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Mental Health Strategy for Canada DRAFT 加拿大精神卫生战略(草案)

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Mental Health Strategy for Canada DRAFT

NOT FOR CIRCULATION


June 3, 2011


Mental Health Commission of Canada

INTRODUCTION

It is with great pleasure that the Mental Health Commission of Canada (MHCC) presents the first ever draft Mental Health Strategy for Canada. This draft Strategy presents a plan of action based on the visi on and goals set out in Toward Recovery and Well-Being: A Framework for a Mental Health Strategy for Canada, which reflected a broad consensus for transforming the mental health system in Canada. Now is the time to turn that consensus into commitment and action.

Toward Recovery and Well-Being has become an important reference point for mental health policy and practice across the country. More broadly, mental health is quickly becoming a high priority in Canada. The public has become i ncreasingly aware of the significance of mental health issues and most provinces and territories are developing, revising or implementing mental health plans or strategies. Both the media and corporate sector are paying more attention to mental health.


The Mental Health Strategy for Canada will help to focus efforts, by setting common priorities and provi ding a way for people across the country to work together to achieve better mental health outcomes and
improve overall mental health and well-being. It will help to mobilize the informal and formal resources that are needed to ensure that individuals and familie s have access to the range of mental health programs, treatments, services and supports they need, when and where they need them. It will encourage action to promote mental health and prevent mental illness and suicide wherever possible, and foster rec overy for people livi ng with mental health problems and illnesses.

Like guiding principles, the visi on and goals set out i n Toward Recovery and Well-Being underpin the Mental Health Strategy for Canada. While these may not always be referred to explicit ly, they are embedded in all the actions and priorities envisi oned by this Strategy, and should be assumed to apply throughout:

Vision:
All people living in Can ada have the opportunity to achieve the best possible mental health and well -being.


Goal 1: People of all ages living with mental health problems and illnesses are actively engaged and supported in their journey of recovery and well-being.
Goal 2: Mental health is promoted, and mental illness is prevented wherever possible.
Goal 3: The mental health system responds to the diverse needs of all people living in Canada.
Goal 4: The role of families in promoting well-being and providing care is recognized, and their needs are supported.
Goal 5: People have equitable and timely access to appropriate and effective programs, treatments, services
and supports that are seamlessly integrated around their needs.
Goal 6: Actions are informed by the best evidence based on multiple sources of knowledge, outcomes are measured, and research is advanced.
Goal 7: People living with mental health problems and illnesses are fully included as val ued members of society.

The draft Mental Health Strategy for Canada is focused on priorities for action that will make the greatest difference to improving mental health outcomes and quality of life, while produci ng the best possi ble return on investment. At the same time, the overall mix of priorities is balanced across different sectors and population groups, and can be acted upon by a broad range of stakeholders without depending exclusively on government endorsement for their success. An ongoing challenge will be to both push the limits of political feasibility in order to truly transform the mental health system, and make recommendations that can be implemented in a challenging economic climate.


The draft Mental Health Strategy for Canada sets out priorities for action under the foll owing six Strategic
Directions:


1. Shift upstream and across sectors
2. Transform relationships and uphold rights
3. Strengthen capacity in the community
4. Improve equity
5. Seek innovation with First Nations, Inuit and Métis
6. Mobilize leadership


A few important elements are still in development and will be i ncluded i n the final Strategy. Work is underway to develop the case for inve stment in mental health, a funding proposal tied to the implementation of the Strategy, and a preliminary indicator framework for measuring progress. To develop Strategic Direction 5, the Mental Health Commission is seeking advice from and working to establish on- going relationships with the Assembl y of First Nations, Inuit Tapiriit Kanatami, Métis National Council, the Congress of A boriginal Peoples, the Native Women’s Association of Canada and other indigenous organizations.


After gathering feedback from targeted stakeholders in June, the Mental Health Commission will subm it a close to final draft Strategy to its Board in October 2011, and then work to prepare the final document for release and implementation early in 2012.


We look forward to hearing your feedba ck, and working with you toward the successful launch and implementation of the Mental Health Strategy for Canada.

STRATEGIC DIRECTIONS AND PRIORITIES AT A GLANCE

Strategic Direction 1: Shift upstream and across sectors (p. 5)
1.1 Increase knowledge and skills relating to mental health, mental illness and suici de prevention.
1.2 For infants, children and youth, increase the capacity of families, school s and communities to promote mental health, reduce stigma, reduce mental illness and suicide, and intervene e arly.
1.3 For adults and ol der adults, increase the capacity of workplaces, long -term care, and communities to promote mental health, reduce stigma, reduce mental illness and suicide, and intervene early.

Strategic Direction 2: Transform relationships and uphold rights (p. 9)
2.1 Re-orient policy and practice toward recovery and well-being.
2.2 Actively involve pe ople living with mental health problems and illne sses and their familie s in deci sion - making at all levels.
2.3 Uphold the rights of people livi ng with mental health problems and illnesses.
2.4 Reduce the proportion of people living with mental health problems and il lnesse s in the criminal justice system and provi de appropriate services, treatment, and supports to those who are in it.

Strategic Direction 3: Strengthen capacity in the community (p. 14)
3.1 Strengthen the capacity of community-based mental health services to foster recovery and well-being.
3.2 Advance the role of primary health care in a transformed mental health system.
3.3 Increase access to peer support as an essential component of a transformed system.
3.4 Improve income to support choice and quality of l ife.
3.5 Provide equitable access to decent, affordable housing and related supports.

Strategic Direction 4: Improve equity (p. 20)
4.1 Reduce inequities - in l iving conditions and mental health outcomes - associated with diversity.
4.2 Improve equity of access to mental health services, treatments and supports.

Strategic Direction 5: Seek innovation with First Nations, Inuit and Métis (p. 24)
[Under development]
5.1 First Nations Stream
5.2 Inuit Stream
5.3 Métis Stream
5.4 Additional focus on gender, urban, rural and northern issues

Strategic Direction 6: Mobilize leadership (p. 25)
6.1 Apply a “whole-of government” approach to the development and implementa tion of mental health policy and in response to the mental health strategy for Canada.
6.2 Strengthen national mental health infrastructure.
6.3 Expand the leadership role of people livi ng with mental health problems and illnesses.
6.4 Fund and sustain transformation.

Strategic Direction 1: Shift upstream and across sectors


Outcome:
More people living in Canada enjoy positive mental health across the lifespan.


What do we mean by making a “shift upstream and across sectors”?


“Shifting upstream” simply means that it is important to investigate problems at their source, eliminate them wherever possible and minimize the impact of the ones we cannot prevent. It reflects the recognition that even if we were able to provide the best possible service, treatments and supports to everyone who required them, we will still be able to deal with less than half the overall impact of mental health problems and illnesse s.1


The call for a shift “across sectors” is ba sed on the fact that there are multiple “sources” of mental health and well-being, as well as mental health problems and illnesses. These include our social, economic, physical, and cultural environments, as well our personal beliefs, strengths and vulnerabilities, our genetic make-up, and our health and lifestyle choices. Thi s means that many of the factors that contribute to good
mental health and to the prevention of mental illness and suicide are not the focus of mental health ser vices
or even of the health care system more broadly. In order to improve mental health and recognize problems early, action is needed in school s, workplaces, and long-term care, and in our homes and comm unities.

