canada. Suicide is a serious public health issue and one that still carries shame, fear and stigma.

The rate of suicide in this province in 2012 was 9.2 people per 100,000 population, compared to the national average of 11.3 people per 100,000 population. For the five-year period between 2009 and 2013, the suicide rate for Nunatsiavut was 275 people per 100,000 population. This is 25 times higher than the national rate and the highest among Inuit regions in Canada. Preventing suicide is everyone’s responsibility and communities must play a role in providing supportive and inclusive environments.

The promotion of good mental health, prevention of mental illness and addictions and reduction of stigma are all key contributors to well-being and suicide prevention. “There is an increasing rate of young adult suicide here. We seem to have increasing numbers of youth seeking help and we need to know why.” Participant The Committee heard about the importance of putting more focus on the promotion of positive mental health and the prevention of mental illness and addictions, especially for young families.

This includes the need for more programs and supports to be available throughout the life course—before birth, in early childhood, during school years, in adulthood and in the senior years. Early intervention is crucial. At the first sign of a mental health or addictions issue, action needs to be taken to help prevent the issue from worsening. Early intervention will not only significantly improve quality of life, but also provide substantial cost savings for the health care system.

23 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Promotion, Prevention and Early Intervention Recommendations 1. Provide all young families with access to programs that focus on: • Parental coping skills to increase resiliency; • Parenting skills and child development; and, • Social and emotional competence of children. 2.

Develop and implement a comprehensive school health and wellness framework that includes evidence-based mental health promotion, prevention and integrated, early intervention programs in schools, which: • Focus on social and emotional learning; • Are embedded in curriculum at every grade; • Help students identify, understand and deal effectively with stress and anxiety; and, • Include content on diversity, social inclusion, social determinants of health and stigma reduction. 3.

Create regional interdisciplinary teams, reporting to the regional health authorities, to provide timely mental health and addictions assessment and treatment for students in schools. 4. Recommend the Premier’s Task Force on Improving Educational Outcomes review the roles of guidance counsellors, educational psychologists, social workers and instructional resource teachers (IRTs) to determine the best way to meet the mental health and addictions needs of students in the school setting and the resources required to do so.

Sample Action: Strengthening Families is an evidence-based family skills training program found to significantly improve parenting skills and family relationships, reduce problem behaviours, delinquency and alcohol and drug abuse in children and to improve social competencies and school performance.

24 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador 5. Encourage post-secondary institutions to provide evidence-based mental health promotion, prevention and early intervention programs for students during orientation and at various points throughout their programs. 6. Encourage community leaders to form coalitions to promote mental wellness, encourage people to seek help and prevent suicide. 7.

Eliminate the stigma and discrimination associated with mental illness and addiction in health care settings, schools, workplaces and communities. This can be achieved through: • Providing contact-based education programs that involve people with personal experience telling stories of recovery and are supported with rigorous evaluation and sustained funding; and, • Encouraging increased uptake of Mental Health First Aid and expanding availability of this program throughout the province.

Sample Actions: The Labrador West Community Coalition is a coalition of town councils, employers, unions, police, Labrador-Grenfell Health and others who are working together to help promote mental wellness, decrease stigma and prevent suicide in their communities. The Mental Health Commission of Canada has several evidence-based programs for health care settings, schools and workplaces. The Front Step, developed by End Homelessness St.

John’s and jointly-led by Choices for Youth and Stella’s Circle, provides housing and supports to individuals experiencing the longest and most frequent episodes of homelessness in the community. Strongest Families is an evidence-based program that offers online or telehealth services to children and families seeking help for mental health or behavioural issues.

25 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador 8. Some families with complex needs receive services from multiple government departments. Service managers at the regional level must be encouraged to develop mechanisms to work together to better meet the needs of these families. 9. Prioritize supporting programs that use a housing-first approach to provide the required services to help people to stay well in their homes. 10.

Amend the Residential Tenancies Act to provide authority to effectively deal with inadequate rental properties, including boarding and rooming houses. 11. Utilize e-mental health and technology-based interventions with a special focus on promoting wellness and early intervention for mild to moderate mental health problems.

26 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Access to Services Timely access to mental health and addictions services is a problem in this province. Stigma, wait lists and service gaps often compound the problems people face as they try to access help. Geography and difficulties in recruiting and retaining health care providers in some communities also pose challenges to providing access to a full range of services.

Mental health and addictions referrals are steadily increasing in the province. Despite efforts to simplify referral processes, centralize intake and introduce group treatment options, referrals continue to outpace the ability to provide timely service. The Committee heard repeatedly about issues with Eastern Health’s central intake process. While some services have no wait times and wait times for other services have been reduced, those services that have long wait times are keeping people from getting the treatment they need in a timely manner.

In fact, the number of people who were waiting for mental health and addictions counselling services increased by about 56 per cent between September 2014 and September 2016.

At the end of September 2016, there were approximately 3,000 people throughout the province waiting for mental health and addictions counselling, not including psychiatry services. “Mental health and addictions issues don’t do well on wait lists.” Participant Psychiatrists are physicians who have completed specialized training in psychiatry, a branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional and behavioural disorders.

Psychologists, on the other hand, study how people think, feel and behave and apply this knowledge to help people understand, explain and change their behaviour. The treatment of mental illnesses, such as bipolar disorder, may require a combination of medication prescribed by a psychiatrist and psychotherapy provided by a psychologist. Wait times vary by individual psychiatrist. The Committee heard that, in some cases, people are waiting as long as 24 months for psychiatry services.

This may be because there is no centralized process for referral and intake for psychiatrists, as these services are managed separately from other mental health and addictions services. It is impossible to determine whether individuals who have been referred to see a psychiatrist have been referred to the most appropriate service for their level of need.

27 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador In some communities, there is no psychologist available. In other communities, the wait time to see a publicly-funded psychologist for non-urgent mental health issues is lengthy.

People with private health insurance or the means to pay for services themselves are usually able to access services much sooner than individuals without insurance or sufficient financial resources to pay privately. “Have to wait 18 months to see a psychologist for first-line treatment.” Participant Many people in need of help for mental health and addictions issues do not know what services are available to them. Likewise, individuals who are aware of programs and services do not always know where to find them.

