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CMHA Ontario Presentation to the Amalgamated Transit Union

March 10, 2006

Our Mission and Vision ►

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Mission and Vision

Mission• To promote the mental health of all individuals and communities in Ontario by providing leadership through knowledge enhancement, policy development, advocacy, and the advancement of best practices in service delivery.

Vision• A society which values human dignity and enhances mental and emotional well-being for all.

Our Values ►

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Our Values

What We Do►

• Social Justice• Individual and collective responsibility• Access to appropriate and adequate supports• Self-determination• Community integration• Integrity• Partnership• Excellence• Accountability• Creativity

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What We Do

What is Mental Illness? ►

•Knowledge Transfer

•Policy Research and Development• Education and Training• Mental Health Works

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What is Mental Illness?

• Mental illness can take many forms.• A continuum of mental illness exists ranging

from minor mental health issues to more serious mental disorders.

• E.g. anxiety disorders, mood disorders, schizophrenia, concurrent disorders, and personality disorders.

Mental Illness in Numbers ►

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Mental Illness in Numbers

Mental Illness in Numbers ►

• Mental illness impacts all Ontarians– 20% of Ontarians will experience a mental illness in

their lifetime (Health Canada, 2002)– 80% of Ontarians will have family, friends or

colleagues who experience a mental illness in their lifetime (Ibid)

– 5-12% of men and 10-25% of women in Ontario will have at least one episode of major depressive disorder in their lifetime (Ibid)

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Mental Illness in Numbers

• Mental illness impacts all Ontarians…– 12% will suffer mild to severe impairment as a result of an

anxiety disorder (Ibid)– 3% will experience bipolar disorder (Ibid)– 1% will experience schizophrenia (Ibid)

• Suicide– The number of suicides in Ontario increased from 930 in

1997 to 1,032 in 2001 (Weir, 2001).– More men in Ontario committed suicide between 1990 and

2000 than died in car crashes: approximately 591 men committed suicide in Ontario in that decade, while 558 men died in car crashes (CIHI, 2002).

Mental Illness in Numbers ►

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Mental Illness in Numbers

Overview of Mental Disorders ►

• Receiving Help– 47.7% with a serious mental illness, 72.3% with a

moderate mental illness, and 89.6% with a mild mental illness will never receive help (Bijl et al, 2003)

• Economic Cost– Lost productivity due to mental illness costs the Canadian

economy approximately $14.4 billion annually (Stephens & Joubert, 2001).

– Disability represents anywhere from 4% -12% of payroll costs in Canada; mental health claims have overtaken cardiovascular disease as the fastest growing category of disability claims (Wilson, 2002).

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Overview of Mental Disorders

Anxiety DisordersMood DisordersSchizophrenia

Concurrent DisordersPersonality Disorders

Anxiety Disorders ►

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Anxiety Disorders

• Are the most common of all mental health problems.• Characterized by intense, prolonged bouts of distress or

fear.• More common in women than in men.• Often accompanied by other symptoms such as

depression, substance abuse, or physical problems.• E.g. panic disorders, generalized anxiety disorders,

phobias (social and specific), post-traumatic stress disorder, and obsessive compulsive disorder.

Mood Disorders ►

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Mood Disorders

• May experience depressive episodes (feeling very "low") or manic episodes (feeling very "high"), or both.

• E.g. depression, major depression, seasonal affective disorder, postpartum depression, manic depression, and bipolar disorder.

Mood Disorders ►

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Mood Disorders

• Depression– Describes a period of time when a person feels very

sad to the point of feeling worthless, hopeless and helpless.

– Symptoms• feeling detached from life and those around you • continued fatigue or loss of energy • feelings of sadness – crying for no apparent reason • inability to concentrate or make decisions • thoughts of suicide • changes in eating or sleeping patterns

Mood Disorders ►

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Mood Disorders

• Bipolar Disorder– Characterized by opposing moods -

experiencing great highs (manic stage) and great lows (depressive stage).

– Attacks of mania come on very quickly, sometimes within a single day, or can build slowly.

– Manic episodes can last for hours, weeks or months.

Mood Disorders ►

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Mood Disorders

• Bipolar Disorder– Symptoms of the Depressive Phase

• feelings of worthlessness, hopelessness, and helplessness

• prolonged sadness and persistent fatigue• jumpiness, irritability • withdrawal from activities• thoughts of death or suicide • loss of appetite or noticeable increase in appetite • insomnia or increase in sleep

Mood Disorders ►

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Mood Disorders

• Bipolar Disorder– Symptoms of the Manic Phase

• sudden onset of exhilaration and giddiness• racing thoughts and rushed speech • thoughts change abruptly from topic to topic • sudden irritability, rage, paranoia, and/or

distractibility • attention is easily diverted to unimportant details

Mood Disorders ►

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Mood Disorders

• Postpartum Depression

• Baby Blues -- most minor form and is characterized by weeping, irritability, lack of sleep, and mood changes.

