Brian's Law (Mental
Health Legislative Reform), 2000, Bill 68, Mrs
Witmer /Loi Brian de 2000 sur la réforme
législative concernant la santé mentale,
projet de loi 68, Mme Witmer
Canadian Civil
Liberties Association
Mr Alan Borovoy
No Force
Coalition
Mr Erick Fabris
Family Mental Health
Alliance
Ms Tunde Szathmary
Ms Ruth
Malloy
Association of General
Hospital Psychiatric Services
Ms June Hylands
Dr Ty Turner
Ontario Council of
Alternative Businesses
Ms Diana Capponi
Canadian Mental
Health Association, Metro Toronto branch
Mr Steve Lurie
Ms Eileen Dawe
STANDING COMMITTEE ON
GENERAL GOVERNMENT
Chair /
Président
Mr Steve Gilchrist (Scarborough East / -Est PC)
Vice-Chair / Vice-Présidente
Mrs Julia Munro (York North / -Nord PC)
Mr Toby Barrett (Norfolk PC)
Mrs Marie Bountrogianni (Hamilton Mountain L)
Mr Ted Chudleigh (Halton PC)
Mr Garfield Dunlop (Simcoe North / -Nord PC)
Mr Steve Gilchrist (Scarborough East / -Est PC)
Mr Dave Levac (Brant L)
Mr Rosario Marchese (Trinity-Spadina ND)
Mrs Julia Munro (York North / -Nord PC)
Substitutions / Membres remplaçants
Mr Brad Clark (Stoney Creek PC)
Ms Frances Lankin (Beaches-East York / -Est ND)
Mrs Lyn McLeod (Thunder Bay-Atikokan L)
Mr Richard Patten (Ottawa Centre / -Centre L)
Clerk pro tem/ Greffier par intérim
Mr Tom Prins
Staff /Personnel
Ms Lorraine Luski, research officer, Research and Information
Services
The committee met at
1534 in committee room 1.
BRIAN'S LAW (MENTAL HEALTH LEGISLATIVE REFORM), 2000
/ LOI BRIAN DE 2000 SUR LA RÉFORME LÉGISLATIVE
CONCERNANT LA SANTÉ MENTALE
Consideration of Bill 68, An
Act, in memory of Brian Smith, to amend the Mental Health Act and
the Health Care Consent Act, 1996 / Projet de loi 68, Loi à
la mémoire de Brian Smith modifiant la Loi sur la santé
mentale et la Loi de 1996 sur le consentement aux soins de
santé.
CANADIAN CIVIL LIBERTIES ASSOCIATION
The Chair (Mr Steve
Gilchrist): Good afternoon, everyone. I call the
committee to order for our continued hearings on Bill 68. Our
first presentation this afternoon will be from the Canadian Civil
Liberties Association, if Mr Borovoy could join us at the witness
table, please. I see you have two associates, if they could come
forward as well. Welcome to the committee. We have 30 minutes for
your presentation, which you can divide as you see fit between
either a presentation or a question-and-answer period.
Mr Richard Patten
(Ottawa Centre): Do you have a document or paper, a
handout?
Mr Alan
Borovoy: No, we have to rely on our charisma.
For today, since we of course
represent the Canadian Civil Liberties Association, I have Steve
McCammon, our associate counsel, on my right, and a field
representative, Andy McDonald-Romano, on my left-that is
physically and not politically, necessarily.
Since we have not been able
to review every aspect of this bill, our remarks today will focus
on one area, and that is the widening of the powers to
involuntarily commit. Principally, we're interested in the
deletion of the word "imminent" and the addition of the words
"substantial mental or physical deterioration."
When this bill was
introduced, much was made of the fact that it's being called
Brian's Law and that it is supposed to prevent repetitions of the
kind of tragedy that occurred with respect to the newscaster
Brian Smith. We find it difficult, however, to see a clear
relationship between these amendments and the objective it was
supposed to serve.
In the first place, the
deletion of the word "imminent": "Imminent" was never used to
restrict situations where bodily harm was the consequence that
was anticipated. It was only used to describe committals that
could be permitted in order to prevent a serious physical
impairment occasioned by a person's lack of ability to look after
himself. That's what it was used for, and not for serious bodily
harm.
As far as "substantial mental
or physical deterioration" is concerned, that of course is broad
enough that by sheer happenstance it might catch some potentially
dangerous people, but it is obviously not designed for that. It
has nothing to do, particularly, with dangerousness. Indeed it's
capable of applying to a wide variety of situations that have
nothing to do with dangerousness.
On that basis, it would
appear that at least one of the objectives of this bill, to
protect tomorrow's Brian Smiths, as far as these amendments are
concerned, is irrelevant.
Now let's take a look at the
wisdom or appropriateness of putting in the criteria "substantial
mental or physical deterioration." Try as I may and look as hard
as I do, I'm unable to appreciate the distinction between
"substantial physical deterioration" and "serious physical
impairment." I don't know where one leaves off and the other
begins. Indeed, to me they look like rather synonymous terms.
As far as substantial mental
deterioration is concerned, this might be able to enable numbers
of Ontario families to ensure that their afflicted loved ones get
the treatment they so badly want them to get. The difficulty is
that it is so wide that it may be capable of applying to numbers
of other situations as well.
1540
Then we look at, what are the
definitions? What can help us? What does "substantial mental
deterioration" mean? No definition for it. There is a definition
for "mental disorder," but not a very helpful one. It's a disease
or disorder of the mind. There's apparently no attempt anywhere
in the bill to limit these things to any recognized set of
diagnostic criteria. But even if it were limited, we're talking
about a very hazardous exercise.
We've been looking recently
at the publication of the American Psychiatric Association,
DSM-IV, which is probably
the source of the most officially recognized diagnostic
categories there is, and it appears to us that we're talking
about a lot of vague and highly subjective criteria. I do not, of
course, expect you to take my word for it. I brought with me some
excerpts from leading scholarly journals in the field of mental
health. They are commenting on the diagnostic categories used by
the American Psychiatric Association.
First from the Australian and
New Zealand Journal of Psychiatry: "First, the introduction of
explicit diagnostic criteria and new classification categories in
psychiatry took place in the context of a discipline that still
lacks conceptual coherence and hence remains easily influenced by
ideological, political and market forces. Secondly, there are
inherent shortcomings in the design of these classification
systems which limit their usefulness and make them liable to
misinterpretation or misuse. Except for rare instances, hardly
any DSM-IV diagnosis relies entirely or primarily on objective
signs or tests."
In the May 1998 issue of the
Psychological Bulletin: "The research is perhaps complicated by
common sources of error. Two sources in particular are emphasized
here: biases in sampling and biases within the diagnostic
criteria themselves. The potential for such biases is illustrated
for a wide variety of mental disorder diagnoses.
From a Netherlands journal,
which I am unable to pronounce, March 27, 1999: "According to the
results of recent epidemiological studies, over three million of
the people in the Netherlands per year are supposed to suffer
from severe mental disorders. The high prevalence should be
regarded in connection with the diagnostic criteria and interview
techniques applied. The final results of such studies depend upon
where one draws the dividing line between clinically relevant
mental disorders and normal problems of life."
The same sort of the thing in
the Journal of Personality Disorders, summer 1998: "It is now
apparent that there are a number of different ways in which the
differential sex prevalence rates for the DSM-IV personality
disorders could reflect a sex bias, including diagnostic
constructs, basic thresholds for diagnosis, biased population
sampling, biased application of diagnostic criteria, biased
instruments of assessment and biased diagnostic criteria."
Social Science and Medicine,
February 1997: "Research in women's health has revealed the
difficulties female patients experience in their attempts to
receive accurate medical diagnoses. Depression may be
misdiagnosed in 30% to 50% of female patients."
Psychiatric Services, March
1999, "Issues in the psychiatric assessment and evaluation of
African-American patients include diagnostic bias that resulted
in overdiagnosis of schizophrenia."
Commentary magazine, probably
one of the leading intellectual publications in the
English-speaking world, one that self-describes as small-c
conservative, written by a psychiatrist: "What was thought to be
true today is often revealed to be false tomorrow. As a result,
the final decisions by the experts on what constitutes a
psychiatric condition and which symptoms define it rely
excessively on the prejudices of the day. Embedded within these
hundreds of pages of the diagnostic manual are some categories of
disorder that are real, some that are dubious in the sense that
they are more like the normal responses of sensitive people than
they are to psychiatric entities, and some that are purely the
inventions of their proponents."
Now, in that connection we
took a look through DSM-IV and some of these are rather
suggestive of a phenomenon that this writer is referring to:
attention deficit-hyperactivity disorder, oppositional defiant
disorder, selective mutism, social phobia, generalized anxiety
disorder, premature ejaculation, histrionic personality disorder,
narcissistic personality disorder, avoidant personality
disorder.
Which of those are supposed
to be genuine? Which are simply dubious? Which were the creations
of the category writers? I don't know. Nor am I suggesting that
it's necessary to agree with all of what these commentators have
said. But the very least we should appreciate is that we are
talking about very controversial subjects, and at the very least
we should also be able to recognize that the diagnosis of mental
disorder is at best a hazardous exercise.
This is not to impugn the
benevolence or the competence of our mental health professionals.
It is simply to question their omnipotence. The issue is not
their character or ability. The issue is the nature of their
discipline. Inevitably woven into their discipline is a whole
question of, how much is it influenced by value judgments, not
clinical judgments; by philosophical and ideological
preferences?
Take a look at DSM-IV. You
see words such as "inappropriate" and "excessive." Those are not
scientific words. Those express value preferences-ones that maybe
in the circumstances most of us would agree with, but
nevertheless value preferences.
Consider the fact that a few
years ago homosexuality was listed as a mental disorder and today
it is not. The decision to remove it, I suggest, went way beyond
clinical judgment. It was also an ethical judgment. The decision
was made, largely for ethical reasons, that it was inappropriate
to continue treating homosexuals as though they were mentally
disordered.
All this might well be
acceptable and digestible if we were talking simply about the
voluntary relationships between doctors and their patients, but
we're talking here about coercive power-the power to confine and
medicate people against their will. And it's for that that we
have to be so concerned about the risks of having these things
affect our judgment, of having these things affect the judgment
to use this kind of power against people in our society. In fact,
we must be concerned that today's psychological diagnosis could
be obliterated by tomorrow's philosophical preferences. That's an
awful power to repose in any group of people, and it's for
reasons of this kind that those of us involved in the reforms of the late 1970s, as I
personally was and as the Canadian Civil Liberties Association
was, urged a more restrictive power where these issues are
concerned.
1550
More and more people began to
recognize at that time that the ability to distinguish an
unacceptable pathology from acceptable nonconformity was beyond
the ability of any of our elites to provide. This simply is not a
subject that most elites can tell us about. On the other hand,
since the ability to recognize an urgent situation was less
encumbered by the risk of ideological baggage, there was an
increase in the pressures for the coercive power involved to be
confined as much as possible to those kinds of circumstances.
That's how we got the narrow criteria that have existed in the
Mental Health Act lo these many years.
At least as far as the
Canadian Civil Liberties Association is concerned, we never
believed this was going to have a good outcome. We took the
position that it was not possible to have a good outcome. These
situations are so painful and so difficult that whatever was
likely to happen was going to be a bad outcome, but our position
was that narrower powers of the kind that were ultimately adopted
were significantly less bad than having a number of open-ended
criteria being able to mandate some of the most pervasive
encroachments that a society can perpetrate on any individual.
it's on that basis that we took the position we did.
I'm sorry to note that, in a
very real way, with this bill we are having to relive that
history of the late 1970s, because what is involved in at least
the two categories I've been talking about here are once more
ill-defined, undefined and unarticulated criteria serving as a
mandate for the forcible confinement and medication of people
against their will. It is the open-ended nature of these criteria
that we are speaking against.
It's interesting to note that
in our criminal law our society would never stand for this. There
we insist on the most objective and precise standards it's
possible to create. I do not understand why we are so prepared,
in view of the comparable risk to freedom, to countenance in the
mental health area what in the criminal area we have no
difficulty rejecting.
This brings me back to the
conclusion, and that is that the Canadian Civil Liberties
Association calls on this committee to reject these two
amendments: In our view, "imminent" should be preserved and
"substantial mental or physical deterioration" should be removed,
all of which is, as always, respectfully submitted.
The Chair:
Thank you, Mr Borovoy. That leaves us with about eight minutes,
so just under three minutes for each caucus. The rotation will
start with Ms McLeod.
Mrs Lyn McLeod
(Thunder Bay-Atikokan): Thank you very much, Mr Borovoy.