We now have growing evidence that a “shift upstream and across sectors” can have considerable impact on mental health. By enhancing those factors which protect mental health and reducing the factors that place people at high risk of mental health problems and illne sses, it is possible not only to achieve better mental and physical health outcomes, but also to im prove educational performance, reduce involvement in crime, enhance people’s employability and enable them to improve their earnings. 2


Attention to these factors will also contribute t o reducing the number of people who attempt and complete suicide in Canada. Suicide takes the lives of almost 4,000 people per year in Canada and affects many more. While suici de is not always associated with mental health problems and illnesses, depressi on, in particular, is commonly present.3 Reducing the stigma associated with suicide and implementing mental health promotion strategies, gatekeeper education and early identification are key aspects of suicide prevention. 4


There is growing evidence about what kinds of “upstream” programs can be effective.5,6 As noted in Toward Recovery and Well-Being, “the best results for mental health promotion, mental illness prevention, and suicide prevention have been achieved by i nitiatives that target specific gr oups (defined by age or other criteria) and settings (school, workplace, family), address a combination of known ri sk and protective
factors, set clear goals, support communities to take action, and are sustained over a long period of time.” 7
Initiatives that aim to improve knowledge and skill s across the population, and anti-stigma initiatives that include direct engagement with people living with mental health problems and ill nesses, also have a critical role to play.

Embracing this “shift” will entail thinking seriously about what really matters for our well-being and looking at how we can measure our progress in enabling more people livi ng in Canada to enjoy positive mental health across the lifespan. It requires us to examine the “upstream” activities that will produce the best
results for each segment of the population. The three priorities in this Strategic Direction examine measures
for: a) infants, children and youth; b) adults and older adults; and c) the whole population.


Other Strategic Directions, in particular Strategic Direction 4 (“Improve Equity”) will examine upstream, actions that can be taken across sectors to reduce the damaging effects of inequities in livi ng conditions such as poverty, which are risk factors for mental illness and contribute to poor mental health.

PRIORITY 1.1
Increase knowledge and skills relating to mental health, mental illness and suicide prevention.


There are steps everyone can take to protect and improve their mental health. For example, the Five Ways to Well-Being initiative in the United Kingdom distilled the best available evidence on positive steps people can take to improve their mental health into five simple me ssages: connect, be active, take notice, keep learning, and give.8 At the same time, these broad messages need to be supported by targeted approaches that are tailored to the specific circumstances that confront diverse population groups and sectors, including inequities in living conditions. 9


Similarly, with appropriate knowledge and skills, all of us can play a role in recognizing mental health problems and il lnesse s early on, and help get support for ourselves and others. 10 Ideally, this kind of mental health literacy training would be as widespread as first aid training for physical illness and injury. However, improving our understanding of the signs and symptoms of mental health problems and illnesses i s not enough on its own to change attitudes and fight the stigma that is still too often associated with mental health problem and illnesses. This can best be done through direct engagement with people living with mental health problems and illnesses who are in recovery. 11


The most promising approach to developing the knowledge and skil ls needed for suicide prevention i nvolve s targeted training for ‘gatekeepers’ – such as family physicians and other primary health care providers, teachers, home-care workers, clergy, police, and corrections staff. Gatekeepers are in the best position to recognize and address a crisis or react to warning signs that someone may be contemplating suicide. 12,13


ACTIONS
1.1.1 Raise awareness of how to improve positive mental health and well-being, by developing key messages and implementing targeted approaches.
1.1.2 Make training broadly accessible on how to recognize mental health problems and illnesses, get
support for oneself i f needed, and secure help for someone el se.
1.1.3 Ensure that direct engagement with people living with mental health problems and illnesses
(“contact-based education”) is central to all anti-stigma initiatives.
1.1.4 Increase the availability of suicide prevention training for “gatekeepers” such as teachers, police,
and family physicians.

For infants, children and youth, increase the capacity of families, schools and communities to promote mental health, reduce stigma, redu ce mental illness and suicide, and intervene early.


Healthy social and emotional development in chil dhood, including early bonding and attachment, lays the foundation for health and well-being across the lifespan. Childhood also presents the greatest opportunity to prevent mental health problems and illnesse s and intervene early, as up to 70% of mental health problems have their onset in childhood. 14 In a recent report, the Institute of Medicine in the United States found that the evidence base for preventing mental health problems in chi ldhood had increased substantially over the past 15 years.15


Comprehensive programs that support parents to promote healthy social and emotional development from infancy to early adolescence – both universal programs for all parents and targeted programs for families at risk and families of chil dren who are experiencing early sig ns of difficulty – have been successful in reducing the risk of aggressive or antisocial behaviour and substance abuse, and in improving parent -child interaction and academic success.16,17,18 In schools, the most effective approaches combi ne universal and ta rgeted interventions within the context of comprehensi ve healthy school initiatives.19 Efforts should i nclude a focus on promoting healthy social and emotional development, buildi ng resilience, reducing psychosocial risk factors for mental health problems, and reducing stigma. 20 Collaboration with mental health services, primary health care, child welfare, and other services are essential.21


Prevention and early intervention programs in school, community and family settings can benefit children who are at higher risk of developing a mental health problem or illness.22,23, 24,25 These include children in care – whose rate of mental health problems is far above the rate in the overall child population – and those who are exposed to risk factors such as family violence, poverty, and parents living with mental health problems, illness or substance abuse.26 Screening infants and young children for social and emotional delays can help to significantly improve mental health outcomes by enabling the targeted delivery of a broad range of services and supports to address these delays. 27


ACTIONS
1.2.1 Increase access to evidence-based programs for parents to promote healthy social and emotional development, starting in early childhood.
1.2.2 Increase the availability of collaborative school-based mental health initiatives that build resilience,
reduce stigma, and promote healthy social and emotional development.
1.2.3 Increase the availability of prevention and early intervention programs for children at high risk 
including children i n care  in school, community and family settings.
1.2.4 Expand initiatives to identify social and emotional delays i n infants and young children, and expand the broad range of services and supports to address these delays.

PRIORITY 1.3
For adults and older adults, increase the capacity of workplaces, long -term care, and communities to promote mental health, reduce stigma, reduce mental illness and suicide, and intervene early.


Working can be beneficial to mental health, yet mental health problems are the number one cause of disability in Canada, accounting for nearly 30% of disability claims and 70% of the total costs. 28 In addition to having to absorb this massi ve cost, employers are increasingly being held legally responsible for the psychol ogical safety of their workplaces. 29 A variety of programs and initiatives can contribute to reducing workplace-related risk factors for mental health problems and illnesses, and help improve the mental health and well-being of employees. These include workplace promotion, prevention and anti-stigma initiatives, management training, and improvements to Employee Assi stance Programs.30,31


For older adults, good physical health and social interaction, along with secure and supportive relationships that contribute to a life of meaning and purpose, are key factors that help prevent mental illness and suicide and promote mental health. When discrimination based on age is combined with the stigma of mental illness, it creates a “double whammy” that can delay the ident ification of and intervention for mental health problems. In order to help ensure that there is access to support as early as possi ble in the course of an illness, older adults, families and those who w ork with older adults i n the community and i n long-term care settings need to be able to recognize the signs of mental health problems and know that they are not just a “normal” part of aging.32,33,34


ACTIONS
1.3.1 Establish and implement psychological safety standards in the workplace and initiatives to c reate mentally healthy workplaces, including prevention and anti-stigma.
1.3.2 Increase managers’ competence in promoting and protecting mental health and responding appropriately to mental health problems and illnesse s in the workplace, and expand the capacity of employee assistance programs.
1.3.3 Reduce discrimination based on age and support older adults to participate in meaningful activities, sustain relationships with others and maintain good physical health.
1.3.4 Increase the availability of early identification and early intervent ion programs for older adults in
long-term care settings and community-based support services

Strategic Direction 2: Transform relationships and uphold rights


Outcome:
Mental health related policy and practice in C anad a are oriented toward recovery and well-being, and the rights of people living with mental health p roblems and illnesses are upheld.