This is further compounded when multiple government departments or community agencies have to be accessed to receive necessary services. While there is substantive knowledge about programs among some health care and education providers, others told the Committee that they are not aware of all of the services available.

In order to ensure people receive the right care, at the right time, in the right place, health care providers and the public need readily available information on how to get help. “When people can actually find out about or reach the services, most are quite good and can/will help people.” Participant Medication is an essential component of a full range of treatment for some individuals living with mental illness and addictions.

While medication costs are covered for people in hospital, prescription costs outside of hospital are only publicly covered if an individual is eligible for coverage under the Newfoundland and Labrador Prescription Drug Program (NLPDP). Some people have coverage through employer-provided private insurance and some people have purchased their own insurance. However, private health insurance plans vary in terms of coverage and while certain medications and services are covered under one plan, they may not be covered under another plan.

Many people must pay out of pocket, or do without the medication they need. “There are lots of specialized first-line drugs but problematic rules with NLPDP.” Participant

28 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Given that not all medications are covered under the NLPDP or private insurance plans, access to certain drug treatment therapies, such as Concerta, a first-line treatment for attention deficit hyperactivity disorder, is limited. Generic versions of Concerta are available under special authorization with the NLPDP; however, for some patients, physicians prefer the brand option to the generic version.

The NLPDP has a special authorization process that allows physicians to request coverage for other medications. Once particular criteria have been met, medications on the benefits list can be covered. The Committee heard that physicians and NLPDP beneficiaries are frustrated with the process and particularly with the amount of time it takes to receive a response to a special authorization request.

Canada remains the only country in the world with a public health care system that does not cover the cost of prescription medications –––––– The mental health and well-being of young people is of great concern to the Committee. The Committee was informed about the alarming number of youth who have had suicidal thoughts and suicide attempts. It heard about young people who died by suicide following attempts to access help. There have been recent media stories about how difficult it is for people with borderline personality disorder to get help.

Access to mental health services for young people is complicated by the fact that while most mental illness begins in childhood, the early signs are often not recognized or addressed. Committee members also heard that families in the child protection system have difficulty accessing mental health and addictions services and that this is having a negative impact on children and youth. For young people, aged 16 to 25 years old, seeking help for the first time for a mental health or addictions issue, it is particularly challenging.

The needs of these young people often cannot be met by either the child or adult systems. There are very few services dedicated to this age group. Young people who received services in the child system are often not well supported as they move into the adult system. One example shared with the Committee was about children and youth living with autism spectrum disorder who may avail of services and supports from the Department of Children, Seniors and Social Development and receive the Special Child Welfare Allowance. However, once they turn 18 years old, these programs and services are no longer accessible.

Applied Behavioural Analysis (ABA) is an umbrella term and includes treatments which incorporate a number of effective strategies that can be effective in treating autism spectrum disorder.

29 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador The Committee was reminded that the system is not always inclusive or accessible, especially for people with disabilities.

The Committee learned that it is not uncommon for individuals to experience concurrent issues, such as someone with autism spectrum disorder who also has an obsessive-compulsive disorder or someone with an eating disorder who also has an anxiety disorder. “English is like a second language for people in the deaf community.” Participant Members of the deaf community have had difficulty accessing services, as language is a significant barrier. Some people in the deaf community do not feel included or supported within the mental health and addictions system.

Individuals shared with the Committee their feelings of isolation. They feel it is unfair that they are not able to access publicly-available health care services because health care providers are not adequately trained to work with them. There is no consistent funding for them to access the few services offered privately. The need for training for health care providers in order to better care for people in the deaf community was raised on several occasions. “The Waterford Hospital is not conducive to getting better.

The only reason it functions is because of the excellent staff.” Participant The Waterford Hospital is a relic of the past. It no longer appropriately meets the changing mental health needs of the population. However, the services provided there must continue until a better solution is found. Upgrades to the existing building will continue to be required to improve conditions for individuals and staff. Significant concerns about the inadequacies of the Waterford Hospital were repeatedly brought to the Committee’s attention.

Following a visit to the Waterford Hospital, the Committee consulted the Mental Health Commission of Canada on the current evidence for options on how to replace outdated provincial psychiatric hospitals. The Committee learned that psychiatric facilities similar to the Waterford Hospital provide in-patient treatment for only 1.5 to three per cent of the population with mental illness. Research shows that the provision of a full range of quality community-based services would mean less reliance on psychiatric hospital beds and allow a larger number of individuals to be served.

A community-focused approach would also provide treatment closer to home and a better quality of life for individuals.

30 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador It is evident that there is a need for improved mental health supports in the correctional system throughout the province, as well as staff training in the areas of mental health and addictions. The Committee heard about the need to replace Her Majesty’s Penitentiary (HMP), a correctional centre for men, located in St. John’s.

Staff at HMP spoke of the challenges of working in an old, dilapidated building and about how it is not conducive to wellness. Staff also expressed concern with overcrowding and lack of physical space for mental health and addictions program delivery. The number of inmates with mental illness and addictions is increasing and mental health services within the prison system are under- resourced and often cannot meet the needs of inmates. It was abundantly clear that the lack of integration between prison health services and the health care system makes continuity of care for inmates difficult to achieve.

Inmates need access to more psychological and counselling services while incarcerated and better programming and continuity of care when transitioning back into the community. HMP officials cited substance abuse as the main issue facing inmates in the prison system, yet, there is only one addictions counsellor working at the facility, with a caseload of 140 to 160 inmates at any given time. Inmates must have access to appropriate addictions services.

The Provincial Government is studying the feasibility of a provincial drug treatment court that would divert individuals with addictions, who have been charged with a non- violent offence, away from the prison system and into community-based treatment programs. Drug treatment courts provide an opportunity for people who have been unable, for whatever reason, to access help for their addiction, to enter a treatment program. This not only improves health and social outcomes for the person, it reduces costs to the justice system.