I'm anxious to get you to respond more specifically to a concern
about the type of situation in which you feel an individual might
be inappropriately and involuntarily admitted to hospital.
Obviously, you've said you're not going to deal with the
community treatment aspect of it. I guess I'm a little bit
concerned in asking my question, so let me be honest about that,
because I do feel as though by taking such a broad approach to
the issue of definition, in terms of the lack of specificity of
definition, you may have also done a disservice to the issue that
people are concerned to deal with, which is the reality of mental
illness. In using both neuroses and psychoses components of the
DSM-IV, which you have used, without separating what may be seen
as neurosis and what may be defined as psychosis, I think you've
mixed those, and in using an analogy to homosexuality-
Mr Borovoy:
I'd be happy to take you through some of the psychotic ones as
well.
Mrs McLeod:
I guess that's what concerns me. I think the analogy to
homosexuality, if I may, is an unfortunate one. It was an
unfortunate one at the time. But I think it takes us away from
dealing with the concern for-admittedly by everyone who has
spoken to the bill and been involved in it, it's a concern for a
very narrow population of people who have in fact a mental
illness in an acute psychotic state, which is an illness defined
by being amenable to medication and for which for a number of
reasons that person is not able to take their medication.
I recognize there may need to
be some redefinitions in this legislation to make it clear that
it's a very targeted population we want to talk about. But if I
could get you to focus on that targeted population, if the bill
addressed that narrow population, what dangers do you feel the
bill poses?
Mr Borovoy:
With great respect, I think you are asking me the wrong question.
I appreciate the fact that there are numbers of people whom most
reasonable people would like to have medicated because of the
terrible circumstances in which they're living. I don't deny the
reality of that. The difficulty, however, that I think must be
addressed is that when you create criteria in a statute, those
criteria then become available not only for the people you think
ought to be the targets of these powers, but wide varieties of
other people as well, because the definitions are that broad that
they're capable of sweeping in the others.
Ultimately you can do either
one of two things, or either one of three things, I suppose. I
don't want to limit your choices. You can rest with the status
quo, which is to recognize that it is an unhappy situation, but
as I have argued, less unhappy than I suggest will be the
situation when open-ended criteria become the mandate for this
kind of power.
You can try to redefine what
you want to target in a much more precise way than you have. That
is another way to go. Then often we have to face at the end of
the day which risks you are prepared to incur in a society like
ours, the risk of locking up the wrong people or the risk of not
locking up the right people, remembering all the time that once
we are talking about an urgent situation, the power is there at
the moment to act.
Incidentally, on community
treatment orders, our position is that they are dependent on the
acceptability of the criteria for coercion. If you have acceptable
criteria for coercion, community treatment orders could then be a
more viable option.
1600
Ms Frances Lankin
(Beaches-East York): Thank you very much, Mr Borovoy. I
appreciate your presentation and I think your clarification with
respect to community treatment orders is also extremely helpful.
I think some of the disquiet people have felt with respect to
that section of the act actually does stem back to the broadening
of involuntary committal powers. I find myself in such agreement
with what you have said, but I think it might be motivated by
ideological and values preferences and I'm cautioned by your
earlier comments that that may not be an appropriate-
Mr Borovoy:
Well, as long as this is between two people on a voluntary basis,
it's fine.
Ms Lankin:
That's true, it's OK. I think you should know that the committee
has had some discussion with previous presenters about the
possibility of attempting to clinically narrow the application of
the legislation. I think we don't know exactly how to do that,
and there's debate, but it is an active issue on the table and
you may want to comment on that.
One of the things we have
heard so clearly from the family members of people with mental
illness, particularly of those suffering from schizophrenia, the
most common group that has come forward, is how difficult it has
been to deal with the existing law, the barriers they have felt
the law has presented them, and how it has prevented them from
getting the help they need. We've heard from others that the law
itself isn't the problem; it's how it has been interpreted and
implemented out there. But that's the imperfect science of
law-making and interpretation. I worry that the new law in its
complexity will equally have problems of a potentially
pendulum-swing nature in its interpretation.
One of the other broadening
provisions you didn't talk about is the power of the police to
convey someone for psychiatric assessment, the change that they
no longer have to observe the behaviour but have to have
reasonable and probable grounds, which is a fairly
well-established legal test.
The other things you've
addressed around imminence and removal of the more vague
terminology of mental and physical impairment: I wonder if you
could address that police provision. What many family members
have told us is that, time and time again, when they do access
the police and get the police to come and intervene, the
behaviour has ceased by the time the police officers intervened,
and the whole intent of these changes is to try and ensure that
the person has a right of treatment as well, that they can get
the treatment when they're not in a position to make that
decision for themselves.
Mr Borovoy:
Then I take it, for those purposes, you would be talking about a
person who poses a much more imminent peril, if I can use that
term without begging any questions. You're talking about the kind
of situation where the person would fall within today's criteria,
the criteria in the current act.
Ms Lankin:
Maybe someone who on an ongoing basis is significantly
threatening bodily harm to themselves or someone else, but when
the police officer, the figure of authority, is on the scene,
they cease that activity, only to resume it again when the person
leaves.
Mr Borovoy:
I noticed that, and I guess my reaction to it was, "Is this
really necessary?" If the family has seen this person behave that
way, could not one member of the family then go before a justice
and swear and provide the sworn testimony that would be needed
under the existing act? In other words, they are the ones who've
had the experience. As a safeguard against abuse, shouldn't a
society like ours insist that those who have seen it put
themselves on the line and swear to it? That's one of the ways we
try to protect against abuse in our society. It's hard to imagine
a situation so dangerous that either that couldn't be done, or
when the police officer comes on the scene, the person isn't
behaving in such a disorderly fashion that the officer could act
in any event.
The Chair:
Thank you. We are out of time. Mr Clark, do you have a very quick
question or comment?
Mr Brad Clark (Stoney
Creek): Just a quick question.
Mr Borovoy:
It may not be a quick answer, though.
Mr Clark:
I've noticed. The legislation itself: Did you have an opportunity
to thoroughly review the proposed legislation?
Mr Borovoy:
To thoroughly review-
Mr Clark: To
thoroughly review the proposed legislation.
Mr Borovoy:
I've not thoroughly reviewed it in its entirety, no. What we have
done is focused on a couple of these things that were issues we
have been very much involved in over the years.
The Chair:
Thank you very much, Mr Borovoy, for coming before us. We
appreciate your comments.
NO FORCE COALITION
The Chair:
Our next group is the No Force Coalition. Could they come forward
to the witness table, please. Good afternoon and welcome to the
committee.
Mr Erick
Fabris: Am I to speak now?
The Chair:
Yes.
Mr Fabris:
Are other people going to be here or-
The Chair: I
think you'll find members wandering in and wandering out
throughout the afternoon.
Mr Fabris:
I'm quite happy to be here and to be able to present to you. I'm
interested in essentially re-informing anyone here who has seen
the No Force Coalition's statements in the past as to what we
stand for and what our position is on community treatment orders.
You've got some of the handouts. I believe there are more coming
your way very shortly.
What we aim to do as an
organization or a coalition is to educate our community and to
ensure that information that isn't readily available through
other journals or other areas is brought forward to people, including the
professionals and family members, who I know you've heard from,
some of whom are opposed to the present legislation and some of
whom are not.
I'm going to start by simply
reading some aspects or some parts of this presentation, starting
with the award that was mailed to members of Parliament some two
months ago. It is an award, in all seriousness, given to those
who would vote against community treatment orders. It says:
"To Ontario MPPs who stand
for human rights.
"The No Force Coalition
offers this award to those who will vote against community
treatment orders, which will be included in the Patients' Bill of
Rights," as we then believed it would be called.
"We urge you to consider
compassion and to respect the dignity of all your constituents.
By forcing involuntary treatment on people struggling to survive
in the community, people who are not a danger to themselves or to
others as understood in the Ontario Mental Health Act, community
treatment orders would strike a deadly blow to our community, and
would destroy basic human rights of freedom and choice. They
would cause unnecessary hardship, and disgrace a mental health
care system still in need of long-awaited reforms, especially the
implementation of less expensive supports and businesses
controlled by psychiatric survivors, which are proven
alternatives, long considered necessary and beneficial to the
emotional and physical well-being of people in need or in
distress. Psychiatric survivors are wrongly considered dangerous
and undesirable, yet we are a people most strongly committed to
the betterment of our community, and a group best able to
understand the impact of coercive treatment on us, on our
families, and on all Ontarians."
It then lists a growing list
of worldwide organizations, some of which are actual coalitions
themselves, some of which are organizations, funded and
non-funded, in Ontario, in Canada, in the United States, in the
UK and abroad. They are all organizations that have endorsed the
coalition's stand against CTOs. These organizations are not a
part of the No Force Coalition. The coalition itself is made up
of about 25 groups and individuals. These organizations have come
on board. I'd like to read that list a little later.
1610
I forgot to mention my name
is Erick Fabris. I am a member of the coalition and I was asked
to represent us here.
I just draw your attention
now to the open letter to members of Ontario's provincial
Parliament dated April 20, 2000. Again, the coalition was sending
in information and mailings that we thought would be of interest
to MPPs long before the present government actually tried to put
a bill together. We started just after Bill 78, which was put
forward by MPP Patten. Since then we've been working on this. So
some of this is going to be a little out of date. It's no longer
called the Patients' Bill of Rights, for example. This letter
reads:
"Thousands of Ontarians
strongly oppose wasting tax revenues and emergency services on
`community treatment orders.' While the Ministry of Health
promises a full continuum of voluntary supports in its policy
document, `Making It Happen,' it singularly works to impose
forced treatment in the community. This exhaustive reliance on
coercion in the guise of preventive care will fail people in
crisis and drive them underground. CTOs, as they are being
proposed, will offer patients a ticket off the ward in exchange
for their basic rights, choices and freedoms, and the cost of
this will be overwhelming in both financial and human terms. A
broad base of citizens has repeatedly decried CTOs in
consultations, in petitions"-we have a petition here that lists
some 322 people; for our community that's a pretty good
showing-"and in letters! It's time provincial legislators joined
their constituents in saying no to CTOs-let's put health care
money where it belongs and is needed most!
"Minister of Health Elizabeth
Witmer boasts that Ontario has already spent $150 million to
prepare for restrictive changes to legislation. According to the
ministry, a single `assertive community treatment team' costs $1
million to run, yet serves just 22 clients! There are examples of
teams that have been on payroll for months without engaging any
clients. Ms Witmer may keep two or three special interest groups
happy with such fast spending, but not taxpayers! One such lobby,
the `Schizophrenia Society,' holds marches and fundraisers for
pharmaceuticals and counsels families to lie to police to get a
family member committed." Incidentally, some of their funding
does come from pharmaceuticals.
"Police should not have to
spend additional hours in admitting rooms to resolve family
disputes by forcing someone to take harmful drugs. Only a handful
of psychiatrists (ie the so-called `Coalition of Ontario
Psychiatrists')"-newly formed-"want the laws changed. The present
Mental Health Act satisfies the" vast "majority, saying people
who appear to be a danger (or an `imminent threat') to self or
others can be locked up and treated against their will. The act
even has a `leave agreement' (Sec 27) that works very much like a
CTO. So why is Ontario shelling out millions to keep fans of
well-endowed pharmaceuticals happy, especially when these groups
don't have the facts about the issue?
"The No Force Coalition has
enclosed some of these facts in pamphlet form"-again as part of
our educational campaign-"and asks that you refer to your
constituents' objections to CTOs for further insight. You may
have already heard the principal arguments: `Mental illness' does
not lead to violence according to decades of research; force
doesn't promote health and is avoided by better health
practitioners; medications don't work for most people and they
often have dangerous effects; cost-effective services that
properly assist people in great need or in crisis need
recognition and funding-the widely popular service `Sound Times,'
for example, operates on $1 per day per visit," by its membership
of 450 and including salaries and rent.
It's a peer organization run by peers. It's well
respected in the community, both by professionals and by its
peers. They deal with some of the hard work of finding housing,
of finding people activities. You won't find that in most of the
clinical services.
"Sixty-eight groups in
Ontario and beyond have endorsed our stand against CTOs, some of
them representing hundreds of member organizations, including
family groups, service providers and especially psychiatric
survivors themselves! They believe CTOs will violate historically
protected human rights and will be resisted or ignored. Ask again
if your constituents want to pay millions to keep a handful of
people from refusing problematical treatments.
"We ask you to speak out and
vote against the CTO bill when it's introduced in the
Legislature, which may be as soon as this month.
"Thank you."