• Postpartum depression -- more debilitating and is characterized by despondency, tearfulness, feelings of inadequacy, guilt, anxiety, irritability and fatigue.

• Postpartum psychosis -- relatively rare disorder. Symptoms include extreme confusion, fatigue, agitation, alterations in mood, feelings of hopelessness and shame, hallucinations and rapid speech or mania.

Schizophrenia ►

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Schizophrenia

• Symptoms of schizophrenia often develop slowly, usually between the ages of 16 and 30.

• The symptoms of schizophrenia vary greatly from person to person, from mild to severe.

• Symptoms include delusions, hallucinations, social withdrawal, bizarre behaviour, lack of motivation, and disorganized thinking.

Concurrent/Personality Disorders ►

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Concurrent and Personality Disorders

• Concurrent Disorders – Combines both a mental health problem and a

substance use problem.• Personality Disorders

– Identified by a pervasive pattern of experience and behavior that is abnormal with respect to any two of the following: thinking, mood, personal relations, and the control of impulses.

– E.g. paranoid, schizoid, schizotypal, anti-social, borderline, and histrionic.

Some Final Points ►

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Some Final Points

• Everyone in Ontario is affected by mental illness.• There is a continuum of mental illness.• Very few people with a mental illness are violent.• People with a mental illness are no more likely

than anyone else to harm strangers. • In fact, people with a mental illness are more

likely to be the victims, rather than the perpetrators of violence.

Responding to Crisis Situations ►

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Responding to Crisis Situations

HallucinationsDelusions

Suicidal BehaviourPanic Attacks

Excited Delirium

Recognizing Hallucinations ►

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Recognizing Hallucinations

• Person senses perceptions that are not real • The person may:

– Talk to self– Experience difficulty following conversations and

instructions– Appear preoccupied and unaware of surroundings – Misinterpret words and actions of others– Experience momentary or extended lapses in

attention– May use radio or sounds to tune out voices

Responding to Hallucinations ►

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Responding to Hallucinations

• Person needs your help in establishing a calm environment.– Do not invade personal space or touch them without

permission– Speak slowly, calmly and quietly, using simple language– Reduce stimuli – turn off flashing lights, loud system, etc.– Address the person by name– Ask questions – Do not pretend that you also experience the hallucination – Be patient – it may take the person longer to process the

information

Recognizing Delusions ►

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Recognizing Delusions

• The person may:– Believe self to be someone of importance– Be extremely suspicious– Appear afraid– Avoid food or medication for fear of poisoning– Be excessively religious– Experience ordinary things in his/her environment as

a threat• Paranoid delusions are the most common.

Responding to Delusions ►

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Responding to Delusions

• Keep a safe distance• Do not touch the person without permission• Position yourself at the person’s level (if safe to do so)• Do not laugh or whisper• Ask questions about the delusion • Do not attack delusions• Ask if there is anything you can do to make the person

feel more comfortable • Always explain your intentions before you act• Phone local crisis number, emergency services, etc.

Responding to Delusions ►

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Responding to Delusions

• Specific to persons in uniform– Both presence and uniform may have an

extremely intimidating effect.– Important to assure them that they are safe,

you are not going to harm them, and that the equipment/uniform is to protect them.

Recognizing Suicidal Behaviour ►

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Recognizing Suicidal Behaviour

• Depression, expressions of hopelessness• Preoccupation with death• Talking or joking about suicide• Self neglect• Self-harming or risk taking behaviour• Hearing voices instructing them to do something

dangerous

Responding to Suicidal Behaviour ►

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Responding to Suicidal Behaviour

• Don’t be afraid to ask direct questions (Do you want to kill yourself?)

• Use clear and simple language• Do not leave the person alone• Phone your local emergency number, crisis line

or take them to the hospital• Myth – People who talk about suicide do not

really want to do it

Recognizing a Panic Attack ►

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Recognizing a Panic Attack

• Rapid breathing and heart rate• Sweating, shaking and wide eyed expression• Difficulty communicating• Feeling of impending doom• Fear of losing it or having a heart attack

Responding to a Panic Attack ►

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Responding to a Panic Attack

• Speak slowly and calmly• Encourage deep breathing• Use short simple sentences• Assure that they are safe• Explain all actions• Remove from noise and confusion• Refer/escort to crisis service

Recognizing and Responding to Excited Delirium ►

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Recognizing and Responding to Excited Delirium

• Causes:– Drug intoxications or psychiatric illness or a combination of both.