The annual cost of incarceration of one provincial inmate in Newfoundland and Labrador is approximately $107,000 –––––– The Committee visited the Newfoundland and Labrador Correctional Centre for Women in Clarenville. Committee members saw first-hand the overcrowded living quarters and lack Examples of community-based services include: supportive housing; access to psychological therapies and primary health care; crisis beds in the community; specialized mobile crisis intervention teams; and, assertive community treatment (ACT) teams.

31 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador of physical space for programming and other activities. They also heard concerns about female inmates not having regular access to female health care providers at the facility. The Committee heard about the high stress levels experienced by correctional staff.

Historically, the justice system has been responsible for providing health care to prison inmates separate from provincial health care systems. As part of the movement throughout North America, and elsewhere, to discharge long-stay patients from psychiatric institutions, the Waterford Hospital closed several units in the 1990s. This was done to provide individuals with mental illness an opportunity to live in the community.

Since the closure of long-term units, some individuals, who would have previously been supported in hospitals for extended periods, have come into conflict with the law and have been incarcerated. This is sometimes referred to as the criminalization of the mentally ill. “Prisons are our new asylums.” Participant Prison health care services in this province are currently funded and managed by the Department of Justice and Public Safety.

Some provinces, states and countries have shifted the responsibility for prison health care from the correctional system to the health care system to better avail of health expertise. This movement is supported by the World Health Organization and supports the human right of inmates to receive health care in correctional centres that is equitable to the health care available in the community. While the challenges people face in accessing services was a consistent message, the Committee also heard about potential solutions for improving access, reducing wait lists and filling the service gaps.

The Committee met with members of the Royal Canadian Mounted Police (RCMP) and the Royal Newfoundland Constabulary (RNC) and learned how heavily the police are relied upon, particularly when people are experiencing a mental health crisis, and about the need for a new approach to address crises in the community. The Committee heard from the RNC about a model for crisis intervention that would include plain-clothed officers riding in unmarked cars with mental health and addictions staff. In this model, police, health services and communities come together to identify how the model might work best for them.

The evidence shows this model can bring effective crisis intervention services directly to a person’s home in a compassionate, safe and non-stigmatizing manner. The use of technology can increase access to treatments, such as cognitive behavioural therapy. It can also support office-based counselling and engage people, where appropriate,

32 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador in managing their own mental health and addictions issues. Electronic health records, telehealth, online self-help supports, video conferencing and online training for health care providers are all tools that can improve collaboration, access and enhance skill development.

While Newfoundland and Labrador has a well-developed telehealth system and has implemented some e-mental health services, there is a growing need to increase immediate access to services to meet individual needs wherever and whenever issues are experienced. Online solutions can be tailored to age, gender and unique mental health or addiction issues. These services can be accessed in the privacy of home or within the community.

People who use e-health technology often report better relationships with health care providers, increased self-disclosure and decreased stigma, when compared to face-to-face services –––––– A stepped-care approach increases access to services by matching mental health needs to the most appropriate level of care. This approach takes pressure off growing wait lists, so people who need higher levels of care can access services more quickly. To provide stepped care, more services are required to meet unique needs with a greater focus on prevention and early intervention.

These services should include walk-in clinics, where people could meet with a therapist for a one-hour single session appointment, without waiting for an appointment time. Some people may be well suited to doing an online program in cognitive behavioural therapy, the gold standard therapy for depression and anxiety, and then meeting with a therapist to discuss their progress. “We need to change how we offer services to keep up with this demand.” Participant The following diagram shows the levels that would be included in a stepped-care approach.

33 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador “There is no stigma going to a primary health clinic.” Participant Primary health care is typically the first contact a person has with the health care system and has the potential to significantly increase access to services for individuals with mental health and addictions issues.

The implementation of well-trained and supported multi- disciplinary primary health care teams would help close the treatment gap by providing mental health and addictions services to individuals faster and closer to home. People are more likely to consult a family physician about a mental health problem or illness than any other health care provider –––––– Access to Services Recommendations 1. The Waterford Hospital must be replaced as an urgent priority.

While it is recognized that some type of infrastructure and in-patient services are needed, having them all located in one psychiatric hospital is not the answer. The Provincial Government must investigate options for replacing the existing hospital with in-patient services as well as more services provided in the community and closer to home. These in-patient and community services should be identified in a plan within the first year of this report’s release. Services delivered at the Waterford Hospital must continue until new service options are in place. 2.

The Provincial Government must immediately ensure the reduction of wait lists and wait times in mental health for everyone by: • Immediately directing the chief executive officer of each regional health authority to reduce the wait list and wait times for mental health and addictions services, including for psychiatrists (wait times not currently available for psychiatrists) within one year of the release of this report; • Developing a wait time reduction action plan, which will include a plan to address no-show rates to better accommodate the challenges faced by some individuals in attending appointments; • Adopting a standardized methodology for collecting and reporting wait times in all regional health authorities; and, • Providing provincial oversight and regular public reporting on wait times and wait time reduction progress.

34 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador 3.

Through a stepped-care approach, develop and offer a range of mental health and addictions services integrated, wherever possible, within existing community and primary health care services throughout the province, including: • Self-management programs for mental wellness, anxiety and depression; • Counselling services; • Strongest Families Program for children, youth and their families; • Therapist-assisted, online, cognitive behavioural therapy for depression, anxiety and addictions; • Peer support; • Provincial Warm Line; • 24/7 access to medical withdrawal management; • Day treatment programs; • Access to in-patient services for eating disorders; • Single session walk-in clinics; • Assertive community treatment (ACT) teams; • Mobile crisis intervention teams; • Dedicated mental health services for first responders, including ambulance personnel, firefighters, police officers and correctional staff; and, • Support for families and caregivers of people living with mental illness and addiction. 4.

Provide access to evidence-based services via technology (telehealth, telephone based, online, text, virtual reality and social media). 5. Increase access to counselling services for inmates in correctional facilities. 6. Assign responsibility for the provision of health services in prisons, and the associated funding to the health and community services system, to improve mental health and addictions services and supports for inmates. 7. The physical state of Her Majesty’s Penitentiary is negatively impacting the mental health of inmates and staff.