I won't read through the
entire list of organizations that are opposed but I want to bring
some to your attention. Let's just go through this: ACHES-MC
hails from Thunder Bay; All Saints Church-Community Centre is
here in Toronto; Alternatives I believe has already presented to
you; ARROW is a local organization as well; A-Way Express
Couriers is one of the peer businesses that were mentioned;
Bazelon Center for Mental
Health Law you've heard from, in Washington; CKLN Radio is of
course a local radio station; Campbell River and North Island
Transition Society in BC; Canadian Association of Elizabeth Fry
Societies are also interested in this legislation; the
Chatham-Kent Consumer/Survivor Network is a peer organization
there; the Clarke Consumer Advocacy Group is something similar to
the Patients Council at Queen Street; Community Resource
Consultants of Toronto, of course, is a larger professional
organization here Toronto; Consumer/Survivor Network of
Haliburton, Northumberland, Peterborough & Victoria is a
recently established group; the Depressive and Manic Depressive
Mutual Support Group in the Ottawa-Carleton Region.
Again, some of these groups
are not the usual groups that you would expect to oppose this
legislation. Many believe in the medical model.
DisAbled Women's Network of
Canada is also very interested in this legislation; Distress
Awareness Training Agency in the UK-I believe they're an
alternative type of group; Edmond Yu Safe House Committee, which
of course you've heard about since the inquest; Family Mental
Health Action Group, one of the family member groups that is
against the CTO legislation; Family Mental Health Alliance;
Family Outreach and Response Program. All of these are in
Toronto.
Fibremoon Studios is down
in the Niagara region; Fresh Start Cleaning and Maintenance,
another local peer business; Friendly Spike Theatre Troupe is a
local peer-driven theatre group; the Gerstein Crisis Centre of
course is renowned for alternative work in this area; the Global
Sisterhood Network;
Irren-Offensive from
Germany; Kitchener-Waterloo Sexual Assault Support Centre-again
many women's groups are also interested in this legislation;
Krasman Centre; Labyrinth Group from St Catharines; MadNation is
a clearing house of information and they're easy to find on the
Internet; Mental Health Legal Committee, whom you've heard from;
Mood Disorders Association of Ontario and Toronto; My Friend's
Place is a local organization;
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The National Association
for Rights Protection and Advocacy in the US; Ottawa Rape Crisis
Centre; Ontario Coalition Against Poverty, of course; Ontario
Council of Alternative Businesses; Ontario Federation of
Community Mental Health and Addiction Programs, which includes
220 agencies; Open City Productions 2002, another art-related
group; Parkdale Activity and Recreation Centre, a local
alternative centre; Parkdale Community Legal Service; People
Against Coercive Treatment; Phoenix Survivors Perth County;
Psychiatric Survivors of Ottawa; Psychiatric Survivor Pride Day
Committee; Queen Street Patients Council; Rosewood Shelter,
Women's Resources of Simcoe;
Saskatoon Sexual Assault
and Information Centre; Saskatchewan Action Committee on the
Status of Women; Saskatchewan Battered Women's Advocacy Network;
Sexual Assault Services of Saskatchewan; Sound Time Support
Services, mentioned in the letter; Speak Up Somerset is a
peer-controlled initiative in the UK; Still-room Collective
Street Health; Sudbury Sexual Assault Crisis Centre; Support
Coalition International, which includes 80 organizations in 11
countries, also a clearing house of information on this matter,
or in these areas; Survivors Psychiatric Advocacy Network, which
is in Lindsay, Ontario;
Toronto Women's Health
Network, which includes 100 and more agencies and individuals;
UnrulyWomen is another Internet group; West Virginia Mental
Health Consumer's Association in the US; Women's Counselling,
Referral and Education Centre here in Toronto; York
Anti-Oppression Coalition, York University; York University
Graduate Students Association; York Women's Centre at York
University.
Would it be fair to
describe the opposition to community treatment orders in
principle and certainly Bill 68 as quite far-ranging? Both
families and providers have enlisted and have spoken out. Let's
have a look at some of their quotes here:
Tunde Szathmary says, "The
concept of community treatment orders in my situation means that
you're denigrating my spouse, my marriage, by saying these are
not people with their own rights. They can be well enough to make
their own decisions. CTOs are just not acceptable because they
assume a person will never become well enough. CTOs are
institutionalization in the community."
Lana Lam Chau says, "Why
force people on medications instead of helping them in their
homes? Where is the happiness in depending on chemicals? It feels
like a contradiction. A
dependency on medication is being created."
Ganesh Pon says, "Anyone
who is resistant to medication is going to be aggravated by
forced medication. My son has not improved by being on
medication. Forcing the medical model is tunnel vision."
Danuta Zbromsky says,
"Medication has helped our family. He functions much better.
However, we are aware there is no cure so we make the best of the
time we have. He has been able to work part-time. But I am
concerned about the violation of his rights. Let's try other
alternatives first."
Pat Oldaker says,
"Education about the existing laws is what is necessary"-I know
that this government has done some of that work-"I can't imagine
ever using a CTO on my daughter."
Hella von Delm says, "I
believe we already have enough laws to take care of patients in
crisis, but we cannot allow all patients to be forced to give up
their rights of self-determination. This is taking away all hope
for a future as a well person. There have been successes in
treating schizophrenia without medication for life, or even many
years."
Service providers obviously
are also on side with the No Force Coalition.
We have Dr Bonnie Burstow
saying, "As an Ontario psychotherapist, I am appalled by the
government's intention to bring in community treatment orders-a
measure appropriately known in the psychiatric survivor community
as `leash laws.' Community treatment orders are about control and
tyranny, not help, and they violate freedom and decency. They
threaten the well-being of all Ontario citizens who have ever
come in contact with the psychiatric system or who ever may."
Cathy Crowe, whom you may
know as a community health nurse, is the coordinator of the
Toronto Disaster Relief Committee. She says: "I've been a
community health nurse for 20 years, for the last 12 as a street
nurse, working with people who are homeless. I know I will never
ever use CTOs. The Mental Health Act functions adequately to
protect people who become very ill. Yet it is no substitute for
the care and support some people need on an ongoing basis and
that includes competent and caring community-based mental health
care, decent housing, mental and emotional health supports and
enough money to live on. These are the building blocks for
dignity for people with mental health problems. Forced
treatments, via CTOs, will simply strip people of the last
vestiges of choice in the health care system. It makes me think
of bad medical experimentation on people. It also makes me think
of what happened in early Fascist Germany," which is not just a
metaphor, by the way.
Continuing on the next
page, Cheryl Rowe, an MD, FRCP and a community psychiatrist and
assistant professor at the University of Toronto, says: "CTOs are
unnecessary and have the potential to violate human rights and
damage the doctor-patient relationship. We have other laws to
protect an individual and society. We need help in building
relationships with patients and creating mutual understanding and
respect so that people can make good choices for themselves and
their treatment."
You may have been
interested in this person's credentials. Some of the individuals
who signed up have credentials that are just as impressive.
Another person who speaks
out against CTOs is Victor Willis, the executive director of the
Parkdale Activity and Recreation Center: "When an ill-conceived
law is put into place we must oppose it or we give up our rights
when further bad legislation is created. The proposed change to
the Mental Health Act, specifically community treatment orders,
is an example of an ill-conceived law. Quality of life does not
come from a needle or a pill. It comes from homes, jobs and
friends. As someone who grew up with a parent who had a diagnosis
of a major mental illness, I am appalled."
Maurice Adongo, a street
outreach worker with Street Health, says: "According to the
government, the CTOs will help provide treatment for people in
the community, but they should ask themselves one question, `For
a homeless person, where is that community going to be?' In the
parks? Or under the bridges? How are we going to force medication
on people who do not even have a place to store the pills? CTOs
are nothing but a cruel joke for the homeless people who are
battling mental health problems. I'll be glad for the day when
our government wakes up and starts dealing with real-life issues
like providing dignified housing as a starting point to help
people put their lives back together. How many times do we have
to continue repeating these obvious things?"
Trish Spindel, a professor
of social services at Humber College, says: "CTOs are nothing
more than the use of coercion by those with power against a
vulnerable population which is unable to defend itself. Coercion
has never improved anyone's quality of life, nor is its use
effective in preventing harm," which of course is backed up by
studies the Bazelon Center has presented. "CTOs will result in
the `relaxing' of innocent people's due process rights, further
expansion of both biomedical and police powers, and they will not
produce the `results' which the government is trumpeting. If
government was to put half as much energy into supporting people
through decent housing, a wide range of community support
options, and a guaranteed annual income, as it is putting into
trampling on people's rights in the name of helping them, we
would be a long way down the road to building a decent society in
which people who have been labeled would feel more secure and
less threatened."
1630
Barbara Cadotte, a systemic
policy adviser at the Psychiatric Patient Advocate Office, says:
"Our current legislation has developed over many years, through
consultation to improve the delivery of mental health care and
the incorporation of legal safeguards to protect the rights
guaranteed under the Canadian Charter of Rights and Freedoms. The
proposed measures to permit community treatment orders will not
ensure people will have
access to the best treatments available, including access to the
best medication with the fewest side effects, nor will it provide
early intervention by knowledgeable health care workers. Further,
using resources to forcibly treat individuals (or to track down
people who choose not accept the prescribed treatment) diverts
attention from the need to ensure a better continuity of mental
health care, and access to a range of resources for those who
require them."
Lynne Raskin, executive
director of Alternatives, says: "Living in the community gives us
the right to make decisions about our own lives. All of us have
both rights and responsibilities as citizens and there are laws
to ensure that criminal transgressions are duly addressed. But
when a society begins passing laws that infringe on the civil
rights of a distinct group, we violate ethical codes, human
rights and we chip away at the moral fabric of that society.
Community treatment orders do just that: Orwellian laws for a
group of citizens who will be left with fewer rights than the
rest of society. Undoubtedly, this will result in fewer people
wanting to seek help from a system that blatantly espouses
disrespect and disempowerment and fewer people wanting to work in
a system that turns support into whistle-blowing and
paternalism."
I'm a psychiatric survivor
myself. I just wanted to show you some suggestions that were
worked out at a meeting approximately two years ago, or was it
one? It was a long time ago; it feels like two.
I'm going to talk about
some alternatives to some of the force that is being promoted in
this legislation. These things won't be forced in Bill 68. You
wouldn't imagine psychotherapy being forced upon you, you
wouldn't imagine affordable and safe housing being forced upon
you-I wish that were-you wouldn't imagine peer support programs,
consumer-survivor-run services and initiatives being forced, but
these are some of the alternatives we need to look to in order to
ensure that the money we put into mental health actually starts
to work for people.
A wider range of choices in
treatment and therapy should include non-coerced services; real
employment, such as peer-run businesses; a parliamentary review
of the costs and aftermath of this bill, of CTOs in Ontario,
should be done; protections and accommodation in the workplace;
enhanced independent legal protections against institutional
abuse; a response to child abuse, to child assault and emotional
trauma; a response to women abuse-rape, battery and emotional
abuse; more support programs such as social and recreational-
The Chair:
Excuse me. I just wanted to put you on notice that you've got
about one minute left in your presentation.
Mr Fabris:
OK. I'll just open the floor for questions if I have the
time.
The Chair:
Sorry, we wouldn't have the time to do the rotation; if you want
to just finish off with concluding comments. We could hardly
state our names in 60 seconds, never mind pose a good
question.
Mr Fabris:
I guess you can read the rest of these alternatives. There's not
much to say at this late date. We've presented the information to
you numerous times. I just hope you've received. I hope you can
read it now if you haven't looked at it already. Please consider
the pamphlets not as trinkets but as distillations of much more
serious research that you will find, given that they quote where
that research comes from.
Given our presentation, not
as the mental patients presenting, ask yourselves whether or not
the suffering of some family members is equal to the suffering of
some mental patients. Ask yourselves whether there is inequality
in the service between those who are not given treatment and
those who are given treatment but it harms them. Ask yourselves
if this bill is simply expanding criteria to give the public a
sense of safety when the present act gives them that safety,
according to Michael Bay. That's all I'd like to say today.
The Chair:
Thank you very much, Mr Fabris. We appreciate your taking the
time to bring your perspective before us here today.
Mrs
McLeod: I'll apologize if the committee has already
asked for this. I'm wondering if it's possible to get a clear
statement about the status of electroshock treatment in Ontario's
psychiatric hospitals.
The Chair:
I don't know whether it's fair to ask Mr Clark. Is that what the
researcher has just-no.
Mrs
McLeod: One of the pamphlets was on electroshock
treatment. I think, as we talk about the issue of any kind of
involuntary treatment, that's one of the issues we should be
concerned about.
The Chair:
We'll ask research to bring you back a definitive answer.