The primary purpose of a transformed mental health system is to support all people living in Canada to achieve the best possible mental health and well-being. Despite the skill, compassi on and dedication of thousands of people across the country, the syst em as a whole is not yet geared to fostering recovery and resilience across the lifespan.


As Toward Recovery and Well-Being made clear, recovery does not mean the same thing as ‘cure’– it “is a
way of living a satisfying, hopeful and contributing life even with the limitations caused by illness.” 35
Understood this way, the hope of recovery i s available to all. Re-orienting policy and practice toward recovery and well-being will not onl y improve quality of l ife for people who experience mental health problems and il lnesse s, but will also bene fit families, communities and the country as a whole. Investing in recovery has the potential to provide hope and opportunities to thousands of people livi ng with mental health problems and ill nesses w ho are currently marginalised.


The relationship between people livi ng with mental health problems and illnesses and their families with those who provi de services must become a genuine partnership – the expertise gained from lived experience should be complemented by professional expertise, not dominated by it. Not only wil l this change in the distribution of power within the mental health system benefit users of services, it will also create a more positive context in which mental health providers can deploy their skills, experience and knowledge.


As well, Toward Recovery and Well-Being affirmed that the unique role of families – whether they are made up of relatives or drawn from people’s broader circles of support – in fostering recovery and well-being across the lifespan must be recognized. Wherever possible, families must become partners in the care and treatment of their loved ones, and integrated into decision-making in a way that respects consent and privacy.36


People living with mental health problems and i llnesses and their families m ust also be actively involved in decision-making at all levels of the mental health system. This will help to dri ve long overdue change in the mental health system and ensure that the system as a whole is firmly focused on supporting people to achieve the best possible mental health and well-being.

There are several key principles that underpin a n orientation towards recovery. In addition to emphasizing that the journey of recovery begins with hope, it is im perative that all people who experience mental health problems and il lnesse s be treated with dignity and respect and are able to maintain responsibility for and control of their own health and well-being. This means that, to the greatest extent possible, people should be able to make informed choices about the programs, services, treatments and supports that best meet their needs. With some adaptation to the different stages of life, these principles apply to everyone.

Consi stently upholding the rights of people living with mental health problem and ill nesses is part and parcel of transforming relationships and enabling people to enjoy a meaningful life in the community. First and foremost, as Toward Recovery and Well-Being insisted, people of all ages living with mental health problems and illnesse s must be “accorded the same respect, rights, and entitlements and have the same opportunities as people dealing with physical illnesses and as other people living in Canada.”37


The recent ratification in 2010 by Canada of the UN Convention on the Rights of Persons with Disabilities underscores the importance of upholding these rights and marks a significant step forward in anchori ng
these rights in a social model of disabil ity. In this model, disability i s understood not as an internal condition, but rather as something that arises from the ways in which external environments interact with people. 38
This means that we must work to eliminate the barriers that hinder the full and effective participation of people livi ng with mental health problems and illnesses in society – whether these barriers are rooted in people’s attitudes and behaviours, in the ways in which programs and institutions are organized, or in the ways in which our school s, workplaces and other everyday environments are structured.

The importance of respecting the rights of people living with mental health problems and ill nesses arises with particular force when they become involved with the criminal justice and corrections systems, as has happened with increasing frequency in recent years. The prevalence of mental health problems and illnesse s among inmates has risen dramatically over the past decades, as the corrections system has borne the brunt of the failure to put in place adequate community-based services in the wake of deinstitutionalization.39 We must re-double our efforts to keep people who experience mental health problems and il lnesse s out of the criminal justice system, and to address the shortfalls in mental health
services, treatments and supports within correctional facilities.


PRIORITY 2.1
Re-orient policy and practice toward recovery and well-being.


In many countries, an orientation towards recovery has been a driving force in mental health system transformation. Here in Canada, it has been over five years since the final report of the Senate Committee, Out of the Shadows at Last, called for recovery to be “placed at the centre of mental health reform,” but we have not yet seen a true cultural shift toward recovery.40 In order to accelerate this change, guidelines and tools are needed to help orient policy and practice and enable us to measure progress in im plementing a recovery orientation. As well, mental health, health and social service providers m ust receive the education and training they need to embrace a recovery orientation from the outset of their careers.


In large part because each person’s journey of recovery will reflect their own unique experience, strengths and needs, recovery cannot be reduced to a simple formula. Setting goals on the road to recovery must be done indi vidually. Moreover, as Towards Recovery and Well-Being insisted, “recovery cannot be done to, or on behalf of, people” because “recovery must be the result of individuals’ own efforts and must be accomplished using their choice of services and supports.” At the same time, since a journey of recovery i s seldom undertaken alone, it is critical that those who often provide the bulk of support and care – families

and broader circles of support– also have access to the information and resources they need to sustain themselves, foster recovery and have their voices heard throughout the mental health system.


Having individual care plans helps to e nsure that people of all ages livi ng with mental health problems and illnesse s are engaged as true partners in their care, are able to build on their strengths and capacities, and are treated with dignity and respect.41 We also need to find innovative ways to support people’s ability to exercise their right to choose, including through programs that provide people living with mental health
problems and il lnesses the opportunity to directly manage part of their social service and healt h budgets.42,43
Without increasing overall costs to government, emerging evidence indicates that participants in these initiatives manage better in the community and enjoy a higher quality of l ife.44


ACTIONS
2.1.1 Develop and implement guidelines and standards for mental health policies and practices in Canada, oriented towards recovery and well-being for people of all ages and backgrounds.
2.1.2 Increase availability and use of i ndivi dual care plans for recovery and well-being.
2.1.3 Incorporate an orientation towards recovery and well-being in curricula and standards for mental health, health and social service providers.
2.1.4 Develop, implement and evaluate self-directed care funding initiatives.
2.1.5 Enhance support for families and circles of support to foster recovery and pr ovide care, and to meet their own needs.

PRIORITY 2.2
Actively involve people living with mental health problems and illnesses and their families in decision - making at all levels.


‘Nothing about us without us. ’ This phrase conveys the importance of includi ng ‘experts by experience’ – people of all ages living with mental health problems and illnesses and family members – in all mental health, health and social service system decisions that have an impact on their lives. 45 As international experience has demonstrated, ensuring the active involvement of people with lived experience and their families is ke y to driving change within the mental health system. Establishing appropriate policies and standards that mandate this involvement will ensure that knowledge gained through lived experience contributes to guiding the transformation of mental health systems.