The building design and physical space are not conducive to providing quality mental health and addictions programs and services. Therefore, government must prioritize the completion of a new facility to replace Her Majesty’s Penitentiary. 8. Review the eligibility criteria for community support services and increase access to interventions with proven effectiveness for the treatment of autism spectrum disorder and other developmental disabilities.

35 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador 9. Ensure primary health care providers have access to mental health and addictions consultation and specialized services for their patients. 10. Provide online information about the mental health and addictions services and how to navigate them. 11.

Conduct a review of the benefit status, special authorization criteria and process under the NLPDP for both attention deficit hyperactivity disorder and neuroleptic medications to determine if changes are required to ensure appropriate and timely access. 12. Advocate for better health insurance programs from personal and employer-funded health insurance providers to align the plan’s provisions with the individual’s needs.

36 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Quality of Care For individuals seeking help, the current mental health and addictions system may seem like a maze, characterized by fragmented services and an overall lack of integration. People shared with the Committee their feelings of frustration as they described being passed from one health care provider to another in hopes of receiving the treatment they needed to get well.

As with the treatment of any illness, effectively treating mental illness and addictions requires continuity of care and the right combination of services and supports when and where people need them. The Committee heard about the need to improve the quality of care for people living with mental health and addictions issues by: • Integrating services and improving continuity of care; • Providing current mental health and addictions best practice education and training to health care providers; • Focusing on recovery and person-centered care; and, • Increasing support for families and caregivers.

The availability of a highly trained and skilled workforce is vital to the delivery of effective mental health and addictions services and has a direct impact on quality of care. While there are hundreds of health care providers working in mental health and addictions in this province, the number of specialists in each discipline varies and resources are not always evenly distributed. The Committee heard from regional health authority front-line staff that they want and need more education and training to learn about advances in treatment options.

Front-line staff, particularly new health care providers and people working in rural or remote parts of the province, emphasized the importance of opportunities to connect with and learn from other mental health and addictions professionals. They also identified the need for more mentoring opportunities and supervision. “I am expected to be a generalist and work with children and adults. I need more training.” Participant People seeking help for mental health and addictions issues deserve to be treated with compassion and respect.

Health care providers must not only recognize, but support, cultural differences, gender and diversity. Ongoing education and training about appropriately supporting and treating individuals are essential. The Committee heard that requests for training opportunities and continuing education are often denied in an effort to contain spending.

37 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador “I feel that I have to teach the medical profession who I am and that I am unique and not like other people.” Participant The mental health and addictions system must be more recovery-focused. In this context, the term recovery does not mean recovery from symptoms of an illness and does not mean a cure.

Rather, recovery is a term used to describe what happens when individuals with a mental illness or addiction feel empowered to make decisions in their lives, are hopeful about the future and can find meaning in their illness experience. The system should be focused on helping recovery take place.

A recovery-focused system: • Places the individual at the centre of the system and makes their needs, as they identify them, the priority; • Provides the right combination of services, treatments and supports; • Facilitates an environment that focuses on people’s strengths and can step in when people need more support, care and treatment; and, • Encourages individuals to take responsibility for their recovery so they can move forward with their lives.

With the appropriate treatment and support, most people living with mental illness and addiction will recover and lead fulfilling lives in the community –––––– In order to implement a recovery-focused system, fundamental changes are required. Decisions must be guided by the needs of the person. Peoples’ needs must come before system needs. Although mental health and addictions staff are to be commended for often putting peoples’ needs first, if the policies and procedures of the system do not support this, it will not always happen. A recovery-focused, person-centered system accommodates a person’s

schedule with evening or weekend hours of operation; develops policy with input from people with lived experience; shares information with family, as much as possible within the limits of the Personal Health Information Act; and, provides services in a welcoming atmosphere of respect and support, without stigma or discrimination. This change will not be possible without the commitment and support of health care providers and the leadership within the four regional health authorities. Individuals, their families and caregivers will all have to play a key role in building a system, which focuses on instilling hope and the belief that recovery is not only possible, but also likely.

38 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Families and caregivers often provide support and care for loved ones with a mental illness or an addiction. The Committee heard from individuals who want to support their loved ones and be included in decision-making and discussions about treatment options, but face barriers in the way the system excludes them.

Committee members also heard about how caregivers experience burnout as they often put the needs of their loved ones first at the expense of their own well-being and that they need better access to information and resources, including respite care and counselling. “What will happen to my son after we are gone?” Parent Quality of Care Recommendations 1.

Prioritize the transition to recovery-focused, person-centered care for all mental health and addictions services and staff by: • Continuing to support the already established Recovery Network, a group of almost 200 staff, physicians and individuals with lived experience throughout the province, and ensuring that the network helps guide the direction of recovery for the mental health and addictions and correctional systems; • Incorporating the ongoing workshops in recovery, that are taking place across the province, into required training for new and existing staff in both the health and correctional systems; • Addressing compassion fatigue, stress and burnout in staff; and, • Involving staff and individuals with lived experience of mental illness and addictions, and incarceration, in the development, implementation, monitoring and evaluation of guidelines for a recovery-focused approach for all mental health and addictions and correctional services staff. 2.

Support the implementation of the Choosing Wisely Guidelines for prescribing psychiatric medication in the province. 3. Encourage and provide opportunities for health care, correctional staff and police to avail of existing education and training modules in mental health and addictions, and implement new ones where needed, that include opportunities for networking, mentoring and skill building.

39 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador 4. Require professional regulatory bodies to mandate ongoing mental health and addictions continuing education requirements for their members. 5.

Recommend, as part of the provincial Personal Health Information Act Statutory Review, that consideration be given to amending the legislation to ensure family members and caregivers providing support to, and often living with, an individual with a mental illness or addiction have access to the appropriate personal health information necessary to provide that support. 6. Develop standards and guidelines, which recognize the critical role of families and caregivers, and provide guidance to staff on how to support families and caregivers, and include them, wherever possible, in treatment decisions. 7.