Mrs
McLeod: I appreciate that. Thank you.
Ms Lankin:
As long as we're on research matters, I wanted to follow up on a
request I made. The days are all blurry at this point, but I
think it may have been at the subcommittee meeting prior to the
beginning of hearings, where I had asked for a summary of the
Mental Health Act and amendments and changes, the pre-1978 and
post-1978 regime. I'm wondering if anyone recalls that I had
asked for that and if work is underway.
Ms Lorraine
Luski: Work is underway.
FAMILY MENTAL HEALTH ALLIANCE
The Chair:
Perhaps we could call forward the next group, the Family Mental
Health Alliance. Good afternoon. Welcome to the committee.
Ms Tunde
Szathmary: I don't know how much I will have to say, but
I'll try and leave some time for questions. I'm sorry that I
didn't get our brief done in time so that we could actually
distribute copies, but hopefully by the end of the week I'll have
it finished and to you.
My name is Tunde Szathmary.
I'm the coordinator of the Family Mental Health Alliance.
The Family Mental Health
Alliance is an umbrella organization of family self-help groups,
agency and/or hospital family support programs and individual
family caregivers in
Metro Toronto. The alliance began as a networking effort in 1995
to enhance the capacity of family self-help organizations to help
families and friends cope with mental illness and mental health
problems in their immediate circle. The opportunity of coming
together also opened the way to amplifying the voice of families
and informal caregivers in mental health planning and formal
system design. Through the sharing of information and the
articulation of the family perspective on a variety of issues,
the steering committee of six group or program representatives
and six individual family members reaches out to 11 other local
family groups as well as government and other stakeholders in the
mental health system.
Our interest in CTOs began
about two years ago, when we realized what a divisive issue it
would be for the family sector. Up until that time we felt that
families had made significant inroads through mental health
reform. In the past, the relationship among stakeholders,
particularly towards families, was very adversarial, and we saw
the beginnings of a new partnership where the dire straits of
families were sometimes raised not only by family members but by
consumer-survivors and service providers who were open enough to
hear what we had to say and carry our concerns forward with the
same legitimacy that they carried their own concerns forward.
We started our approach to
CTOs, therefore, by trying to inform our community of families
what it was about and trying to present all points of view. We
basically produced a paper, called Community Treatment Orders:
Solution or Symptom, in which we looked at the attitudes the
consumer-survivors might have about it, and some family members,
that CTOs make community tenure look like a lifetime probation,
that treatment recommendations look like parole restrictions or
bail conditions, that hospitalization feels like punishment for
disobedience or jail for the crime of illness and
deterioration.
We wondered what this would
do to our relatives and what it would mean for us. We were
concerned about enforcement and whether the responsibility would
twist the therapeutic relationship into something that wasn't
therapeutic. We wondered if the responsibility ultimately
wouldn't devolve to families, the way so much of everything else
has. We were concerned about breaches in civil rights and in
human rights. For caring family members, there's a real horror of
seeing their family member as totally discredited and
discounted.
1640
We asked why our relatives
and other people become non-compliant with medication and we
looked at that issue, because the implicit assumption in CTOs is
that repeated hospitalization or relapse is caused by treatment
non-compliance. We came up with a number of answers. I won't go
reading all of them now, but essentially the answers are not much
different than the reasons for non-compliance among seniors, 50%
of whom also don't comply, and other people in the community who
are dealing with heart disease or other illnesses. We wonder why,
then, this applies only to our consumer-survivor relatives and
other consumers-survivors in the community.
We concluded, after our
evaluation, that treatment non-compliance was multifaceted and
required an appropriate response in every case. A
one-size-fits-all CTO would be a disservice to our relatives. It
could even be dangerous because of the possibilities that come
with CTOs. There are very severe adverse side effects: tardive
dyskinesia, neuroleptic malignant syndrome and other kinds of
morbid and mortal risks. The system sometimes enhances racism,
and CTOs could lock in a person very inappropriately. There is an
increased stereotyping of people with mental illness as
dangerous, ignorant or inherently uncooperative in some of the
criteria that have been put forth for CTOs. We're afraid CTOs
would increase the stigma for help-seeking, and there's always
the increased potential for abuse. As much as I like to defend
families, there are always problems and there obviously have been
incidents where families have abused relatives, as have other
caregivers, and we feel that kind of risk needs to be taken very
seriously.
The potential for CTO to be
seen as an entitlement for service that could force service
provision, or a service order, in other words, could barely
balance the risks, in our estimation. Everything would lie in how
the CTO provisions were laid out. We felt that with the
inadequacy of system resources now, CTO would merely cover system
failure and do violence to vulnerable individuals who are already
vilified in our society for their mental health problems.
Bill 68, Brian's Law,
basically has said it heard from families. The FMHA and the
families it has talked to are not in support of CTOs. We have
grave concerns about forced treatment, not only because of some
of the elements that I mentioned above, but because of the nature
of treatment which usually devolves to drugs. Please don't
misunderstand us on this. Families by and large are in favour of
medication. However, we see that the revolving door of repeated
psychiatric hospitalization is due as much to the failure of
medication as it is to the induction of relapse by stress from
poverty, idleness, loneliness and insecure futures in housing and
treatment services. Medication non-compliance is just one part of
it. We believe that the benefits of medication are and can be
made self-evident with appropriate community supports rather than
CTOs.
In The Psychotic Patient:
Medication and Psychotherapy, 1985, Collier Macmillan, Dr David
Greenfeld notes that consent can be obtained with patience,
sensitivity to the client's own dissatisfaction with the
experience of psychosis, and honesty about alternatives. Success
requires an intensification of time and effort, which are much
more benign to the client than force. More recently, Healey et al
described the use of a new psychological intervention called
compliance therapy, which was more effective and cost-efficient
than the usual counselling. These items are referenced in my
paper. Non-compliance with medication, which is the implicit
issue in the hospitalization criteria of Bill 68, can be better handled without
legislation which places people at risk.
There is an underlying
assumption in CTOs for medication, that medication is always
beneficial and that errors in treatment are benign. At this time
I would like you to think about Ewan Fastofsky. Gabriella, his
mother, is in the audience today. She survives her only son, who
died at age 38 this past January 5. Gabriella has told us that
Ewan died of thromboembolism. She had been concerned about his
deteriorating condition since last October and her appeals to his
doctor were largely ignored. In grief, she went to the Metro
reference library to investigate why her son died. In a volume on
pharmaceutical and specialty drugs, she discovered that
Clozapine, the miracle drug we have all heard about, came out in
the 1960s and was banned in Sweden because of a link to
thromboembolism. It was only last week that I downloaded an
article from the Internet which reports that a Swedish study on
thromboembolism was published in the Lancet this April 1.
Gabriella asks you to enforce the laws on informed consent for
people who will ultimately bear the risks of the range of adverse
effects which accompany any serious psychiatric medication. Her
son should have had a chance to say no without the backdrop of
CTOs if he did.
The FMHA would ask you also
to ensure that substitute decision-makers who step in for their
relatives when they are incapable of consent be similarly fully
informed and free from pressure. We would like the decision of a
substitute to err on the side of caution to be respected in the
treatment centre. Lana Lam Chau, who is also in the audience
today, is a mother who lost her right and her son's right to have
her make decisions for him because she disagreed with his
doctor's advice. Her son, Thai, 37, is called uncooperative, but
Lana tells us that he is scared of the staff involved in his
care. He has not stabilized with the treatment imposed and Lana
fears he never will while it continues without his or her input.
The system does not appreciate that ethnoracial derivation may
make the usual script of treatment inappropriate. Lana asks you
to ensure that a substitute's authority to follow prior wishes or
assess new ones according to the substitute's knowledge of the
values and the beliefs of his or her relative will not be
challenged. Most specifically, ethnocultural and ethnoracial
factors need to be accommodated. The Family Mental Health
Alliance agrees. Bill 68, however, introduces several
amendments which would allow strangers to intervene.
The FMHA believes that
overriding a substitute decision-maker is in most cases
fundamentally wrong. It is also concerned that Bill 68 amendments
could be used to force an unwilling substitute to consent to CTOs
or risk losing any formal place in the protection of a relative's
interests. You may point out to me that the system is there for
our relatives. It didn't work in the case of Regis Belmar.
Mary Belmar is here today
as well and wants me to tell you about what happened to her son,
Reggie, 39, who died last July 14 through a series of
misadventures in the mental health and the health care systems.
His death was the culmination of a woefully inadequate response
to a medical condition, compromised by physical restraints that
were placed on him when he got upset over being transported to
hospital by a community worker who offered to take him for a
ride. Reggie had not been in hospital for eight years and didn't
like it because of an untreated infection he had suffered there
years before. He was doing all right except for weight gain,
which led him to go off his meds. In trust, he told a community
worker, and ended up subdued, involuntarily hospitalized and
vulnerable. Mary would ask you to reconsider the issue of
betrayal that's inherent in CTO enforcement. It can backfire
tragically.
These women and countless
others have experienced a variety of traumas in the mental health
care system and they fear, quite reasonably, we believe, that
CTOs may be a way that the system can avoid looking at itself for
faults. It is in the nature of families, as it is in the
self-help and mutual aid groups which gave rise to the FMHA, to
be concerned about systems issues like quality of care.
1650
The FMHA believes that it
would be complicit in an unknown and as yet unknowable level of
suffering if it did not reiterate its message of caution about
CTOs. The mental health system needs to be resourced adequately
first so that it is able to provide the time and the expertise to
individualize treatments and supports. If, after all the
alternatives are tried, a rare individual may need something like
a CTO, we'd all have a better idea of who needs it and why.
Fine-tuning legislation may then work, as Bill 68 does not.
There are a number of
issues that we found in Bill 68 and these are the parts that I
didn't quite manage to get typed up. Essentially, some of them
have to do with the mishmash of criteria for getting someone in
for an assessment. One of the elements that we were concerned
about was the criteria for finding previous treatment for a
disorder with a likelihood of harm. We don't believe we've ever
seen any research that indicates that there is a disorder likely
to cause harm. That is not one of the classic signs and symptoms.
Basically, that kind of criteria is unworkable.
We also had trouble with
the criteria that talks about having shown previous improvement
to treatment. There is research certainly in the mood disorders
field, which is my family experience and where I come from, that
interrupted treatment very often means that the treatment that
was effective previously is no longer effective. You cannot
assume just because someone has had a particular kind of illness
at one point and has had a particular kind of treatment at one
point that it will be effective again, and the criteria really
rest on that.
The same kinds of things
actually come up in the CTO criteria. We found a couple of other
problems there. We were concerned that part of the criteria had
to do with hospitalization: accumulative, 30 days, or in-patient
two or more times in three years. This suggests that
hospitalization is a
sign of failure. Sometimes hospitalization is a sign of success.
People who need help would be wise to go to hospital, especially
if they're suicidal or homicidal. Sometimes people have
breakthroughs for no reason whatsoever to do with treatment. I
mentioned earlier the issue of stress. I could relate one very
stressful incident from my own family this past January. My
father-in-law was dying and my 85-year-old mother-in-law asked my
husband to look after his father overnight because she needed
rest. They could not get home care. I urged him not to do it
because of the risks but he did it and within three days he was
manic, after five years of being somewhat level. He ended up
spending a week in hospital. He did not do anything that would
justify having his hospitalization held against him, so I have
concerns about that kind of statement in criteria.
We were concerned also that
the nature of the plan was not clearly defined as to what could
be included and what couldn't. Could, for example, part of the
plan deny people access to their friends in the consumer-survivor
community? In the past, very often staff in hospital would not
allow a consumer-survivor to come back and visit friends once
they were discharged. A lot of service providers and family
members are sometimes suspicious of the consumer-survivor
movement because they're afraid that it will convince them either
that the families are to blame or that treatments don't work and
it would make them non-compliant. We wonder what kind of
restrictions can be included, since none is specifically
excluded.
The Chair:
Excuse me, Ms Szathmary. We're at the end of the 20 minutes but
I'd like to allow you another minute or so if you've got any
concluding comments.
Ms
Szathmary: One last conclusion and this would, I think,
be most addressed to Mr Patten.
We found that the same
elements that were in his proposed amendments a year or two ago
when a person did not comply with CTO or the release conditions
held. That specifically was that the person would be notified
that they had abrogated the agreement and a whole set of
conditions or steps would follow in which they would be notified
and they would be offered assistance to help in compliance etc.
What concerns us is that one of the elements there is, if a
person is dangerous to himself or others, those kinds of steps
ultimately will delay very necessary treatment. There are a
number of little points like that that we would like to make in
our final submission.