It is also important that people with lived experience are welcomed into the mental health workforce. Not only will thi s contribute to the mental health of the people who are employed but it can also enhance quality of the services provi ded and contribute to the ongoing transformation of mental health systems. 46


ACTIONS
2.2.1 Increase and strengthen the role of people of all ages living with mental health problems and illnesse s and their families in governance, accreditation, monitoring activities and advisory bodie s.
2.2.2 Actively recruit people living with mental health problems and ill nesses to enter, stay and flourish at
all levels of the mental health workforce.

PRIORITY 2.3
Uphold the rights of people living with mental health problems and illnesses.


The ratification of the United Nations Convention on the Rights of Persons with Disabil ities (CRPD) by the Government of Canada in 2010 provide s a new touchstone for mental health legislation. The CRPD pushes for legislation to place a greater focus on protecting human right s, rather than exclusively specifying the conditions under which it is legally permissible to restrict people’s freedom against their w ill (‘committal’).47
It also highlights the importance of eliminating barriers in schools, workplaces and communities that prevent
the full participation of people l iving with mental health problems and il lnesse s.


As Towards Recovery and Well-Being noted, a key impetus for the growing prominence of recovery and well- being around the world has been advocacy by people li ving with mental health problems and ill nesses. 48
Beyond helping to change attitudes, studies have noted the success of advocacy acti vities by organizations run by people with lived experience in bringing about changes in public policy and legislation, as well as having an impact on many local policies, from securing additional housing to obtaining subsidies for bus passes to preventing the closure of regional hospitals. At the same time, various factors – most notably the lack of adequate funding – continue to limit the ability of people l iving with mental health problems and illnesse s to play a strong advocacy role.49


Towards Recovery and Well-Being also pointed out that “a principle of recovery-oriented mental health policy and legislation must be to always employ the least intrusive and least restrictive interventions possi ble.”50 The use of seclusion and restraint must come to be seen as a failure of the system, as it has in many institutions i n the United States and around the world that have been able to virtually eliminate seclusion and restraint through the development of multi-level programs that create safe environments.51,52


ACTIONS
2.3.1 Review and reform legislation and policies across jurisdictions and sectors, in alignment with the UN Convention on the Rights of Persons with Disabilities.
2.3.2 Support advocacy by and with pe ople living with mental health problems and illne sses and their
families, including through organizational support to undertake court challenges and human rights complaints.
2.3.3 Remove barriers to full participation of people living with mental health problems or illne sses,
workplaces, schools (includi ng colleges and universities) and other settings.
2.3.4 Develop and implement strength-based, trauma-informed and recovery oriented alternatives to the use of secl usion and restraint, with a view to reducing and eventually elimina ting these practices.


PRIORITY 2.4
Reduce the proportion of people living with mental health problems and illnesses in the criminal justice system and provide appropriate services, treatment, and supports to those who are in it.


The best way to avoid involving people li ving with mental health problems and ill nesses with the criminal justice system is to strengthen prevention efforts and ensure timely access to services, treatments and

supports i n the community to all who need them. Diversion programs (includi ng mental health courts and restorative justice programs) represent the next line of defence because these can ensure that people who are about to enter the criminal justice system get access to needed services, treatments and supports that can help prevent them crossing the threshold. 53


When people l iving with mental health problems and il lnesse s do end up i n the criminal justice system, they have a right to appropriate mental health services, treatments and supports. 54 While correctional systems have made some progress in building capacity, there continue to be significant and sometimes tragic shortfalls in meeting the mental health needs of inmates, and in shi fting correctional culture toward a better balance between treatment and security.55,56,57


Internationally, many correctional systems are strengthening their mental health capacity and improving continuity of care by working more closely with ‘civil’ mental health systems or even transferring responsibility for service delivery to them. It is important to better understand how these models m ight be applied in the Canadian context, and to draw on lessons learned in different provinces where some of these approaches have been tried.58 There is also a need to establish ‘intermediate treatment’ programs for people with serious and complicated mental health problems and ill nesses who nevertheless do not meet the criteria for residential treatment. Without such access, they too often end up isolated in segregation.59


The police also have a critical role to play in improvi ng the response of the criminal justice system to mental health problems and ill nesses. They are frequently the first responders when someone i s experiencing a mental health crisis, and it essential for them to have the very best training in how to interact with people living with mental health problems and illne sses. 60,61 In addition, when police respond to people in crisis and drive them to the hospital, this information can be di sclosed at a later date during police record checks. This practice inhibits people’s ability to volunteer or get a job, and should be stopped.


ACTIONS
2.4.1 Increase availability of diversi on programs, with links to community-based services, treatments and supports.
2.4.2 Strengthen the full continuum of mental health services within correctional facilities, and through better partnerships with remand, health, social and community systems.
2.4.3 Reduce segregation of offenders living with mental health problems and illne sses through the
development of ‘intermediate’ treatment programs.
2.4.4 Support positive interactions between police and people l iving with mental health problems and illnesse s, and eliminate the disclosure of civil mental health apprehensions in police record checks.

Strategic Direction 3: Strengthen capacity in the community


Outcome: People living with mental health problems an d illnesses and their families have access to treatments, services and supp orts in the community, as close as possible to where they live.

As Out of the Shadows At Last made clear, a transformed mental health system shoul d be primarily based in the community, while still ensuring an appropriate balance of community and i nstitutional services. 62
Having access to services, treatments and supports in the community contributes to people spending less time in hospital and improved quality of life. 63 De-institutionalization was, and remains, the right policy. What was – and still is – lacking are sufficient services and supports in the community.


Toward Recovery and Well-Being insisted that such a system must be “seamlessly integrated within and across the public, private, and voluntary sectors, across jurisdictions, and across the l ifespan,” while acknowledging that there will never be a single template for achieving this. 64 A ‘tiered’ service system model provides a way of thinking about how to improve the flow and efficiency of mental health- related services, and of promoting a shift to less intensive services wherever possible. 65


A tiered model encourages us to think of the entire service system as a pyramid divi ded into se veral layers or tiers. Each tier represents a cluster of services and supports with similar levels of intensity. At the lower tiers the focus is on providing less intensive and less expensive services to large numbers of people. Services and supports at this level should be available in most communities, and can include population-wide mental health promotion and prevention i nitiatives. They may also include l ow-intensity supports in the community for people with mental health problems and i llnesses. School -based prevention programs, primary care screening for depression, and peer support programs for people with lived experience are ‘located’ in the lower tiers.


Moving up the pyramid, the degree of intensity and level of spec ialization increase – along with the cost of delivering these services – but fewer people need to make use of these services. The top tier focuses on providing the most intensive and expensi ve services to address the most complex needs, such as treatment for people with developmental delays and mental illness that are in trouble with the law. Services at the upper tiers will often be available on a regional basis and can involve longer term facility-based services.


A fully-functioning tiered system woul d be coordi nated, flexible and responsi ve. People should be able to access the services at the appropriate level of intensity as they progress on their journe y of recovery and their needs change, “stepping up” and “stepping down” easily between tiers. For example, people with severe and complex problems may require specialized services for a time, but as their needs are addressed and they build on their strengths, they may need less intensive on-going support. Similarly, people who had been utilizing less intensi ve supports may go through life challenges that require more intensive services for a time. Where more than one service at the same tier or level of intensity can meet people’s needs, they may choose where to access services. People may also choose to access supports at several tiers at once. For example, someone could make use of community supports while also receiving specialized care.