Provide web-based information on education, self-care and self-management for families and caregivers. 8. Ensure primary health care providers have improved access to information about programs and services to share with families. 9.

Increase the number of physicians and nurse practitioners involved in addictions medicine by: • Encouraging Memorial University’s Faculty of Medicine to create a Clinical Program Director of Addictions Medicine within the Discipline of Family Practice; and, • Encouraging the development of a network of physicians and nurse practitioners to provide opportunities for continuing medical education, consultation and mentorship in addictions medicine.

40 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Policy and Programming Factors such as unemployment, poor housing conditions, lack of affordable transportation, poverty and violence can negatively impact people living with mental illness and addictions. These factors are influenced by policies made not only in the health sector, but also, for example, in government departments.

As a result, the effective and efficient delivery of mental health and addictions services is sometimes hindered by the unintentional impacts of policies made outside the health system. The Committee met many people who felt their unique circumstances were not well understood and that their needs were not properly represented within the existing mental health and addictions system. The Committee heard about the challenges faced by Indigenous populations; seniors; women; and, members of the lesbian, gay, bisexual, trans, queer and Two Spirit (LGBTQ2S) community among others.

It is apparent that regardless of region, age, gender, ethnicity, religion, sexual orientation or socioeconomic status, everyone must have access to programs and services that are inclusive, accessible and responsive. Indigenous Peoples The All-Party Committee met with representatives of the Innu Nation, Nunatsiavut Government, NunatuKavut Community Council Inc. and Miawpukek First Nation. The Committee also spoke with members of the Innu communities of Sheshatshiu and Natuashish, Inuit beneficiaries of the Labrador Inuit Land Claims Agreement and members of Nunatsiavut, as well as NunatuKavut members.

Through these meetings, the Committee gained important insight into some of the challenges faced by Indigenous peoples in this province. The Committee acknowledges the pride, strength and resilience in the individuals they met with and their passion to heal their communities. Indigenous communities in Newfoundland and Labrador have rich cultures and resilient, resourceful and vibrant populations. The Committee is grateful so many individuals met and shared with them very difficult personal circumstances.

While each community is unique, the Committee heard that they face similar issues related to intergenerational trauma from the experiences of colonization, land resettlement and residential schools that contributed to the erosion of culture, language and identity. These traumas fueled the social distress that led many to experience mental health issues, drug and alcohol addiction, domestic violence and suicide. Communities share a deeply rooted concern for the health and well-being of their people, particularly youth.

41 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador The Labrador Innu have grave concerns about high suicide rates; the lack of both culturally- appropriate programming and funding to support youth going out on the land; challenges faced by young people with fetal alcohol spectrum disorder; and, the removal of children from their families and communities.

Overcrowded living conditions and, in some cases, no housing at all, are contributing to mental health and addictions issues, such as drug and solvent abuse. People shared their frustration with having to tell their stories repeatedly to different levels of government and health care providers in an attempt to get the help they need. The Committee heard that parents need more support in the community; health care providers and educators need more culturally appropriate training; and, more resources are needed in communities.

The Labrador Inuit of Nunatsiavut are also deeply concerned about the high number of suicides within their communities, particularly among youth. Residents recognize the need for more cultural-based activities and programs for youth to achieve well-being and a healthy lifestyle. Young people expressed concerns about their peers drinking underage; getting into trouble; and, not having a place to go when they are feeling endangered, alone, cold or hungry. People also spoke of challenges relating to drug and alcohol abuse, overcrowding and housing issues.

Nunatsiavut Inuit communities also experience high rates of unemployment, food and energy insecurity, and low literacy rates, all of which negatively affect mental well-being. The All-Party Committee heard about the geographical and financial barriers faced by residents who have to travel for health care services and the difficulty accessing psychiatry services within Nunatsiavut Inuit communities. People experience significant hardship when their children are placed in protective care and moved to another community for foster care.

Removal from the community causes significant trauma for both children and their parents. Furthermore, fostering children in Nunatsiavut Inuit communities is also challenging as individuals interested in becoming foster parents are met with significant delays in the applicant review process. Suicide rates for Inuit youth are among the highest in the world, at 11 times more than the national average –––––– Members of the NunatuKavut Community Council Inc. experience similar issues with addictions, housing and lack of appropriate cultural programming for youth.

The Committee noted that people are challenged by the stigma surrounding mental illness and addictions that still exists within the community. The All-Party Committee heard about gaps in aftercare programs and services available to people returning home following the completion of a treatment program, as well as the lack of mental health and addictions

42 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador services available for residents living in communities on the south coast of Labrador. The Committee also heard about the need for more promotion and prevention efforts, support in schools and a new treatment centre in Labrador. “We are a resilient people.

We want to teach culturally-relevant ways of dealing with stress.” Member, NunatuKavut Community Council The Miawpukek First Nation in Conne River has experienced an increase in addictions in recent years, including prescription drug abuse and video lottery terminal (VLT) gambling. The Committee heard about the challenges in getting people into treatment programs, mainly because residents are often apprehensive about leaving their community to receive services and are, therefore, difficult to engage in treatment.

The Committee also heard from Conne River Health and Social Services staff who feel their mental health and addictions services are serving the community very well. Staff attributed this success to their integrated health and social services system, where mental health and addictions, primary health care and emergency services are all located within the same facility. While Indigenous peoples in Newfoundland and Labrador often face significant intergenerational trauma and mental health and addictions issues, these challenges are not insurmountable.

With the appropriate resources, Indigenous communities can build on their strengths, culture and experiences to find solutions that will improve quality of life for residents and support better outcomes for youth. Seniors One in four seniors lives with a mental health problem or mental illness. Newfoundland and Labrador has the fastest aging population in Canada. As this population grows, so too will the need for more mental health services. Some common mental health and addictions issues experienced by seniors include depression, dementia, anxiety, prescription drug abuse and gambling.

Seniors experience particular challenges that affect their mental health and well-being. These challenges include life changes like bereavement over the loss of loved ones; retirement; and, changes in social supports, such as when adult children move out of the home. Furthermore, seniors may face physical challenges associated with hearing and vision loss, illness, medication side effects and mobility issues. Some may also experience elder abuse and homelessness.