The Chair:
Thank you very much. We appreciate you and the members of your
association coming down before us. We know how difficult it is to
share those stories with us, but we truly appreciate your taking
the time to come down and be part of the hearings on the
bill.
RUTH MALLOY
The Chair:
Our next presentation is from Ms Ruth Malloy. Could Ms Malloy
come forward. Good afternoon. We have 10 minutes for your
presentation.
Ms Ruth
Malloy: I can tell you about myself. There are three
things I really like doing a whole lot. One is making trouble,
one is talking about my kids and the other one is answering
questions.
The Chair:
You'll have trouble deciding between number 2 and number 3 then
in the time that you have.
Ms Malloy:
If I don't get questions, I'm going to start making trouble and
talking about my kids.
The Chair:
Please proceed.
Ms Malloy:
I may begin. I worked really hard on this. It doesn't answer all
the questions, but it says some of the things that are in my
heart.
My views on schizophrenia
have evolved over the past 20 years through living and working
with people with schizophrenia, formal study, reading books and
journals and attendance at conferences and public forums,
augmented by daily contact with three wonderful children who
suffer from schizophrenia.
From where I sit it looks
as if CTOs and the abandonment of the dangerousness criterion for
involuntary treatment would help people with schizophrenia to
enjoy more freedom and to live consistently fuller, more
productive lives in less restrictive community environments. What
I don't understand is, why have you waited so long to do
this?
Please let me emphasize
that it is not the intent of the proposed amendments to take away
any of the genuine rights and freedoms presently enjoyed by the
mentally ill. The target population for CTOs would be that small
proportion of the mentally ill who lack insight into their mental
state, have a history of robust response to medication, repeated
readmissions to hospital and a chronic history of treatment
non-compliance. Others have no reason to fear loss of
autonomy.
Rigorous scientific
investigation suggests that schizophrenia is a brain disease. The
schizophrenia syndrome originates from neurochemical overactivity
in the part of the brain where raw incoming sensory stimuli are
sorted and formulated into thoughts and perceptions. The symptoms
typically include two or more of illogical thinking, social
withdrawal and false perceptions, such as hearing voices, and
false beliefs that seem so totally real that it is impossible for
another, no matter how eloquent their arguments, to reason them
away. These symptoms respond well to traditional anti-psychotic
medication, and the medications are safer than aspirin. My son
swallowed 73 pills on one of his three suicide attempts.
In addition to the florid
symptoms, there is a broad spectrum of treatment-resistant
deficits, such as impaired memory and concentration, loss of
abstract and analytic thinking, loss of self esteem and feelings
of persecution which are masked by more florid symptoms during
acute episodes. I'm going fast so I'll have more time for
questions.
1700
The deficit symptoms are
frequently mistaken for medication side effects because they do
not become apparent until after the medication has removed the
more florid symptoms. New medications that help to relieve
some of the deficit
symptoms, in addition to the more florid ones, have come on the
market recently. My son and one of my daughters recently changed
to Olanzapine. They both like the new drug. According to my son,
the switch to non-traditional medication "gave me my life
back."
In about a month they will
experience the full benefit achievable on their present dose, and
the physician will adjust the dose accordingly. My other
daughter, who went on Clozapine in February, is finding that her
voices are getting softer and less frequent and I am noticing
that she is thinking more clearly.
I have to make a reference
to the former speaker. There are an awful lot of people with
schizophrenia who die from suicide. In fact, the rate is one in
10 and 40% try. So there's a death rate there that needs to be
considered when you're looking at what happened to her son.
When anti-psychotic
medication, the penicillin of schizophrenia, was developed in the
mid 1950s, community care for people with schizophrenia became
workable. On the other hand, it takes up to three months of
continuous treatment to achieve maximal benefit, and ongoing
prophylactic dosage is essential to achieve maximal blockage on
the neurochemical overactivity. Deterioration inevitably takes
place when an individual stops taking their medication.
Using CTOs to keep people
living in the community on their medication would virtually
eliminate rehospitalization due to medication noncompliance. In
one early study in the United States, for example, 95% of people
with schizophrenia readmitted to hospital were not taking
medication at the time of their readmission. Moreover, compliance
is frequently confounded by the individual's lack of insight into
their own mental state. Approximately half the people with
schizophrenia do lack insight into their mental state. Dogged
insistence on voluntary consent to treatment does them a gross
injustice. Without anti-psychotic medication, all the services
and all the freedoms in the world are of no use. Sadly, a return
to custodial care in large institutions would be the only
compassionate alternative to medication.
My daughter once tried not
taking medication. She eventually withdrew to her room where she
fantasized herself to be held prisoner by aliens who were sending
vibrations from outer space. She could have starved to death if
she had been living alone. She was not ready to benefit from
services again until after she had resumed pharmacotherapy.
A brief word now about the
proposal to abandon the dangerousness criterion for involuntary
hospitalization. I strongly support this proposal. Dangerousness
is far too difficult, even for seasoned experts with years of
experience, to assess accurately. Consequently, it is too awkward
and clumsy a criterion to have realistic value. Furthermore, it
permits many people who are afflicted with severe mental
deterioration and desperately in need of compassionate
intervention to slip through the cracks. I once waited five
months for my daughter to become sufficiently psychotic to be
admitted to the Clarke.
Speaking again from where I
sit, it looks as if a significant proportion of those homeless
who have died on our streets, mentally ill persons shot by
terrified policemen and bizarre slaughters of family members,
likely involved people with untreated schizophrenia who would
undoubtedly have benefited from CTOs. Furthermore, abandonment of
the dangerousness criterion for involuntary treatment would
reduce poverty, unemployment, marriage breakdown, child abuse and
the need for psychiatric housing, in addition to diverting more
people with schizophrenia away from the justice system.
The Chair:
Thank you, Ms Malloy. You were able to use number 2 to great
effect. You've left only a few seconds before the end of the
10-minute mark. If you had any other closing comments I think
rather than try to play Solomon here-
Ms Malloy:
I could comment on some of the things I've been listening to.
The Chair:
If you can do that in a minute or so.
Ms Malloy:
A lot of these things have really big holes in them as arguments.
I remember one night my son had had a few beers. A person who has
schizophrenia who is also a substance abuser can be very
dangerous. That's enough about the dangerousness thing. We were
just in absolute terror. He was burning himself with cigarette
butts. He wasn't making very much sense. He was carrying a knife
around the apartment. I ran for security. His two brothers, while
I was talking to the police, both came down and asked them to
hurry, and he went off like a little lamb. And you know, he
didn't hold this against us, that we made him go in. It didn't
destroy the therapeutic relationship. In fact, I have worked with
people who will go and ask to be put in restraints because they
know they have an episode coming on.
Any questions? OK, I'll go
on talking about my kids.
The Chair:
We've actually gone over the 10 minutes, but we very much
appreciate your bringing your perspective to the committee
hearings today. Thank you very much for taking the time.
ASSOCIATION OF GENERAL HOSPITAL PSYCHIATRIC
SERVICES
The Chair:
That takes us to our next presentation, from the Association of
General Hospital Psychiatric Services. Could they come forward,
please. Welcome to the committee. We have 20 minutes for your
group presentation this afternoon. If you care to leave time for
questions and answers, that's your prerogative.
Ms June
Hylands: Thank you. I think we'll have time for
questions. We certainly hope so.
I'm June Hylands, the
executive director of the AGHPS. With me is Dr Turner, the
president. We would like to thank the committee for the
opportunity to be able to respond and give our perspective on the
mental health amendments.
The Association of General Hospital Psychiatric
Services has been in existence since the early 1980s. We
represent about 50 general hospital and schedule 1 facilities.
These are hospitals that are all over the province. Our board is
comprised of about 20 members and is in a unique position in that
it is made up of chiefs of psychiatry and directors of mental
health programs, so it really gives a comprehensive perspective
on the general hospitals' viewpoint.
We are responsible, as you
know, for in-patient, outpatient, day surgery and emergency
services, and therefore we represent the mental health providers
who will be responsible for implementing the changes that occur
as a result of these amendments. What we would like to focus on
today is the implementation of these amendments.
Dr Ty
Turner: My name is Ty Turner. I'm a psychiatrist. I'm
the president of the Association of General Hospital Psychiatric
Services. I'm also the chief of psychiatry at St Joseph's Health
Centre in the Parkdale area of Toronto, one of the busiest
hospitals in the province. Before that I was the chief at Doctors
Hospital. I've been in the mental health system for over 35
years. Before I became a psychiatrist, I was the first provincial
coordinator of the Psychiatric Patient Advocate Office, a program
of the Ministry of Health.
I just want to amplify some
of what June has said and then expand a bit further.
As general hospitals,
having 24-hour, open-ended intakes called emergency departments
and being empowered under the Mental Health Act, we are really it
for the most part for this legislation. We're the ones who are
going to be required to implement it. We have very significant
concerns about the implementability of these proposed changes to
the act.
In our setting, in
hospitals, if a person is apprehended in the community by the
police, conveyed to a hospital for psychiatric examination,
detained and, if necessary, restrained and examined, this happens
in our hospitals for the most part. If the person then is ill and
meets the Mental Health Act criteria for commitment, it's
generally to our hospitals. If somebody is really ill, ill enough
to be on one of these proposed community treatment orders, it's
very likely that the designated psychiatrist is going to be one
of our staff, because often the community treatment order will
start with a hospital admission.
I'd like to provide a bit
of context about what's happening in the general hospital system.
As I'm sure everybody here is aware, the mental health system has
been very significantly downsized. There has been a policy geared
towards reducing the number of beds in the mental health system
in Ontario, from about 58 per 100,000 to about 35 per 100,000. In
some parts of the province we're probably at or below that number
at this time. Most of the bed reductions have come from or are
expected to come from closing down provincial psychiatric
hospital beds. Some, probably a small number, will come from
further erosion of general hospital beds.
1710
In this downsized system,
we have very significant problems in respect of general
hospitals, for the most part within the context of mental health
reform, not having achieved significant recognition for our role,
and to some extent we have to accept responsibility. We haven't
always had our act together. For the last few years, for the most
part we've been dealing with hospital restructuring. Some of our
hospitals have been closed, others have been amalgamated and this
has preoccupied us. We're about ready to come out of that now and
begin to offer perspective.
We also have very
significant issues in respect of staff shortages. We're currently
depleted by about 200 psychiatrists. These, for the most part,
are the physicians who will be required to implement the Mental
Health Act changes. We have shortages even in alleged
overserviced areas. Let me tell you, I just came down from
Timmins where they only have two psychiatrists. Covering 24-7
with two psychiatrists is pretty difficult. In Kenora they have
two psychiatrists. In Sault Ste Marie they only have three
psychiatrists. I think if we go across the province, we'll find
these shortages are reasonably prevalent.
When we do find small
numbers of psychiatrists, often we'll see that these
psychiatrists tend, like myself, to be rather middle-aged and
over the next 10 to 15 years will be coming up for retirement.
The other day I was speaking to a chief of psychiatry at one
hospital who was telling me about a five-person rotation covering
24-7. Four out of five psychiatrists are over 60. There have been
significant problems attracting and retaining psychiatrists to
work in general hospitals.
We've also had issues
around dollars. I'm sure you know a lot about this. Basically our
budgets have been protected but that means flatlined, and
flatlined for the last four or five years. We've actually had
some loss in terms of that aspect of the budget that helps to
retain psychiatrists called sessional money. That was reduced by
25% back in 1993. With the current OMA agreement, that will be
restored back to 1993 levels. This is before we had the major
part of the bed reductions I've just referred to.
In respect of the specifics
of the proposed legislation, I see two general areas. One is
about community treatment orders, and I'm sure you've heard a
great deal about that. The other part of the proposed changes
will probably impact even more on our work.
In terms of the first, the
community treatment order, I'm sure you've heard a lot of
opinions on both sides. I can say that within the psychiatric
profession there is some controversy about community treatment
orders and their ability to truly function, their acceptability
by psychiatrists, the degree to which they will be utilized, and
also how effective they are in terms of not only protecting
patients and their families but also protecting very scarce
resources. I know the focus of these proposed changes is not
about resources, but I think we need to have the kind of reality
check that would be helpful in terms of knowing what the actual
implementation of these
changes would look like. So we're not sure about the community
treatment orders.
In terms of the other side
of the proposed changes, having to do with loosening the
commitment criteria and with enhancing or enabling police
apprehensions, these are actually designed to bring more people
into hospitals and cause more people to be kept. Ladies and
gentlemen, quite frankly, as somebody who has been practising in
hospitals and has practised in over 20 different hospitals over
the last 25 to 30 years, I don't know how we're going to do it. I
have no sense of how we're going to achieve the objectives of
this act. I'm very concerned that the act, which was born out of
noble and altruistic intentions, could become discredited through
its unimplementability, if that's an English word.