• Symptoms: – Bizarre and/or aggressive behaviour– Disorientation– Hallucinations and acute onset of paranoia– Impaired thinking– Unexpected physical strength– Sweating, fever, heat intolerance– Significantly diminished sense of pain

• Response:– Know the symptoms– If excited delirium is suspected call emergency medical services

immediately for transport to a medical facility.

Crisis Response Do’s and Don’ts ►

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Crisis Response Do’s and Don’ts

DO’s• Take your time & eliminate

noise• Ask permission first• Treat with dignity and respect• Keep your distance and

respect personnel space• Talk slowly and quietly• Ask of how you can be of

assistance• Give choices when possible• Develop a sense of “working

together”

DON’Ts• Do not challenge• Do not deceive• Do not tease or belittle• Do not violate personal space• Do not forget the pain or fear

he/she is experiencing• Do not forget to ask about

medications

Crisis Services in Ontario ►

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Crisis Services in Ontario

Types of Crisis Services

Resources and Contact Information

Pro-active Steps

Types of Crisis Services ►

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Types of Crisis Services

• Crisis Telephone Lines– Provides free and confidential telephone counseling,

24 hours a day, 7 days a week.• 24 hour Mobile Crisis Team

– Provides a 24-hour crisis line with a mobile team component (with or without police partnerships).

• Community Crisis Centre– Crisis workers provide 24-hour support to individuals

in crisis, and provide access to temporary accommodation if required.

Resources and Contact Information ►

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Resources and Contact Information

• Mental Health Service Information Ontario (MHSIO)– Provides comprehensive information about mental health

services and supports across Ontario (24/7)– 1-866-531-2600 or visit www.mhsio.on.ca

• Distress Centres Ontario– For centres in your area call (416) 537-7373 or see

www.dcontario.org/centres.htm• 211 Ontario

– Provides information about community, social, health, and government services (Local sites for Toronto, Niagara, & Simcoe)

– See www.211ontario.ca

Pro-Active Steps ►

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Pro-Active Steps

• Establish and build relationships with mental health agencies in your area.

• Educate yourself, colleagues, and all employees on mental health issues and mental illness.

• Attend educational workshops and training sessions (e.g. suicide intervention, mental health information sessions, understanding people in crisis, living with stress, etc.).

• Continue to foster on-going partnerships with mental health agencies, hospitals, and police.

Mental Illness and the CJS ►

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Mental Illness and the Criminal Justice System

CMHA Diversion ProgramsJustice Funding

Crisis Response/Outreach ServicesCourt Support and Post Charge Diversion

Mental Illness and the CJS ►

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Mental Illness and the CJS

CMHA Diversion Programs ►

Need for Service:

• Recognizing that police are often the first responders to individuals who are experiencing a mental health crisis – the need for a coordinated and collaborative approach between community agencies, mental health agencies, hospitals, and the criminal justice system is imperative.

• Mental Health Diversion provides alternatives to the criminal justice system and is available to persons with a mental illness who have come in contact with the law.

• Mental Health Diversion programs include: Police pre-arrest diversion; Court Diversion and Mental Health Courts

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CMHA Diversion Programs

Justice Funding►

• Crisis Response/Outreach Services– Designed to assist and provide support for individuals with a

mental illness experiencing a crisis. The primary objective is to assist the individual to regain control of their distress and to prevent hospitalizations.

• Court Support and Post-Charge Diversion– Supports people with a serious mental illness navigate the

criminal justice system by providing community alternatives and facilitates access to psychiatric treatment. Court support and post-charge diversion programs are voluntary.

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Justice Funding

– On January 12, 2005, the Ministry of Health and Long-Term Care announced $27.5 million in new funding for community services.

– CMHA as a whole received $12,4451,411, or 46% of the provincial funding going to 25 branches.

– Funding was directed at five service areas: court support, short-term crisis beds, intensive case management, crisis response/outreach and supportive housing.