43 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Seniors with mental illness and addictions not only face the stigma associated with those issues, but must also contend with the stigma associated with aging. Despite common belief, depression is not a normal part of aging and mental health and addictions issues should not be considered an inevitable part of getting older.

Age should not affect the quality or availability of mental health and addictions services. The Committee heard that more training in seniors’ mental health is needed not only for health care providers, but also for personal care home and home support workers. By 2041, seniors will have the highest rate of mental illness in Canada –––––– By virtue of their life experiences, many seniors are resilient and have remarkable coping, crisis management and problem-solving skills.

To ensure seniors continue to thrive within their communities, more community-based services, such as home care and opportunities for social support and inclusion are needed. Lesbian, Gay, Bisexual, Trans, Queer and Two Spirit (LGBTQ2S) The Committee learned about the challenges experienced by the LGBTQ2S community and that the mental health of LGBTQ2S youth is of great concern. LGBTQ2S youth often face fear, hostility and discrimination.

LGBTQ2S youth are six times more likely to experience mental health issues than the general population –––––– Research shows that LGBTQ2S individuals are at higher risk than others of experiencing mental health and addictions issues. A person may identify themselves as a non-binary or some combination of identities. Fear of disclosing sexual orientation or gender identity and being discriminated against can lead to depression, thoughts of suicide and substance abuse. This is in addition to the stigma associated with mental illness and addiction that keeps people from seeking help.

The Committee heard about the need to support the LGBTQ2S community by providing timely access to appropriate services and specialized training for health care providers, school counsellors and social workers. In addition, experts identified the need for more support in the community, such as the development of safe and positive spaces for LGBTQ2S youth within schools and LGBTQ2S-specific mental health and awareness campaigns, workshops and community events.

44 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Gender While the overall rates of mental illness are consistent between women and men, the prevalence of certain mental illnesses and addictions, the patterns of how they affect each gender and the risk factors, are different. Some mental illnesses are more predominant in women, such as depression and anxiety, while the prevalence of alcohol dependence is twice as high in men. Men are more likely to be diagnosed with anti-social personality disorder,

whereas depression is diagnosed more often in women. Research shows that depression in men may go undiagnosed as their symptoms often differ from the more traditional symptoms and may include anger, irritability and aggression. Women are more likely to seek help from a primary health care physician and disclose a mental health issue, compared to men who are more likely to seek specialist care and in-patient services and disclose addictions issues.

Approximately one in every two women over the age of 15 in this province will experience at least one incident of sexual or physical violence throughout their lifetime –––––– Risk factors that predispose women to mental health and addictions issues include increased caregiving responsibilities, such as caring for children and other family members; and, the higher rates of poverty, gender discrimination, domestic violence and sexual abuse they experience. The Committee heard about the lack of services designed to specifically respond to the needs of women.

In comparison, men typically have less access to social networks to provide support in times of distress. Men are also affected by society’s expectation that they must be mentally and physically strong, independent and always in control. As a result, men often delay seeking help until their problems have progressed and their mental health has significantly worsened. Given the many differences in the experience of mental health and addictions issues among men and women, standards, policies and programs that specifically address gender-based needs are required.

The high prevalence of sexual violence that women are exposed to renders them the largest single group of people affected by PTSD ––––––

45 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Harm Reduction The Committee also learned about the importance of harm reduction policies in protecting the safety and well-being of individuals who partake in high-risk behaviours, such as intravenous drug use. Harm reduction focuses on people who are already experiencing some harm due to mental illness or addiction, with the ultimate goal being to reduce the level of harm.

Application of a harm reduction focus in policies and programming would help reduce negative health outcomes. “We must take into consideration the lifesaving qualities of harm reduction and how it really needs to be implemented right across the board.” Participant Examples of current harm reduction initiatives in the province include: • Methadone or Suboxone for treatment of opioid addiction.

These medications reduce or eliminate cravings, thereby decreasing the need for opioids and the risk of criminal behaviour, overdose and death; • The Safe Works Access Program (SWAP), which is run by the Aids Committee of Newfoundland and Labrador and funded by the Provincial Government. This program provides clean needles and other supplies to intravenous drug users to help prevent the spread of disease; and, • The Naloxone Take-Home Kit Program, a partnership between the Provincial Government, regional health authorities and the Aids Committee of Newfoundland and Labrador.

This program prevents opioid-related overdose deaths, through the public distribution of naloxone, a safe and effective compound that reverses the effects of opioid overdose. Public policy development that does not include robust analysis across government departments can have negative effects on vulnerable populations. Health-in-all-policies is a formal approach to public policy that aims to improve population health by taking into account health impacts in policy making.

Implementation of a health-in-all-policies approach would reduce the likelihood of inadvertently placing people at greater risk of poor mental health outcomes. The social determinants of health are mostly shaped by decisions made outside the health sector. In order to prevent illness and support health and wellness, collaboration between the government departments and agencies that most directly affect the conditions under which people are born, live, work and age is essential.

46 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Policy and Programming Recommendations 1. Adopt harm reduction as a foundational approach to the provision of mental health and addictions services. 2. Support Indigenous people to achieve their mental wellness goals by providing resources to assist with sustained land-based programming. 3. Ensure psychiatrists provide regular visits to Labrador coastal communities, as needed. 4.

Establish four to six dedicated mental health beds in Labrador, which will include services that are inclusive and culturally appropriate for all Labradorians. 5. Prioritize the recruitment of two permanent full-time psychiatrists (while establishing a sustained commitment for regular locum coverage) to ensure psychiatric coverage for: • New mental health beds in Labrador; • Emergency departments in the Labrador Health Centre and Labrador West Health Centre; and, • Out-patient clinics for Labrador West and Happy Valley-Goose Bay. 6.