It causes me to think about
some other jurisdictions where legislation like this was passed,
such as in Washington state in 1982 when commitment criteria were
opened up and there were floods of patients coming into the
hospitals and this created great disorder; or in Italy in 1978
with law 180, where there was a major deinstitutionalization,
developed and passed by the Italian Parliament with no
significant implementation plan. That law became discredited, not
out of the intention behind the law but by major difficulties in
implementation.
So we're very significantly
concerned here, and as a result of that, flowing from that, our
recommendation is very simple: that however legislators decide to
deal with these proposed changes, whether to pass them or not,
whether to amend them or not, the law not be proclaimed until we
have an adequate implementation plan.
In Ontario we have a
precedent for this. In 1978 the Honourable Dennis Timbrell led
the passage of amendments to the Mental Health Act that we're
currently seeking to reverse to some extent. There were two
sections, 66 and 67, which had to do with mandatory notification
of the legal aid plan and provisions for more due process at
commitment hearings before the administrative tribunal. If I
recall, these sections were not proclaimed until six years later.
In the AGHPS, we're not necessarily recommending six years. We're
just recommending that proclamation be delayed long enough to
allow the stakeholders to come together with government and
develop a suitable plan for implementation.
That pretty much completes
my presentation. June, would you like to add to that?
Ms
Hylands: Just to reinforce that, our association's
position is that we conceptually support the amendments to the
Mental Health Act. We feel it would be a tragedy if they were not
implementable. We congratulate the government on the profile
that's been given to mental health and the sincere effort, and
we'd like very much to work with the government to ensure this is
implemented in a way that is constructive and useful. We
sincerely believe that the stakeholders within general hospitals
and schedule 1 facilities need to be involved in forums and in a
meaningful way to establish the mechanisms for doing that.
We thank you once again for
your time and we welcome any questions.
The Vice-Chair (Mrs
Julia Munro): Thank you very much. We have about three
minutes per caucus for questions; I believe, in rotation, we're
with the government members.
Mr Clark:
During the consultations I had this last round, the issue of
implementation and proclamation came up quite consistently. One
of the concerns that was raised by a number of groups was similar
to your position. Is it your position in essence that the entire
bill should not be proclaimed until there are sufficient
resources to allow for success? One of the concerns I raised
during the consultations was that we can do all the legislative
reform we want, but if we don't have the resources in the
community to support the patients, it's going to fail. Would you
care to comment on that?
Dr Turner:
As an association, we would want to see the entire legislation
reviewed in respect of implementability, though there are really
these two broad areas. The area where we are most concerned about
implementation has to do with loosened commitment criteria and
with facilitated police apprehensions. They're the ones that are
really going to strain the system even further. These are the
ones where I would say the concerns about implementation are
particularly grievous.
Ms
Hylands: Also, I think our concerns around
implementation are not exclusively around resources. Obviously
that's a major concern and I know it comes up consistently. But
we are concerned in areas regarding governance. Who will be a
designated psychiatrist? There are many questions we don't have
answers for that are not tied directly to resources, and that
would certainly go a long way.
Dr Turner:
There are issues such as, what if a psychiatrist doesn't want to
participate in the legislation? There are concerns about
psychiatrists' resistance to participation in respect of the
Saskatchewan legislation, and we've heard about that in other
jurisdictions.
1720
Mr Patten:
Thank you for your presentation. I will read your questions in
detail because I think we as well have been asking some of the
questions you ask. They will certainly stimulate some suggestions
for amendments.
I think your point about
the resources is absolutely and totally fundamental to the whole
backdrop of this. I, for one, have always said, "Don't consider
implementing this if you're not prepared"-this government or any
future government-"to back it up with additional resources." It
requires additional resources and you talked about a couple of
ways in which that would put pressure on it.
In terms of the community
treatment agreement or plan, as I would call it-I don't like the
term CTO actually. I think it's almost a punitive term and it
comes from a court historical backdrop from the United States. I
think it's a different context. It's actually from a court and it
is an order. I think we're trying to get at a different thing here, with a very small
population of people, maximizing the consensual model.
Having said that, right in
the criteria is the fact that there must be demonstrable evidence
to show-by agreement. You can't put together a plan without
having your community partners-agencies and professionals-who are
part of the plan. They must be identified. So if there are not
the resources there, they cannot move forward with that
particular plan. I think it's a safeguard. I would welcome your
reaction to that.
Dr Turner:
That would be a safeguard. Actually, we'd like to see the same
attention to safeguards on the other side of the act, to
facilitate police apprehensions and the loosened commitment
criteria. I guess what we're saying is that as general hospitals
funded through the public purse, we see ourselves as instruments
of social policy, of public policy. We just want to be shown how
we can make public policy translate into an everyday reality.
Ms Lankin:
I have two questions I'm going to try and get in. The first one:
Addressing, Dr Turner, the comments you've made about resources,
I've spoken to the heads of psychiatry of a number of general
hospitals-I've put this on the record a few times already-who
have, similar to what your association is saying, raised the
concern about the loosening of involuntary committal criteria
increasing the population who will be coming into the emergency
room, whom your department will have to deal with.
I put that question to the
OMA, asking whether they were concerned, for example, about the
hospital restructuring commission's number-crunching exercises
based on previous legislation, not these new criteria, and did we
need to address the issues of facility-based and
institution-based resources. Their response was essentially no,
that CTOs are going to put people out the other side and this
won't be a problem.
Further, I've been told
that there are people currently-form 4 or form 3-who are not
admitted because there aren't beds, not because they don't
necessarily meet the criteria. Could you comment on that-I hate
to put you on the spot-and whether or not you agree with what the
OMA had to say on that?
Dr Turner:
The OMA reflects the position of the psychiatric profession in a
formal way. We reflect the hospitals whose services will be very
much involved in implementation of these proposed changes. We've
opened up the controversy about whether community treatment
orders work and how they work and all that. There is some
difference of opinion within the profession. There is also some
difference of opinion in the literature. My colleagues in the
psychiatric profession have reassured themselves that for the
most part, community treatment orders are a positive change. I
don't see myself as needing to actually conflict with that
position.
Ms Lankin:
I'm asking more specifically about the stress on hospital-based
resources and the loosening of the criteria. They felt that CTOs
would compensate, essentially, for the broadening of the
criteria.
Dr Turner:
The CTOs, if they're designed to reach a relatively small number
of people in this province, probably will not have significant
impact on the hospital system. What will have far more impact
will be the closure of provincial psychiatric hospital beds. That
ties in to a whole other type of program that we're developing
called assertive community treatment teams. I don't know how much
we need to get into that.
In terms of the form 1s, 3s
and 4s, with the opening up of the commitment criteria, there are
a significant number of people who don't currently qualify who
would qualify. Whether or not those forms will actually be
implemented on a given patient, to some extent, will depend on
professional discretion. If we think of it, there are in this
city probably about 400 to 500 to 600, I don't have an exact
count, of people, many of whom are homeless mentally ill, who
would probably meet these criteria. If they were to come into the
hospital system-I'm just projecting, I'm dealing with a
hypothetical-they would either wait in line for the beds or we
would have to use professional discretion not to impose form 1s
and form 3s on people.
In the profession, we would
rather have our role be sufficiently clarified. We would like to
know what public policy wants of us, and we would like to then be
able to provide what is wanted, what is needed.
The
Vice-Chair: Thank you very much for coming here today.
I'm sorry, we've run out of time and must move on.
Mrs
McLeod: A point of information: If I'm the only
committee member that needs to know that, I'd be happy to be
given private information and save research some time. We've just
heard reference to a number of different schedules and
forms-schedule 1, schedule 3, schedule 4-and an indication
of the ways in which this legislation and the broadening of
criteria would, I think the term was "significantly expand," the
number of people who could be considered for admission under one
of those forms. I'm wondering if we could get some clarification
again so we understand what we're doing here as to what those
different forms are and how much broader a population this would
be extended to with the criteria in the proposed act.
The
Vice-Chair: I have assurance from research that that's
quite possible.
Mrs
McLeod: It may be too broad, but I think we need to get
some sense of-I get concerned when I hear a statement that the
criteria expand to a significant number of people, when we're
supposedly dealing with a very narrow targeted population. Again,
I think that's a dilemma we have to come to grips with as a
committee. Whatever information we can get that would help us
define appropriately the group we're trying to address would be
helpful.
Ms Lankin:
I'm perplexed. I can understand it's very easy for legislative
research to produce the list of the form 1, it being the form
that the physician signs to send you for an assessment, or form
2, the JP, or the form 3, where the psychiatric assessment has
taken place and you're actually committed, or the form 4, where
it's renewed. We can get
those definitions. The impact of the widening of the criteria is
in fact the subject of debate. That's why I wish we would have
had much more time, because I think you're right that the breadth
of that, and that's what we heard from the Canadian Civil
Liberties Association as well, is the concern counterpoised
against all of the talk we've heard about the CTOs applying to a
relatively small number of people. These are very different
impacts, and here's the group that could tell us most of that.
Perhaps we should ask for unanimous consent to see if we could
have Mrs McLeod's question put to the association and see if they
could give us some guesstimate on that.
The
Vice-Chair: I'm very conscious of the time. We have two
more presentations, and we are limited in terms of the time at
which we can sit. I think it is something that certainly we need
to move on as a committee, as opposed to taking up our deputants'
time. I appreciate the interest and I recognize that it's shared
by all sides.
Mrs
McLeod: I appreciate that, Madam Chair. I think it might
be appropriate for legislative research to provide whatever
information would be a response to my question which might
involve a phone call later on to the people who have just made
the presentation, if that's appropriate.
The
Vice-Chair: Yes, fine.
Thank you very much for
coming here today.
1730
ONTARIO COUNCIL OF ALTERNATIVE BUSINESSES
The
Vice-Chair: I'd like to call on the Ontario Council of
Alternative Businesses. Welcome to the committee. For the
purposes of Hansard, will you introduce yourself, please.
Ms Diana
Capponi: My name is Diana Capponi. I am a psychiatric
survivor. I'm also a founding member and the present executive
director of the Ontario Council of Alternative Businesses. We
receive funding from the Ontario Ministry of Health and Long-Term
Care to provide employment opportunities for psychiatric
survivors through the development of economic initiatives. Many
of you may be familiar with some of our businesses, which include
the Raging Spoon restaurant here in Toronto, A-Way Express
Couriers, Fresh Start Cleaning and Abel Enterprises in Simcoe. I
would like to take this opportunity to introduce you to the staff
of the Raging Spoon, who I am honored to have here today
supporting me through this whole submission.
The Ontario Council of
Alternative Businesses is mandated to address the overwhelmingly
high rate of unemployment, recorded at 85%, faced by people who
have received a mental health diagnosis.
I will go back to the term
"survivor." What does it mean? To many in the mental health
sector, this term insults them, so I want to be sure that you
folks have a strong understanding of where "survivor" comes from.
There are certain outcomes which can just about be guaranteed
once an individual has been labeled a schizophrenic or a manic
depressive or whatever. These outcomes include isolation, extreme
poverty and most often homelessness or horrific housing. In
particular for people who end up in provincial psychiatric
institutions and who have become institutionalized, these
outcomes are a certainty. The term "survivor" does not refer to
the illness, or should I say the perceived illness or diagnosis.
It has to deal with the outcomes I've already mentioned. The
folks that this province deems problematic, the folks on the
street, the folks who talk to themselves, have unusual tics and
body language are the true survivors of the system. They are
examples of the impact of the system. It has nothing to do with
the diagnosis.
For your information, you
must know that the behaviours I have talked about are the result
of medication and are side effects of these drugs. People
mistakenly believe that what they are seeing is the mental
illness or the schizophrenia. What they are truly seeing are the
extremely negative side effects of very powerful medications.
Furthermore, for many people, in fact the majority of folks, with
the diagnosis I have already talked about, the drugs do not work.
In fact, if this province were really concerned about the health
of people with mental illness, I question why some of the new
anti-psychotic drugs with less harmful side effects are not
included with our drug care plan in the province.
I am a member of the
Provincial Advisory Committee on Mental Health in Ontario. Over a
year ago, this committee reviewed a number of issues related to
mental health reform. The committee is made up of stakeholder
groups from across the province: service providers, psychiatric
survivors, family members and labour. The committee was
established to make recommendations and to advise the Ministry of
Health on mental health reform in this province. We reviewed the
possibility of legislative review and decided to determine,
first, why the existing Mental Health Act was not being adhered
to and why the public has so little knowledge about it. We voted,
and other than one vote from the Schizophrenia Society, all
others were in favor of not changing the legislation.