A tiered approach points to the importance of strengthening the capacity of community-based mental health services and primary health care, and increasing access to ‘talking’ therapies, so that the mental health
needs of a greater part of the population can be met in the least intensive manner possible. To support a transformed mental health system, one that is truly grounded in an orientation to recovery and well-being, the quality of relationships between service providers and people li ving with mental health problems and illnesse s must be a central focus. In addition, a ‘tiered model’ must build in the importance of assi sting people in obtaining a decent income, employment, housing and peer support (‘a home, a job and a friend’).


While Strategic Direction 3 focuses on these comm unity-based services in particular, the other Strategic Directions also contain important elements of a ‘tiered’ system model, such as promoting positive mental health across the population and building capacity in other sectors, empowering people, families and communities, and addressing inequities in access to services and mental health outcomes.


PRIORITY 3.1
Strengthen the capacity of community -based mental health services to foster recovery and well-being.


The long-standing shortfalls in the overall capacity of mental health services in the community must be addressed.66 A number of measures can be taken to improve coordination between mental health services, primary health care, schools, the justice system and other sectors, includi ng greater use of indivi dualized care plans, along with protocols for their implementation. People and families can benefit from support to help navigate the system, particularly in times of crisis. More seamless transitions are also needed across the lifespan and across ‘tiers,’ such as when youth transition to adult mental health services, or wh en people move between acute care and community settings.


There is very good evidence that ‘talking’ therapies (also known as psychotherapy, clinical counselli ng, psychol ogical therapy, etc.) can complement, or provide an alternative to, medication for people li ving with a broad range of mental health problems and ill nesses. 67,68 Expanding access to ‘talking’ therapies under publicly funded systems has been made a priority internationally, notably in the United Kingdom and Australia. The evidence is very strong for Cognitive Behavioural Therapy (‘CBT’), but is also increasingly recognizing the importance of individualized approaches and enabli ng choice in general.69,70, 71


Although 'talking' therapies in Canada are available on a limited basis in publicl y-funded settings such as hospitals and some mental health centres, wait -lists are long and there is minimal choice for the person seeking treatment. 'Talking' therapies provided by mental health professionals (other than physicians) who work in private practice are out of reach for many people who lack private insurance and cannot afford to pay out-of-pocket. It will be necessary to explore a variety of funding mechanisms i n order to enable more people to have access to ‘talking’ therapies from a range of qualified providers.

Access to intensive services – such as crisi s intervention and support, intensive case management and assertive community treatment – has improve d in recent years, but continue s to fall short of the need. 72 In particular, these services and supports play a key role in sustaining people in housing, helping them to avoid

becoming involved with the criminal justice system, reducing reliance on acute care services, and managing transitions from one part of the sy stem to another.73


ACTIONS
3.1.1 Strengthen coordination between community-based mental health, acute mental health, health, justice, education, and other social services through protocols, individualized care plans and system navigation.
3.1.2 Increase access to ‘talking’ therapies regardless of ability to pay, with due consideration of best
available evidence.
3.1.3 Improve access to intensive services in the community suc h as crisis intervention and response, intensive case management and assertive community treatment.


PRIORITY 3.2
Advance the role of primary health care in a transformed mental health system.


In Canada, people are more likely to consult their family physician about a mental health problem or illness than any other type of health care provider.74 Strengthening the mental health capacity of primary health care yields important benefits includi ng improved access, better use of resources, improved outcomes and greater satisfaction with care.75,76 Efforts to expand collaborative approaches to mental health care in primary health care settings in Canada over the past 15 years ha ve made a difference by: promoting a shift in attitudes towards collaboration; providing training; changing fee structures; and including mental health as a priority in primary health care teams.77


Despite this progress, there is still plenty of room to advance the role of primary health care and to develop stronger linkages with community-based mental health services. This can be accomplished by better defining competencies, establishing protocols, and expanding access to more flexible fee structures and appropriate training opportunities. Above all it is e ssential to buil d strong relationships amongst all providers and foster on-going communication.78


A variety of approaches are being used to re-orient primary health care toward recovery and well-being. Examples include: seeking input and feedback from people living with mental health problems and il lnesse s and their families; proactive outreach and follow-up; facilitating self-management and peer support; and promoting positive mental health and well-being.79 There is also a tremendous opportunity to address c o- occurring mental and physical health problems and ill nesse s in the context of primary health care. The fact that the lives of people living with serious me ntal health problems and ill nesses can be shortened by as
many as 25 years by chronic di sease and suicide must be addressed.80 At the same time, people with chronic
diseases are at increased risk for the development of mental health problems and illne sses such as depression and anxiety.81,82


ACTIONS
3.2.1 Strengthen collaboration between primary health care and mental health services, through defined competencies, protocols, supportive fee structures, on-going communication, and training.

3.2.2 Improve satisfaction with services by honouring input and feedback from people livi ng with mental health problems and ill nesses and their families, and through proactive outreach and follow-up.
3.2.3 Enhance the role of primary health care in facilitating self-management and peer support, and promoting positive mental health.
3.2.4 Make screening for mental health problems and illnesse s a routine practice in primary health care
for people at high risk such as those with chronic physical illnesses.
3.2.5 Reduce mortality rates for people living with mental health problems and il lnesse s by im proving physical health care and acting to prevent suicide.


PRIORITY 3.3
Increase access to peer support as an essential component of a transformed system.


The use of peer support is founded on the understanding that people living with mental health problems and illnesse s and their families can offer beneficial support, encouragement and hope to each other when facing similar situations. Peer support can take place in a variety of settings, ranging from peer-run organizations and family support programs to workplaces, universities, and healthcare settings. Peer -run organizations play an essential role in the continued development of peer support capacity, both by providing peer
support directly and by providi ng support to peers working in mainstream settings.83


Outcome studies conclude that peer support in a variety of organizational settings can be as effective, or more effective, than non-peer services. Peer support for people l iving with mental health problems and illnesse s is associated with: reductions in hospitalization for mental health problems; reductions in
‘symptom’ distress; improvement in social support; and improvement in people’s quality of life. 84


Peer support is provided i n both mainstream and peer-run settings across Canada. However, the proportion of mental health funding directed towards peer support initiatives remains negligible. Developing guidelines and standards for practice will enhance the credibility of peer support services and contribute to the growth of peer support as an essential component of a transformed mental health system.85 Family peer support and family-led education can improve family members’ understanding of the mental health system, and
their sense of empowerment, ability to cope and self-care.86,87,88 It is important that family members be
supported to promote recovery.89,90


ACTIONS
3.3.1 Increase availability of appropriately-resourced peer initiatives, in both peer-run and mainstream settings.
3.3.2 Develop peer worker competencies and voluntary standards in collaboration with peer support organizations.
3.3.3 Increase opportunities for peer support between families.

PRIORITY 3.4
Improve income to support choice and quality of life.


Having meaningful work and access to an adequate income contributes to everyone’s ability to achieve and sustain a good quality of life. People li ving with mental health problems and ill nesses have high rates of unemployment, and many are unable to develop their skills and talents.91 There is a need to remove barriers to full participation in the workforce and increase access to effective employment supports that help people to obtain competitive employment.92 Social enterprises, many of which are peer-run, employ people within a supportive environment and can be a valuable alternative.