Provide general education to community leaders and policy makers, with a specific focus on seniors’ mental health to increase understanding of aging and mental health, stigma and ageism. 7. Provide specialized training for people who work one on one with seniors. This must include family physicians; nurses; ambulance personnel; counsellors; and, individuals who work in the areas of primary health care, mental health and addictions and long- term care and supportive services. 8. Develop standards, policies and programs specifically to address mental health and addictions gender-based needs. 9.

Provide general education to community leaders and policy makers, with a specific focus on LGBTQ2S youth, to increase understanding of sexual orientation, gender identity and mental health concerns. 10. Provide specialized training for people who work one on one with LGBTQ2S individuals. This must include physicians, nurses, community and school-based psychologists, teachers, counsellors and social workers.

47 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador 11. Continue to support the implementation and evolution of the provincial Opioid Action Plan. 12. Increase provincial mental health and addictions spending from approximately 5.7 per cent of the total annual health care budget to nine per cent in five years (by April 2022), to better align with the recommended national average. 13.

Develop a comprehensive, government-wide inclusion policy to be applied to all mental health and addictions services to ensure the diverse needs of all populations are recognized and addressed. 14. Establish standards for youth transitioning into adulthood (16-25 years old) that include a requirement for collaboration and evidence-based practices so that programs and services are geared to young people’s needs wherever they live.

The provincial Opioid Action Plan includes the following initiatives: • Development of a safe prescribing course in partnership with the College of Physicians and Surgeons of Newfoundland and Labrador and Memorial University’s Faculty of Medicine; • New regulatory standards from the Newfoundland and Labrador Pharmacy Board requiring all pharmacies to be connected to the Provincial Pharmacy Network; • Development of a province-wide Prescription Monitoring Program; • Provincial distribution of Naloxone take-home kits; • Proclamation of secure withdrawal management legislation for youth with addiction; • Improved access to effective treatment options, including suboxone as an alternative to methadone; and, • Development of a provincial public awareness and education program on opioids.

Planning mental health service delivery that ensures the inclusion of diverse needs of populations, such as women; immigrants; refugees; ethnocultural and racialized individuals; members of the deaf community; and, people with disabilities.

48 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador 15. Develop specific provincial action plans for: • Alcohol abuse, which would include a focus on promotion and prevention, as well as screening, brief intervention and referral; and, • Suicide prevention, with the aim of reducing stigma and empowering communities to build resilience and inclusiveness. 16. The Provincial Government must adopt a health-in-all-policies approach to ensure health impact considerations are built into all policy decisions.

49 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Community Supports Community, as used in this report, refers to community-based services provided by regional health authorities and supported and supplemented by services provided by non- government organizations, such as CHANNAL, which is a self-help network for individuals with mental health issues in Newfoundland and Labrador.

Other examples of non- government organizations include the Community Mental Health Initiative (CMHI), which provides mental wellness programs in Corner Brook; and, the Justice Program, developed by the Canadian Mental Health Association, which helps individuals with mental illness while incarcerated and upon their release. The U-Turn Centre also fills a gap by providing peer services for individuals pursuing recovery from addiction.

Community support groups and advocacy bodies, such as the Community Coalition 4 Mental Health, have played an important role in highlighting the need for change in the mental health and addictions system. High school groups who, with the support of their teachers, promote mental health through school-based awareness initiatives and peer support, must be encouraged and supported to continue to work together and generate ideas about how to address mental health and addictions issues for youth throughout the province.

Adequate multi-year funding of community groups would provide stability to enable them to focus on delivery of their respective mandates, as well as planning and evaluation. Community groups also expressed an interest in collaborating more with government departments, regional health authorities and each other, to more effectively deliver services. “Stabilizing the core funding that is being provided is critical and key.” Participant Appropriately supported, evidence-based services delivered in the community are responsive, efficient and lead to improved quality of life and reduced hospitalizations.

Responding to mental health and addictions issues is a shared responsibility and requires the support of community-based partners and advocates. Government departments, regional health authorities, community groups and individuals with lived experience must work together to address challenges.

50 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Community Supports Recommendations 1.

Regional health authorities and community agencies must work more closely together to ensure smooth service delivery for individuals by: • Strengthening existing partnerships (and creating ones where they do not formally exist) through regular communication, meetings and sharing education, strategic planning and other opportunities for engagement; and, • Using change management principles to set the expectation that community agencies and regional health authorities share non-confidential information and consult each other on the evolving needs of individuals and how best to meet them. 2.

Develop adequate multi-year funding models for community agencies. Sample Action: The Downtown Health Care Collaborative provides health care services to at-risk individuals in Downtown St. John’s. The Collaborative focuses on mental health and addictions- related health care needs and works with community partners, such as the Gathering Place and Choices for Youth, to bring services to the people who need them.

51 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Accountability and Performance Monitoring Systemic problems can only be addressed by a focused effort and long-term commitment. Changes have to be made in the most efficient and cost effective way in order to be sustainable. Changing the culture of the mental health and addictions system will be difficult work and require much more than just an investment of financial resources.

Silos must be dismantled. Government departments, community agencies, regional health authorities and health care providers must break down barriers, focus on people and learn new ways of working together. As the recommendations in this report are implemented, ongoing performance monitoring, evaluation and public reporting will be essential. Strong evaluation will show whether changes are achieving their stated outcomes and will inform course corrections when necessary. Individuals, families, community agencies and mental health and addictions staff should be involved in this process.

Public reporting on the status of the implementation of the Committee’s recommendations in this report will keep everyone informed and decision makers accountable. Accountability and Performance Monitoring Recommendations 1. Develop and publicly release an implementation plan for the recommendations in this report by June 30, 2017. 2. Establish an accountability and performance monitoring framework to track results of the implementation plan. 3. The Minister of Health and Community Services must report publicly on the implementation of the report’s recommendations.

The first report must be released 6 months after the release of this report, with subsequent reports released at 12 and 24 months. 4. Revise the mandate of the Provincial Mental Health and Addictions Advisory Council to include oversight for the implementation of the recommendations in this report.

52 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Conclusion In 2015, the Committee set out to conduct a full review of the provincial mental health and addictions system. The Committee saw firsthand that mental illness and addiction does not discriminate. It can affect anyone at any time regardless of age, gender, or socioeconomic status.