Why then are we here today?
The advice of this committee was not taken, and we can only guess
why this legislation is coming forward. I am aware that many have
come forward to submit to you about the civil rights issues
inherent in this legislation. I will leave all that to them and
only hope that you have heard them. A society is judged by how
they treat the most vulnerable. Keep that in mind. Additionally,
I'd like to add that it is common knowledge that the less power
individuals have over their own lives, the more likely they will
be abused. It is no wonder that women, women with disabilities
and children are often victims of abuse and violence. It is no
wonder that group home workers are facing prosecution for abusing
their powers when locking out a developmentally disabled man from
his home, leading to the amputation of his limbs due to exposure.
It is no wonder that the last few psychiatrists in the
Peterborough area are all incarcerated in jail. It's no wonder that
the head of psychiatry at the University of British Columbia has
been convicted of rape and sodomy.
Unfortunately, these
stories don't make big headlines in the press and they're not as
good as "Schizophrenic Pushes Someone in Front of Subway." This
sells more papers. The general public is very misinformed, and
unfortunately so is Mr Patten, who originally buckled under the
pressure of the Schizophrenia Society and CAVEAT. One always
wants to respond to terrible stories of victimization in a quick
way or in a way that will ensure it never happens again. The
proposed changes to the Mental Health Act and Consent to
Treatment Act will not end these stories.
Much of the good news
lately in either the print or electronic media has come from our
businesses. Our organization is entirely run by psychiatric
survivors. We are all people who carry the label schizophrenia,
manic-depressive, depressive, schizoid affective disorder,
obsessive-compulsive disorder-the list goes on. We are not
pushing people in front of subways. We are not killing anybody.
We are running, managing and directing businesses. Many within
the Schizophrenia Society-I'll call them SS-would have you
believe that we are not the folks that are talked about in this
legislation. I'd like to confront that right here. All of us who
are here today have been formed or put into hospital against our
will. We have experienced forced treatment. We have been in jail
and we have lived on the streets. Now we have, through our own
efforts, rebuilt our lives. We feel productive. We control our
own decisions, largely because work became available. We were no
longer treated like children. Other survivors had faith in us. We
pay taxes. We feel productive.
Being a burden on society
does not do anyone's mental health any good. One thing that
happens when you are surrounded by well-intentioned workers
within the system is that decisions are constantly made for you.
You are taught not to accept or trust your own judgment. You are
told when to get up, where to live, what drugs to take, how much
money you get. Everyone who speaks with you is paid to do so. No
one expects anything from you but violence or weird behavior. Any
behaviour becomes pathologized. You are too happy, you are too
sad, you are too angry, and that goes on. This is bound to happen
within a paternalistic system which feels they have our best
interests at heart. Those two words, "best interests," scare us
the most. Class, culture and race have a lot to do with perceived
best interests.
1740
Our organization today
represents approximately 800 people who are now working and
running their businesses. They are providing goods and services
to their geographic community. They are proud of their
businesses, they are productive and they are less dependent on
disability pensions. These are all people who were previously
deemed permanently unemployable. We got fed up with systems that
left us out-employment programs, therapeutic programs-because we
were deemed not to benefit from any of them. We have turned all
that around and have proven concretely what people with a mental
illness or a diagnosis can do. Discrimination and ignorance are
far too rampant, and I would hope that members of this committee
will educate themselves on who we are and not be prey to the
sensationalizing of some bad stories by a small percentage of
people in our community. These stories are few and far between.
That is why we look the way we do today; we are healthy because
we are productive. Had you seen me coming out of Queen Street
Mental Health Centre 17 years ago, you would not believe where I
am today. I find it hard to believe myself.
The largest barrier to
people maintaining their health and being productive is the
discrimination we face due to the sensationalism of our perceived
illness. People are afraid of us. Why? Because of media, and
because of an industry that makes us become undesirable.
I went from Queen Street to
the infamous Shannon Court, a privately operated rooming and
boarding house, housing minimally 70 people, many of whom were
severely ill. Jail would have been better. No amount of
medication or ACT teams would have helped my mental health while
I lived in a home meant for undesirables, where I suffered with
lice and scabies while taking antipsychotic drugs and eating a
diet consisting largely of Kraft dinner. I looked funny, I
smelled bad, I acted badly due to medications, and I had no
money. I was asked to leave places because of how I looked. As
much as the SS will tell you this doesn't affect us, it does.
We have improved our
health. We have amazing success stories. We have had much
publicity of what we're doing. Don't dismiss our opinion because
we now appear healthy. Don't buy the "it won't apply to you"
story. CTOs should not apply to anyone. You have heard from the
Ontario division of the Canadian Mental Health Association, you
have heard from a number of organizations dedicated to improving
the lives of psychiatric survivors, who are, in the majority,
opposed to these changes. These changes could apply to all of
us.
Today, gladly, I discovered
that similar legislation in Connecticut was defeated just
yesterday. Recently the province of New Brunswick also defeated
it.
The changes to the existing
legislation, the Substitute Decisions Act, include an avenue to
change the prescribed wish of a person in care, wishes made while
competent. With this new law those changes can be appealed, those
wishes can be changed.
Mr Patten said that he
didn't like the term "community treatment order"; it sounded
punitive. I think language like "increasing consequences" sounds
very punitive should anyone not be in compliance with their
treatment. That's very scary indeed to all of us as
survivors.
All people in the province
of Ontario should be afraid of these changes. Think about your
mothers and fathers, think about people with HIV, think about
other people with life-threatening illness. This legislation can
affect all of us.
I would like to focus on the message this
committee, even the talk of legislative changes, has given to the
public at large. It has reconfirmed that mentally ill people are
not to be trusted, that we are violent, that we are dangerous and
we can't be trusted to know what's good for us. All of the hard
work of the council, of the Raging Spoon employees here today and
all the other businesses trying to improve quality of life for
our community, trying to educate the public, has basically been
nullified by this stuff. It makes our work so much harder.
We spend so much time and
effort spreading the message that psychiatric survivors do have
skills and abilities; we are able to be productive citizens; we
are able to work; that the most common determinant of violence is
drugs and alcohol, not a mental health label. This is proven, and
I hope there has been some research study into this. All the work
that we have been doing is nullified by the press releases of
these kinds of committee hearings. The public sees it and assumes
that we should be put away. We are angered by this. We, with very
little support, have struggled to have a little bit more economic
advantage, to have a little more self-esteem. We market our
businesses as survivor businesses. We fight consistently with
traditional agencies and others who think we cannot produce. Now
we feel we've stepped back 50 years.
We recently produced a
one-hour documentary entitled Working Like Crazy which had a
national airing. The Ministry of Health funded it because it
would educate the public so that survivors would not be
discriminated against. The news of this legislative change has
blown any effects that the documentary may have had. The
government should be ashamed. You should hang your heads in
shame.
The existing act covers
public safety issues. Most of us who have been formed, whenever
we say we want a review while on involuntary status, miraculously
become voluntary patients. Don't trust the psychiatric
profession.
We need to improve
services, we need improvements in medications and more
importantly we need to continue to support organizations like
ourselves who actually impact a person's quality of life.
And mostly, stop sending
out horror stories about us. We are no more likely to be violent
than other segments of the society. Do you force drunk drivers to
take medication ensuring they won't drink and drive again? No,
because you wouldn't get away with it. Do you force people who
have abused their spouses into treatment? No, because you
wouldn't get away with it.
Ignorance and
discrimination should not be utilized to score political points.
That is what we feel this government is doing. All the experts,
especially us, will largely agree that this legislation will not
only have little impact on the issues you are concerned about,
but will cost money and be impossible, frankly, to enforce.
Hospital beds do not exist.
Where will you put people? Are all our services going to be CTO
police? Where are the appeal mechanisms? Are we going to end up
in jails? Lately, it seems, in talking about survivors, there's
always a relationship to the criminal justice system. Is that a
plan? Is that more discrimination?
Look at us and look at the
Raging Spoon employees. Don't buy the SS stories that it's not
us. It is us. There are many other family organizations that do
not support this bill. However, the SS is well-connected and very
powerful lobbyists. Let's spend our time and energy and money to
address the issues that each horror story raises. The issue is
not the lack of legislation; it's the lack of appropriate care
and treatment. No one chooses to be ill; no one wants to be ill.
If help is effective and decent and available, people take
advantage of it.
Don't use our community to
trick the public into believing all is well now. This most
certainly will backfire on you.
The
Vice-Chair: Thank you very much. We really do not have
time for questions; you've used most of the time available. But
we certainly appreciate your coming forward today with the
information you've given us.
Ms Lankin:
Madam Chair, just a couple of requests then: first, of
legislative research. Ms Capponi made reference to the
documentary that was recently aired on TVO. I'm wondering if we
might attempt to obtain a copy of that. Perhaps in consultation
with the clerk you might determine whether there is a time on the
committee's agenda when we might view this. If that time is being
taken up by presenters, perhaps there is an opportunity where,
following the recess of the committee, those of us who are
interested may stay and watch it collectively at some point. I
would prefer if it could be on the record because I would
actually like to see the transcript of Hansard have the
transcript of the documentary.
Second, a request to the
ministry: It's been raised a number of times that some of the
newest psychotropic drugs and drugs for treatment of serious
mental illness with the least severe adverse effects are not
covered under the Ontario drug benefit program and the formulary.
I would like the ministry to provide a response to the committee
as to why that is the case and what the plans are for the listing
of those particular drugs.
Lastly, I would suggest a
recommendation to committee members. I've had the opportunity to
have some experience with the Ontario Council of Alternative
Businesses that Ms Capponi represents and some of the individual
businesses like Fresh Start, which is under contract with my
constituency office, and A-Way Express which is directly across
from my constituency office.
I would really encourage,
if committee members have not visited and toured an alternative
business, having the council set that opportunity up for you
because it's a very enlightening experience and it is one of the
options, irrespective of what we do in legislation, and we should
support the ministry in its continued and expanded support of
it.
The
Vice-Chair: Thank you very much and thank you, Ms
Capponi, for coming.
1750
CANADIAN MENTAL HEALTH ASSOCIATION, METRO
TORONTO BRANCH
The
Vice-Chair: Our last presenter is the Canadian Mental
Health Association, Metro Toronto Branch, Steve Lurie.
Mr Steve
Lurie: I'd like to turn the floor over to my president,
Eileen Dawe. She will start first; I'll follow.
Ms Eileen
Dawe: My name is Eileen Dawe and I am the president of
the board of directors of the Canadian Mental Health Association,
Metro Toronto branch. Last year we provided community support and
housing services to 461 people with serious mental illness: 60%
have schizophrenia and 31% have mood disorders like myself. Most
of the people we serve would meet the previous hospitalization
criteria in your bill.
I am a volunteer who has
been involved with CMHA for over eight years and am also a
consumer of mental health services. I have battled depression for
over 30 years. I've been homeless, jobless, suicidal and unable
to function. This bill would not have helped me. What has helped
me are three things: a good psychiatrist and social worker from
my local hospital in Scarborough; housing and community supports
provided by CMHA; meaningful daily activity, which for me is my
volunteer work with CMHA.
I lost my job, my
apartment, my trailer, all my material belongings, all that I
had, because of my illness. I had to go and stay at my sister's,
away from Toronto and away from my support system, sleeping on
her couch, living out of a suitcase. I had no self-esteem. I was
very resentful. I was thinking of death continually and I had
problems with my medication.
Through my psychiatrist and
social worker at the hospital, I got connected to CMHA and they
helped me find subsidized housing and provided a community worker
for support. When I got the apartment, this was something I never
thought I would have again. Housing is so very important to
us.
I still have bouts of
recurring depression. In fact today, before coming here, I
visited my therapist because right now I'm in a bout of my
depression. Coming here is very hard. She told me to just take
deep breaths and remember why I'm going there. I think it's
important. There are times when I can't leave my apartment, or it
takes me 45 minutes to maybe an hour to decide what I should take
out of the freezer to have for supper. My support system helps me
get through these times. They are there for me. That's what is
important.
The other thing that helps
is my involvement with CMHA. Everyone has a basic need to feel
that they can contribute and that their lives have some meaning.
For so many years this feeling was gone for me and the darkness
that surrounded me was swallowing me up into the depths of hell.
With the continual support from this triad support system, I am
beginning to realize that having an illness, any type of illness,
does not mean your life is meaningless.
I must admit that my life
is not the easiest. Each morning I awake with a certain amount of
dread. Each day is a fight for me. I have choices to help me to
survive, and I do choose to survive. It means taking my
medication, realizing that I do have choices, and the result is
that even though I still suffer from depression, I am able to
cope, use the knowledge I've gained, and use the supports that
have become a stronghold for me when I get ill.