Canada lags behind other developed countries both in ensuring adequate access to disability benefits and in how disability benefits are assessed and administered.93 A number of elements shoul d be at the heart of disability asse ssment and admini stration, including: integrated incapacity and capacity assessment; recognition of episodic disabil ity; providing inc ome support as needed; and support for indi viduals to build on their strengths. Financial disincentives to return to work because of the way these programs are structured, as well as disincentives that arise through the interaction with other social programs, must also be addressed.94


For families and circles of support, providing unpaid care for a person livi ng with a mental health problem or illness can hinder their own participation in the workforce and cause them serious economic hardship. One study reported that 27% of caregivers experienced a reduction in income and 29% incurred major financial costs. 95 Families and circles of support need increased access to financial support such as tax credits, caregiver allowances and respite care, and policies that make possible more flexible work environments, including allowing caregiver leaves and flexible hours. 96


ACTIONS
3.4.1 Improve access to income support programs for people living with mental health problems and illnesse s, and address financial di sincentives that hinder their return to work.
3.4.2 Strengthen supports for people living with mental health problems to work i n competitive
employment, and support the development of social enterprises.
3.4.3 Increase financial/income support and flexible w ork environment policies for caregivers.


PRIORITY 3.5
Provide equitable access to decent, affordable housing and related supports.


The elements of secure housing include affordabi lity, security of tenure, desirability and safety of l ocation , as well as the condition of the dwelling unit itself. All of these elements add up to something that is called “home.” A home is the foundation for an independent life in the community, and indeed for health and
well-being.97 While this i s true for everyone, it is doubly true when people are experiencing mental health
problems and il lnesse s. In a transformed mental health system that is grounded in recovery and well -bei ng, people livi ng with mental health problems and illnesses must be supported to live in the community, to choose their place of residence and to choose from among a range of community support services.

There is strong evidence that improving housing contributes to im proved outcomes, and a strong business case can be made based on the significant costs of i naction that are being borne by the acute care system, the justice system, and the private sector. Action is needed on many fronts: increasing access to affordable and adequate housing stock; providing greater access to rent supplements; and shifting from custodial housing model s to model s that support greater choice and privacy.98 At a minimum, the discrimination faced by people living with mental health problems and illne sses with regard to housi ng must be addressed. There is a greater percentage of people living with mental health problems and i llnesse s who lack access to adequate housing (27%) than the percentage of the general population that faces housing need (15%). 99

Between 23% - 74% of people who are homeless in Canada have a mental health problem or illness. 100
‘Housing first’ approaches provide housing and supports according to people’s preferences, without preconditions. These model s are showing great promise for improving outcomes and quality of life for the homeless population i n Canada and internationally, and must be sustained and expanded across the country.101,102,103,104 Providi ng appropriate housing and related supports to homeless pe ople who are livi ng with a mental health problem or illness also saves mone y. The cumulative costs of shelters, increased health services use, and other services outweigh the costs of simpl y provi ding a place to live and support to stay there.105,106

ACTIONS
3.5.1 Ensure that people of all ages living with mental health problems and illne sses have at least as much access to adequate and affordable housing as the general population.
3.5.2 Sustain and expand access to ‘housing first’ initiatives for homeless people living with mental health
problems or il lnesse s.
3.5.3 Increase access to the range of services, treat ments and supports that are needed to acquire and sustain housing.

Strategic Direction 4: Improve equity


Outcome:
Inequities in addressing mental health needs are reduced, whether b ased on s tage of life, geographical location, diversity of b ackground, or degree of complexity.

All people li ving in Canada should have the opportunity to achieve the best possible mental health and well- being. However, many population groups in Canada continue to have poorer mental health outcomes overall compared to the population as a whole. 107,108 There are many inequities in li ving conditions – such as inadequate access to housing, lower rates of employment and education, and poverty – that influence these poorer outcomes. As well, barriers that inhibit access to mental health services, such as the limited availability of culturally safe and culturally competent services, also play a role. In Canada and around the world, there is growing recognition that addressing these kinds of inequities m ust become central to the effort to improve health and social outcomes, including mental health outcomes.109


As stated in Toward Recovery and Well-Being, a transformed mental health system must respond to the disparities and diverse needs that can arise from First Nations, Inuit or Métis identity; ethno -cultural background, experience of racism, and migration history; stage of life; language spoken; sex, gender and sexual orientation; geographic location; different abilities; socio-economic status; and spiritual or religious beliefs.110


Mental health has often been described as the “orphan” of the health care system because it has not received the attention and resources to respond adequately to the mental health needs of the Canadian population. At the same time that mental health overall has been neglected compared to other dimensions of the health care system, there have been sectors within the mental health system itsel f that have experienced even greater levels of neglect. For example, infant, child and youth mental health has sometimes been referred to as the “orphan of the orphan” because it has suffered from fewer resources, an inadequate workforce, and lack of investment in research. Therefore, at the same time that efforts need to be made to bring up the level of resources devoted to mental health, it is also important to pay particular attention to those sectors and population groups that have experienced, and continue to experience, particular disadvantage.


This additional layer of ine quity is reflected either in inferior access to services, treatments and supports than is available to the population as a whole, or in poorer mental health outcomes. Most often, it is reflected in both. Of course, this does not mean that the situation is as good as it should be for the population as a whole. We know, for example, that only one third of adults who could bene fit from mental health services, treatments or supports actually have access to them.111 Compared to the treatment of just about any physical ailment, this is far less than adequate. More striking, however, is that only one quarter of children and youth has access to the mental health services, treatments and supports that they need.112


The next Strategic Direction (“Seek innovation with First Nations, Inuit and Métis”) looks at what needs to be
done with respect to improving mental health outcomes for First Nations, Inuit and Métis. This is e ssential

both in order to bui ld on the traditional and cultural knowledge of indigenous people s, but also because of the poorer mental health outcomes experienced by many First Nations, Inuit and Métis people and communities.113 This Strategic Direction examines inequities in mental health outcomes associated more broadly with diversity, as well as inequities in access to services, treatments and supports.


PRIORITY 4.1
Reduce inequities in mental health outcomes associated with diversity.


Poverty, inadequate housing and barriers to employment and education affect quality of life and contribute to poorer mental health outcomes. The varying impact of these factors on different groups within the population helps to shape the diversity of mental health needs. For example, recent immigrants are finding it increasingly difficult to obtain employment, particularly employment that matches their level of skills and education, with negative consequences for their mental health.114,115

The most successful approaches to addressi ng inequities in living conditions, including innovative anti- poverty initiatives that are underway in different parts of the country, have taken collaborative action that spans the public, private and voluntary sectors and invol ves multiple government depa rtments. They have engaged senior political leaders and have supported local communities to take action. 116,117 ,118,119 A health equity lens i s useful tool for judging the impact of new policie s and programs on mental health and for ensuring that some people are not inadvertently made worse off. 120


With respect to the mental health system itself, there continue to be significant barriers that keep many people livi ng in Canada with diverse needs from seeking or obtaining help. 121, 122, 123, 124 Although cultural safety and cultural competence have been recognized as core competencies by some professional associations and in accreditation standards, faster uptake and implementation is needed as too many people lack access to treatments, services and supports that are safe and are effective. 125,126


At the same time, people in many communities w ho are dealing with mental health problems and illnesses may turn first to people and organizations within their own communities, whether or not they specialize in dealing with mental health concerns. It is important that these community-based organizations be adequately linked to appropriate services and supports in the ma instream mental health system. Finally, there is a need to increase access to information, services and supports in diverse languages, both for Francophones l iving in mi nority communities outside of Quebec, and also for the 12% of people l iving in Canada who speak a language other than French or English at home.127


ACTIONS
4.1.1 Engage government decision-makers and diverse population groups i n addressi ng barriers to appropriate employment, education, housing and income.
4.1.2 Support diverse comm unities to asse ss local needs and strengths and take collaborative action on
local priorities, in collaboration with local service systems.
4.1.3 Use a health equity lens when evaluating all new policies and programs that have an impact on mental health.