Despite sometimes scarce resources and dated infrastructure, hardworking, compassionate people are working every day with individuals, families and caregivers to help improve the lives of people living with mental illness and addictions in this province. Newfoundland and Labrador should be a province that promotes positive mental well-being and resilience and supports individuals and families with lived experience of mental illness and addiction to live full and rewarding lives. We believe a different approach to the treatment of mental illness and addiction is required.

We need a system that is person-centered, integrated and recovery focused. The recommendations in this report address the service gaps identified during the review and support what is currently working well. System transformation is a high priority for the people of this province and a priority that requires immediate action.

53 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Appendix A: All-Party Committee Membership Current Membership (December 2015 – Present) Honourable John Haggie, Minister of Health and Community Services; Chair Honourable Sherry Gambin-Walsh, Minister of Children, Seniors and Social Development; Minister Responsible for the Newfoundland and Labrador Housing Corporation and for the Status of Persons with Disabilities; Alternate Chair Mr.

Bernard Davis, Parliamentary Secretary to the Minister of Health and Community Services Ms. Lisa Dempster, MHA for Cartwright – L ’Anse au Clair Mr. Steve Kent, MHA for Mount Pearl North Mr. Barry Petten, MHA for Conception Bay South Ms. Gerry Rogers, MHA for St. John’s Centre Alternates Mr. Paul Davis, MHA for Topsail – Paradise Mr. John Finn, MHA for Stephenville – Port au Port Ms. Lorraine Michael, MHA for St. John’s East – Quidi Vidi

54 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Former Membership (January 2015 – November 2015)1 The Honourable Steve Kent, Deputy Premier and Minister of Health and Community Services; Chair The Honourable Felix Collins, Attorney General Mr. Dwight Ball, Leader of the Official Opposition and MHA for Humber Valley Mr. Andrew Parsons, Official Opposition Critic for Health and Community Services and MHA for Burgeo – La Poile Ms.

Tracey Perry, Parliamentary Secretary to the Premier and MHA for Fortune Bay – Cape La Hune Mr. Kevin Pollard, Parliamentary Secretary to the Minister of Health and Community Services and MHA for Baie Verte – Springdale Ms. Gerry Rogers, MHA for St. John’s Centre Alternates Ms. Lorraine Michael, MHA for Signal Hill – Quidi Vidi Mr. Christopher Mitchelmore, MHA for The Straits – White Bay North Mr. Kevin Parsons, MHA for Cape St. Francis 1. Changes in membership occurred following the Provincial General Election on November 30, 2015.

55 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Appendix B: Invited Expert Presentations Ms. Louise Bradley, President & CEO, Mental Health Commission of Canada • Mental Health Commission of Canada overview • Alternatives to institution-based services Dr. Mario Cappelli, Director of Psychiatric and Mental Health Research, Children’s Hospital of Eastern Ontario & Ms.

Jenny Carver, Executive Director, Stella’s Place, Toronto, Ontario • Making emerging adults with mental health needs a priority in Canada Dr. Norman Giesbrecht, Associate Professor, Dalla Lana School of Public Health, University of Toronto • Reducing alcohol-related harm through effective alcohol policies and prevention strategies Dr. Nick Kates, Chair, Department of Psychiatry, McMaster University • Improving collaboration between mental health and primary care services Ms. Rita Notarandrea, CEO, Canadian Centre on Substance Abuse • Canadian Centre on Substance Abuse overview Ms.

Ann Marie O’Brien, Clinical Lead, Women’s Health Program, The Royal Ottawa Mental Health Centre • Women’s mental health within an institutional setting • Caregivers’ right to health information Ms. Susan Rose, President, EGALE Canada Human Rights Trust & Ms. Kathleen Pye, Researcher and Policy Analyst, EGALE Canada Human Rights Trust • Improving mental health services in Newfoundland and Labrador for LBGTQ communities Ms. Linda Ross, President and CEO, Provincial Advisory Council on the Status of Women, Newfoundland and Labrador • Women with complex needs Ms. Jenny Wright, Executive Director, St.

John’s Status of Women Council • Women and mental health Dr. Christopher Smith, Assistant Professor, MUN School of Social Work • Harm reduction and Methadone maintenance treatment (MMT) in Newfoundland and Labrador Dr. Margaret Steele, Dean, MUN School of Medicine • Child and adolescent psychiatry The All-Party Committee was also fortunate to hear from many other individuals who shared valuable perspectives.

56 Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Towards Recovery: A Vision for a Renewed Mental Health and Addictions System for Newfoundland and Labrador Glossary of Terms Accountability Accountability is the ownership of responsibilities, combined with an obligation to report to a higher authority on the discharge of those responsibilities and on the results obtained.

All-Party Committee on Mental Health and Addictions (All-Party Committee) The All-Party Committee on Mental Health and Addictions was established in January 2015 and consists of members from all parties of the House of Assembly. Its mandate is to review the provincial mental health and addictions system with the goal of identifying gaps in services and improving mental health and addictions programs and services to better serve the needs of residents in the province.

Assertive Community Treatment (ACT) Teams Assertive community treatment (ACT) teams provide intensive case management and other multidisciplinary services for individuals with severe and persistent mental illness. Services are available on an on-call basis 24-hours-a-day, 7-days-a-week, in St. John’s, Grand Falls- Windsor and Corner Brook. Change Management Change management refers to the planning and introduction of new processes and work methods in an organization. Choosing Wisely Choosing Wisely is a national campaign to help clinicians and patients take

part in conversations about tests and treatments that may be unnecessary. The campaign also focuses on smart and effective decision-making to ensure high-quality care. Choosing Wisely is a “bottom up” approach which is led by clinicians with a focus on both primary and specialty care. Cognitive Behavioural Therapy (CBT) Cognitive behavioural therapy (CBT) is a form of short-term therapy that helps people to develop practical skills and strategies to achieve health and well-being. While taking

part in this type of therapy, people are encouraged to examine how they make sense of their day-to-day life, what is happening around them and the feel

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