Having resources available
to you and being able to choose how you use them is a major part
of recovery and empowerment. This bill is coercive and not
empowering. To think that I could be arrested for up to 30 days
after I told my psychiatrist I no longer need a CTO.
This bill does nothing to
provide the 3,800 additional units of supportive housing that are
still needed in Toronto. It makes no progress putting more
resources into community mental health services.
The right thing to do would
be to withdraw this bill and bring in community mental health
systems legislation which would ensure at least $351 million of
additional funding for community supports and housing.
I want everybody to know I
am my own best caregiver. It is my responsibility. I do not want
to be thought of as some victim, some voiceless person who needs
others to speak for me, care for me or think for me.
To do this, though, I need
the means to do such, not as how some people think of people with
a disability, but as a citizen of this country and this province.
It is not handouts we are asking for, but a reaching out from all
sources to help us be the people we were, the people we are and
the people we are going to be. So much is up to you. So this I
ask you: Withdraw the bill and do the right things. We are all in
this game of life together. Thank you.
I'd now like to turn it
over to our executive director, Steve Lurie, to provide some
additional comments on the bill.
Mr Lurie:
Thanks, Eileen. That's going to be a tough act for me to follow.
I would remind this committee that about every 10 or 15 years we
debate what to do with the mental health system, and so far
haven't done the right thing. You can think back to the debates
on Bill 190 in 1987 when David Reville brought forward, with some
of our urging, draft community mental health legislation. All
three parties thought it was a great idea. We're still
waiting.
This bill, Bill 68, sets a
different standard that we've not had before. It flies in the
face of last year's Supreme Court Winko decision that says that
for somebody who's not criminally responsible, unless there's an
absolute and significant risk of serious criminal offences
occurring, you must grant an absolute discharge.
We're saying that on the
criminal law side-that's the Supreme Court saying, not Steve
Lurie saying-people, unless you can prove a serious criminal
offence is likely to occur, should be free from any coercion
based on their mental
disability. This act moves in the wrong direction. It increases
the stigma against the mentally ill as well. This is particularly
important because we've ignored the advice of experts.
Marnie Rice and Grant
Harris wrote a marvelous article which I've included in the
package for the clerk that says: "Mental disorder and psychiatric
disturbance are poor predictors of violence. Actuarial methods
are more accurate in predicting risk than unaided clinical
judgment." In other words, to pick up on Diana's point, you can't
trust the clinicians on this one. Clinical judgment is a poor
index. "Our research has shown that a diagnosis of schizophrenia
is associated with a lower risk of violence."
You might ask: Why do we
have this legislation before us? We should be putting in place
more supportive housing. We should have been increasing the
community-based mental health services that began with Mr
Grossman's initiative in 1982, Mrs Caplan's initiatives in 1987
and Ms Lankin's initiatives in the early 1990s in mental health
reform, but we're still not there. We're seven years into the
mental health reform declared by the previous government and we
have not even come close to meeting the spending targets. At
least an additional $351 million needs to be put on the table. It
was an embarrassment that this was a health care budget and there
was no money announced for mental health reform.
1800
The current legislation
should be withdrawn and replaced by mental health systems
legislation. As Diana mentioned in her remarks, the provincial
advisory committee of which I am a member was consulted on the
need for provincial legislation to build a mental health system
and we were beginning to undertake that task. Now we have a much
narrower and flawed approach to legislation.
We participated in the
consultations about the proposed legislation. The overwhelming
opinion in every consultation across the province was that the
legislation was unnecessary and that the focus of activity should
be on putting community mental health services in place.
This is further supported
by a recent release of the World Health Organization study, which
came out just weeks ago, on mental illness in seven countries,
including Canada. It showed that 37.5% of the Canadian sample
experienced at least one mental disorder, but only 21.8% had
received any mental health services in the previous 12 months. We
should be focusing on that. How do we ensure that all Ontarians
have timely access to a full range of mental health services?
That's what the bill should be about, not what we're talking
about.
At the same time, CMHA and
others are recognizing that the government has a majority. Unless
this committee as a group is prepared to stand up and say, "Get
back to square one," the bill will pass in some form. In that
spirit, I've tried to bring forward some suggestions to make what
I think is a badly drafted piece of legislation more
workable.
(1) The Saskatchewan
criteria for CTOs should be used rather than the current broad
provisions, and in particular, I'm offended that the OMA's brief
suggests broadening CTOs for everybody.
(2) The requirement for
individual service providers to sign the orders will render the
legislation unworkable, especially as an alternative to
hospitalization.
It's 6 o'clock in the
evening. Think about it. Somebody shows up, a psychiatrist has to
inform them of their rights advice, consult with other service
providers, arrange housing, arrange medication, get service
providers to agree because their signatures are on the order and
they're liable for a failure to bring the order through. This
will just not work. What if the worker won't sign? What if the
worker goes on vacation? What if they get sick during the term of
the order? Would a whole ACT team need to sign an order by a team
psychiatrist, or only an order from outside psychiatrist?
The process could be
simplified using procedures that work for the support and
provision of non-criminally responsible patients by provincial
psychiatric hospitals. This approach would allow a psychiatrist
to approve the provision of service by a service provider in the
same way that a provincial psychiatric hospital administrator can
approve where an NCR patient lives in the community and can
assign supervision to approved persons. In this context, this
should be based on point three.
(3) With the consent of the
client and the service provider, the psychiatrist could approve
case management services, attendance at clubhouse programs,
living arrangements or other community programs. There could and
probably should be an agreement between the service provider and
the psychiatrist to notify the psychiatrist in the event of the
deterioration of the client to the point where an examination
would be warranted under the Mental Health Act.
Not only does that make
sense, it's based on the duty-to-warn principle anyway. It would
provide for an ability to say, "We think something is happening
here, we think there may be some risk, we'd like to have the
client examined," but not hauled in by the police, as this act
provides for.
(4) The act should specify
that CTOs can only be implemented by designated hospitals and
psychiatrists. This would allow it to start slowly. It would
allow for some control over who issues them and make monitoring
easier. The thought that every physician in the province could
issue a CTO is very, very scary, when the experience in most
jurisdictions is that CTOs are rarely used to avoid
hospitalization, they are more frequently used to shorten
hospital stay.
(5) Most important, if you
do proceed to go forward with this legislation, it must ensure
that independent rights advice and advocacy is available to
anyone who would be subject to a CTO. This will require a
provincial strategy and increased funding to expand the
operations of the provincial psychiatric advocate's office to
provide rights advice and advocacy in both institutional and
community settings. Right now the PPAO can only provide advice in institutional
settings and its whole future is limited by the divestment of the
psychiatric hospitals.
(6) Most important-and this
point was made by the Association of General Hospital Psychiatric
Services-proclamation should not occur until the rights advice,
advocacy and CTO administration regimes are in place, along with
the full range of community mental health and housing support
services across the province. The ministry regional offices
should have to signify that a sufficient supply of services
exists and that housing is in place in each region before CTOs
can be issued.
(7) Probably most
important, the legislation should be subject to a sunset clause,
with continuation based on the results of evaluation showing that
it has met its public policy objectives.
As a final point, our CMHA,
Ontario division, presented you with 70 amendments. We ask you to
consider our suggestions and theirs very seriously, but I must
tell you honestly, I'm not sure you can make a silk purse out of
a sow's ear.
The Chair:
That leaves us about two and a half or three minutes. I think in
the interests of logic, the NDP was next up in the rotation, so
Ms Lankin, I'll afford you the opportunity to use those three
minutes.
Ms Lankin:
I appreciate both of your presentations today, and I want to say
particularly that I know it must be difficult and that sometimes
the settings are intimidating. I hope you will know that it's
very important to us as well that you took the time to come.
I also wanted to speak
directly with Mr Lurie. You've made reference to mental health
reform. Not all committee members may know your long history with
respect to this issue. A lot of people have come before us and
said that if the resources were there in the community, these
sorts of things would be unnecessary. Others have made references
to things like the document that was produced by our government
in 1993, Putting People First, and you had much to do with the
preparation of that. Could you give us your opinion about what
elements of mental health reform have not been proceeded with
that would preclude the need for this legislation?
Let me just put a
particular twist on that question. Accepting everything that has
been said around the civil liberties issue and human rights
issue, there are still some people who have presented before us
who have told us very tragic stories about their families. We've
heard many tragic stories about many people who have been victims
of the system as well. They have told us tragic stories about
their families and how they truly believe that while there should
be more community supports, that wouldn't have helped their
family members and that they needed some measures like this to
intervene. Could you address community health reform, how you see
it preventing the need for such legislation and whether or not
you can address the concerns these family members have
raised?
Mr Lurie:
I guess the fundamental issue is the money required to shift the
spending from an institutional basis to a community basis, a
minimum of $400 million. Actually, in a report done for the
previous administration to yours, the funding strategy group
identified a need for $600 million in new dollars to deal with
the shortfall in funding for services for the seriously mentally
ill in the community. So on the one hand you need services like
the kind of things Diana Capponi mentioned: consumer supports,
other employment programs, housing, more case management.
For example, the recent
ACTT initiative of the Ministry of Health, which is to be
commended, didn't deal with the fact that for most housing
programs, for most case management programs, there are huge
waiting lists of years, not just months. We have 70 people on our
supportive housing waiting list, but because they're not
homeless, they don't qualify for any of the new units that are
being brought on stream in Toronto. So clearly across the
province we need to do a whole lot more to put in place that full
range of community supports: more outpatient programs, more
clubhouses, more case management, more employment programs, more
housing.
To deal with the issue of
whether a CTO would prevent some of the tragedies, I guess I have
to say that tragedies are going to occur. The problem is that the
profession and all of us who work in the mental health field have
to acknowledge that we're not very good at predicting violent
acts. We're also not very good at intervening appropriately. But
if you have more options for people and if you build more
supports around people, other jurisdictions have found that these
things work.
The problem we face is that
you need to have a range of services that people will choose to
come to. The literature on serving the homeless population, which
is one of the more difficult populations to serve, has
demonstrated that you really need a variety of services and
housing forms that we haven't even begun to think about yet here
in this country. There have been some very interesting
initiatives south of the border. I would argue that if you
provide more choice for people about a range of supports and
actually make those supports visible and available, you're less
likely to have to rely on coercion.
Also I think that includes
the kind of thing I talked about where you would encourage
agreements and arrangements between people and services and make
it easy for people to be examined if there was risk. These days,
if there's risk, you don't have many doctors who will move around
and come to see a person, so you have to get the person to a
hospital. That's still a problem in the current bill. So we need
to think of many more creative ways where physicians and other
professionals could be trained to provide support.
I also think back to 20
years ago when I started working here in Toronto. Friends and
advocates had a crisis program which was peer support, where
consumers went to other people's homes and supported them through
crisis. I think we need to expand those services far more than we
have. Many of the groups, like CMHA and the Ontario Federation of
Community Mental Health and Addictions Programs, who will be
speaking to you I guess at the end of the month, have always said
if you put the
services in place, this will work. If you build it, they will
come, but we haven't built it yet.
The Chair:
Thank you both very much for coming before us here today. Ms
Dawe, you did an excellent job. No reason to be worried at
all.
That concludes our hearings
in Toronto today. Just to put on the record-the committee members
have already been notified-unfortunately we only had four
expressions of interest in Thunder Bay and I think it makes no
sense to have 10 people traveling the province at great expense
to the taxpayers. The clerk will be inviting those people,
including the CMHA, Sudbury division, to send in written briefs
and they will certainly be circulated to all the members.
I should say to our friends
from CMHA who are here today that you might want to indicate that
because the Ottawa branch is making presentations, if the Sudbury
branch has any different views they would like to put on the
record, we'd certainly look forward to hearing them in Ottawa,
because we do want to hear people's views. If they aren't
comfortable with written briefs, we would make available video
conferencing in room 151 during one of our subsequent hearing
days. But I think we can leave that in abeyance until the clerk
hears the responses from the other three groups.
Ms Lankin:
I have a query with respect to the remaining Toronto hearings and
whether or not there is still time and space available there. One
of the things I was thinking was, if we receive written
submissions and we don't take time for video conferencing and if
we get additional Toronto requests, we may need to have a
subcommittee meeting to look at scheduling another Toronto day at
some point and getting permission from the House. That's all I
was going to flag, Mr Chair.
The Chair:
Thank you for those comments. Since we won't see everyone on
Tuesday, the committee stands adjourned until Wednesday,
tentatively at 11 o'clock, in Ottawa.