4.1.4 Support the implementation of cultural safety and competency standards through accreditation bodies and professional associations.
4.1.5 Increase the number of mental health services and supports that connect to and build on the strengths of existing community-based organizations serving diverse communities.
4.1.6 Increase access to linguistically appropriate information a nd mental health services, treatments and
supports for minority francophone and di verse language communities.


PRIORITY 4.2
Improve equity of access to mental health services, treatments and supports.


While it is often difficult for anyone li ving in Canada to access the mental health system, it can be most challenging for the youngest and oldest among us, for those li ving in northern, rural and remote areas, and for those livi ng with substance use problems or devel opmental disabilities in combination with mental health problems and ill nesses.

The children’s mental health system is beleaguered by underfunding, fragmentation and shortages of personnel, with tremendous costs for the quality of life of children and youth experiencing mental health problems and il lnesse s and for society as a whole. 128 As well, youth in transition from child to adult mental health services are at even greater risk of falling through the cracks, and there is a lack of appropriate linkages between mental health, health and social services, and the school system. At the other end of the life span, there are nowhere near sufficient mental health services, supports and treatments for older adults, who are also the most likely to have combinations of physical and mental health problem s. With the
population of older adults set to double over the next 30 years, this shortage risks becoming even more acute.129


Getting help for mental health problems and illnesses – without having to travel far from home – is particularly hard for people living in northern, remote and rural communities. Unique challenges include isolation, higher costs of service provision, lack of quali fied service providers, cultural diversity, and complex social and jurisdictional issues. Telemental health and the internet have demonstrated great value in helping to provide services m uch closer to where people l ive, but such services are still not widely available enough. At the same time that these services are expanded, communities must be supported to develop their own solutions and bui ld local capacity over time.


All too often people living with substance use problem s in com bination with mental health problems and illnesse s (‘concurrent disorders’) or developmental disabilities (‘dual diagnosis’) are shunted between services without ever receiving the treatment and care they require. While provincial and territorial governments have made considerable progress in integrating mental health and addictions systems at the administrative level, work is needed to tailor services on the ground to a wide range of needs and circumstances.130 Children and adults with developme ntal disabilities who ex perience mental health problems and illnesse s (‘dual diagnosis’) confront complex social and economic problems and se vere symptoms that require much better coordination between health, mental health, de velopmental and social services.

ACTIONS
4.2.1 Develop and support the implementation of children’s mental health wait -time standards, including
for ‘children in care.’
4.2.2 Support the successful transition to adulthood of young people with mental health problems and illnesse s by im proving coordination and linkages between child and adult services.
4.2.3 Increase mental health services for seniors, including community outreach services, outreach services to residential care facilities, and specialized geriatric inpatient services.
4.2.4 Support northern, rural and remote communities to strengthen local capacity, and accelerate the
uptake of tele-mental health and the internet.
4.2.5 Implement targeted approaches to concurrent mental health and substance use problems at the service delivery level.
4.2.6 Improve the coordination of and access to services for children and adults with developmental
disabilities who also have mental health problems or illnesses (‘dual diagnosis’).

Strategic Direction 5: Seek innovation with First Nations, Inuit and Métis


[UNDER DEVELOPMENT]


5.1 First Nations Stream


5.2 Inuit Stream


5.3 Métis Stream


5.4 Additional focus on gender, urban, rural and northern issues


Toward Recovery and Well-Being rightly insists that, “A mental health strategy for Canada must acknowledge
the unique circumstances, rights and contributions of First Nations, Inuit and Métis in Canada, and respond to their needs.” This is important for everyone li ving in Canada, and will be a key focal point of the Mental Health Strategy for Canada when it is released early in 2012.

To recognize First Nations, Inuit and Métis as distinct cultural groups with unique rights and needs, this Strategic Direction will include di stinct streams for First Nations, Inuit and Métis, with a cross-cutting focus on gender, northern, urban and rural issues. The Mental Health Commission of Canada is seeking advice from and working to establish on-going relationships with the Assembly of First Na tions, Inuit Tapiriit Kanatami, Métis National Council, the Congress of Aboriginal Peoples, the Native Women’s Association of Canada and other indigenous organizations. The Commission also draws on the knowledge and experience of the MHCC First Nations, I nuit and Métis Advisory Committee.


Priorities for action are being developed for each stream that respect traditional and cultural knowledge from First Nations, Inuit and Métis communities.

Strategic Direction 6: Mobilize leadership


Achieving the objectives set out in thi s strategy will not happen overnight. This Strategic Direction focuses on key enablers of change: the human and financial resources that will be needed to implement the recommendations in the strategy; the leadership at multiple levels required to sustain and buil d on the momentum for change; and the creation of the infrastructure that can support the process of transformation and measure our progress over time.


The past decade has seen a remarkable rise in the attention paid to mental health issues in government, the media and amongst people right across the country. Beginning with efforts by mental health stakeholders to develop a common call for action on mental health, many have already played an important leadership role. Out of the Shadows at Last, the report on mental health by the Senate Committee on Social Affairs, Science and Technology, shone a spotlight on the urgent need to transform mental health systems across the
country and led to the creation of the Mental Health Commission of Canada. In parallel to the work of the
Commission, numerous governments have undertaken work to develop their own mental health plans and strategies.

In order to build on thi s momentum and sustain it over time, leadership at many levels will be required. It has often been rightly noted that mental health cannot be seen exclusively as a ‘health’ issue. Poor mental health undermines the objectives of many government departments and agencies – from child and youth services, to housing, to finance – whose work i n turn has an impact on mental health outcomes. This underscores the importance for all governments to effectively coordinate their efforts and to take a “whole - of-government” approach to mental health issues. Internationally, mental health strategies have increasingly incorporated plans to implement such approaches, and whole -of-government approaches have also demonstrated their value in a number of provinces here in Canada in areas such as poverty reduction , healthy children, and promoting community safety. 131,132,133

In order to achieve the best results in the most efficient way possible , it is necessary both to define our objectives as clearly as possible and collect the information needed to measure progress. While the organization and delivery of service s will remain largely the responsibi lity of the Provinces and Territories, there are many areas where developing and strengthening pan-Canadian infrastructure could help all jurisdictions. For example, authoritative bodies in a number of countries have contributed to enhancing quality across their mental health systems. It should be possi ble to replicate their success in Canada. Human resource planning and establishing outcomes targets and collecting the data needed to know if we are achieving them are other areas where it will be important to strengthen efforts that cross jurisdictional boundaries.

Many other countries have reported that the participation of people living with mental health problems and illnesse s and their families has been a critical element in initiating and sustaining change within their mental health systems. Expanding the leadership role of people with lived experience by investing in leadership and organizational development at the national, regional and local levels will be essential for success i n Canada
as well.

It is clear that the kind of change envisaged in this strategy cannot occur without renewed investment in the broad sphere of mental health by governments across the country. Whi le there is no established target for spending on mental health and it is difficult to estimate accurately the total spending by all departments and levels of government, the best available research indicates that Canada spends considerably less on mental health than those countries that are setting the standard. In Canada, mental health funding makes up 7% of overall health spending, far below the 10+% spent by other developed countries such as N ew Zealand and the UK.134 Given the perpetual competition for government resources, it will take a strong social movement to sustain pressure on governments to make the necessary increase in investments i n mental health.


PRIOIRITY 6.1
Apply a “whole-of government” approach to the development and implementation of mental health
policy and in response to the mental health strategy for Canada.


Mental health both influences and is influenced by policies and programs that span multiple government ministries. Success i n dealing with complex, cross-departmental and cross-juri sdictional issues such as mental health depends on many factors, including strong leadership by government. There are many examples, at home and abroad, of approaches to horizontal manage ment in government ranging from the establishment of a dedicated authority responsible for coordi nating activity across ministries to the designation of an existing ministry or department to assume leadership. 135 While the most appropriate mechanism for ensuring that a “whole-of-government” approach is adopted will always vary from one jurisdiction to the next, the evidence suggests that it is very important that leadership be located at the highest level possible within government and the bureaucracy.


At the same time, there are many actions that are only achievable if there is coordinated action across the country. In particular, the mental health workforce represents roughly 80% of costs in direct mental health care. Ensuring that the workforce is the right size, has the right skills, and has the right mix of specialties cannot be achieved by each jurisdiction working on its own. It is important to undertake human resource planning in order to address immediate issues and align the future workforce with the changing orientation of the mental health system.136 Current issues incl ude shortages of professionals in many disciplines, the uneven distribution of providers across the country, and the inability of services to hire certain kinds of providers because they cannot afford them. Implementing the recommendations in this strategy will require many adjustments to the composition of the workforce, from ensuring that there are sufficient peer support workers to facilitating inter-disciplinary practices and promoting cultural competence.


In accordance with their rights and responsibilities, First Nations, Inuit and Métis leaders and governments must be engaged by the highest levels of federal, provincial and territorial governments. Such a forum is needed to address the many complex jurisdictional and governance issues that have a significant impact on policies, programs and outcomes related to First Nations, Inuit and Métis mental health.

ACTIONS
6.1.1 In every jurisdiction, establish cross-departmental Mental Health Committees sanctioned by the
Prime Minister or the Premier, as well as a mechanism for inter -governmental collaboration.
6.1.2 Develop cross-juri sdictional capacity for human resource planni ng, education and supply management to support recovery and well-being.
6.1.3 Work with First Nations, Inuit and Métis communities and leaders to address mental health-related jurisdictional and governance issues.

PRIORITY 6.2
Strengthen national mental health infrastructure.


There are many areas where developing and strengthening national and cross-juri sdictional infrastructure can be of great benefit to each jurisdiction, as well as to the country as a whole. Credible indicators and meaningful data on mental health and mental illness are required to measure progress both in transforming the service system and improvi ng outcomes over time. Given the significant areas for which data is simply not currently available, as well as the many instances in which it is collected in different ways in di fferent parts of the country, it will be important to adopt a “twin-track” approach. We need to identify indicators that can be supported by existing data sources – even if these are not ideal – in order to begin measuring our progress. At the same time, we need to develop a comprehensive outcomes framework and put in place the capacity to collect the data needed for its implementation.

The release of this strategy is only one step i n the planning process that will be required to realize the goal of a transformed mental health system. Not only must this strategy be reviewed and updated, but it will also need to be supplemented by a variety of other planning initiatives. There are many areas not covered at all by this strategy, and others for which only a limited set of recommendations has been proposed. Plans for specific sectors and population groups need to be developed along with guidelines and standards for a range of policie s and practices. This work needs to be done in an i nclusi ve and collaborative fashion and must be supported by a research agenda that spans the full spectrum of issues that relate to mental health and mental illness. At the same time, the translation of this knowledge into policy and practice must be accelerated.

Some of this work is currently bei ng undertaken by existing organizations, including the Mental Health Commission of Canada, but it is all too often not bei ng done in a systematic and coordinated fashion. As in other countries, sustaining this work over time will require a robust institut ional framework that will build credibility amongst all stakeholders and foster ongoing coordination and collaboration across jurisdictions and organizations.137

ACTIONS
Designate or establish a body (or bodie s) that would have the capacity to:
6.2.1 Develop and implement an outcomes framework that would enable the measurement of progress in transforming mental health systems in Canada and in improvi ng mental health outcomes across the population.

6.2.2 Collaborate with stakeholders to develop mental health plans for various population groups and sectors.
6.2.3 Develop guidelines and standards to guide quality improvements in me ntal health-related policies and practices.
6.2.4 Work with existing research agencies and universities to develop and implement a mental health
research agenda that supports the transformation of the mental health system.
6.2.5 Provide assi stance to jurisdictions and organizations working to transform the mental health system.


PRIORITY 6.3
Expand the leadership role of people living with mental health problems and illnesses.


As was discussed in Strategic Direction 2 (“Transform Relationships and Uphold Rights”) ‘nothing about us without us’ conveys the principle of the active invol vement of people l iving with mental health problems and illnesse s in all aspects of the planning, delivery, evaluation, monitoring and research of programs and
policies that affect their lives.


The involvement of pe ople living with mental health problems and illne sses and their familie s has been a key lever for the shift toward a recovery orientation around the world. This has been supported through investments in organizations that led by people with lived experience at the national, regional and community level, such as the Mental Health Council of Australia.138 Not only i s this the best way to ensure that people living with mental health problems and illnesses have strong voice s in determining mental health policy, but the presence of strong leaders and strong organizations will shape service delivery,
administration, research, peer support and efforts to eradicate stigma and discrimination.


ACTIONS
6.3.1 Establish guidelines to ensure that people of li ving with mental health problems and illne sses have a strong leadership role in the development and implementation of menta l health-related policies and programs.
6.3.2 Increase support for the development of organizations that are led by people living with mental
health problems and ill nesses at the national, regional and local levels.
6.3.3 Increase support for people living with mental health problems and illne sses to participate in and lead research.


PRIORITY 6.4
Fund and sustain transformation.


Good mental health is associated with better physical health, success in education, participation in the workforce and better productivity.139 Investments in mental health, not just in the health sector but across many social sectors, will contribute to sustaining the health care system. As the government of New Brunswick said in its 2011 Mental Health Action Plan, “we can no longer afford to under-invest in mental health.”140 In Canada, mental health funding makes up 7.2% of overall health spending, far below the 10+%
spent by other developed countries such as New Zealand and the UK.141

There is always much competition for government and priva te sector attention and resources, and this can become even more intense during times of economic and fi scal constraint. A strong social movement for mental health is needed in order to buil d on the momentum achieved thus far by the mental health community, and take it to the next level by engaging the private sector, the voluntary sector, people living with mental health problems and illnesses and their families, service providers and admini strators, researchers, people from diverse backgrounds, and most importantly each of us as indi viduals and
community members. This is the only way to sustain pressure on governments and other decisi on-makers to
make the necessary investments in mental health, and to keep mental health from drifting back into the shadows.

ACTIONS
6.4.1 [funding proposal under development]
6.4.2 Build a dynamic, broadly based social movement for mental health.

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