Justice Funding►

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Justice Funding

• Court support: funding went to 24 CMHA branches, 12 of whom will be starting new programs

• Short-term Crisis beds: funding went to 6 CMHA branches, all of whom will be starting new programs

• Intensive Case Management: funding went to 19 CMHA branches, 7 of whom will be starting new programs

• Crisis Response/Outreach: funding went to 6 CMHA branches, all of whom will be starting new programs

• Supportive Housing: funding went to 6 CMHA branches, 3 of whom will be staring new programs

Crisis Response/Outreach Services ►

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Services and Process:• 24 crisis line providing a comprehensive assessment of

client needs (with or without mobile team component).• Staff respond and assist callers in dealing with their

immediate crisis, provide information, support and referrals to appropriate resources.

• Core functions include: assessment and planning; crisis support/counseling; medical and environmental interventions; crisis stabilization; review/follow-up/referral; information liaison; advocacy; consultation and collaboration.

Crisis Response/Outreach Services ►

Crisis Response/Outreach Services

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Crisis Response/Outreach Services

Short-term Crisis Beds – a component of crisis response– Services are provided for people with serious mental

illness who are in crisis and come in contact with the law.

– Safe beds provide alternatives to incarceration and hospital admissions.

– Specially trained CMHA staff are on call and respond to calls from police, mobile crisis team, or other community agencies.

Crisis Response/Outreach Services ►

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A CMHA Regional Perspective

• 20 of our 33 branches provide crisis/outreach services.

• 15 branches are in the process of developing a mobile team or currently provide mobile services.

• 9 branches are working in partnership with local police services.

Crisis Response/Outreach Services ►

Crisis Response/Outreach Services

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Example of a service model:• Chatham-Kent Police Service HELP Team

– Consists of specially trained police officers and assisted by partnerships with the Chatham-Kent Health Alliance, CMHA-Chatham-Kent Branch and the Program of Assertive Community Treatment.

– All HELP Team members provide assistance to the investigating officer, if the person is not admitted to the hospital then the HELP team will contact a community partner to assist with the crisis situation.

– If the EDP is CMHA’s client then they will respond to the police scene and provide assistance and follow-up.

Crisis Response/Outreach Services ►

Crisis Response/Outreach Services

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Crisis Response/Outreach Services

• CMHA Training Sessions– Many CMHAs across the region have initiated

training sessions with local police• CMHA Barrie Simcoe

– Branch will be providing on-going mental illness and crisis intervention training for officers being re-certified.

– March 7th – all day community training workshop for both the OPP (Central region) and Barrie Police Service.

Crisis Response/Outreach Services ►

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Crisis Response/Outreach Services

Crisis Response/Outreach Services ►

– CMHA Chatham-Kent• First training session took place in 2001 with local Chatham-

Kent police and other mental health organizations within the region. Continuing to provide refresher courses to police approximately every two years.

– CMHA Windsor• In October, 2003, CMHA provided a 2 day training session

for all police departments in the area. • Training updates are provided every couple of years.

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Crisis Response/Outreach Services

Crisis Response/Outreach Services ►

• Service Agreements– Many CMHA branches have established service

agreements with other mental health agencies, hospitals, and police.

– Considering many of the programs are new, a large majority of the service agreements between agencies are currently informal working partnerships. As programs develop and evolve service agreements will become more formalized.

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Crisis Response/Outreach Services

Court Support/Post-Charge Diversion ►

• Best Practices– Based on pre-arrest literature the following four key elements

have been identified as elements for success 1. All mental health, substance abuse, and criminal justice agencies

should be involved in the development of the program from the start.

2. Regular meetings involving key personnel from all agencies should be held.

3. Streamlining services through the creation of a drop off centre with a no-refusal policy for police cases is seen as crucial.

4. Liaison person or committee to help coordinate the various agencies.

Source: (Hartford et al, 2004)

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Court Support and Post Charge Diversion

Post-Charge Diversion:• Is granted only by the Crown Attorney.• Offered mainly for class 1 offences; these may include

joy riding, theft or fraud under $5,000 in damages.• May also be offered for class 2 offences in which there

are extenuating circumstances not involving violence – such as uttering threats, public mischief, break and enter.

• Usually violent crime renders the offender ineligible for diversion.

Court Support/Post-Charge Diversion ►

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Court Support and Post Charge Diversion

Services Include:• Linking individuals to both short/long-term services and supports• Information and support for family members and/or significant others• For those clients who are not deemed eligible for diversion,

consultation is provided linking individuals to mental health and support systems to facilitate bail or to assist with sentencing

• Staff provide consultation and advice to the judiciary on cases referred for diversion

Court Support/Post-Charge Diversion

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Court Support and Post Charge Diversion

A CMHA Regional Perspective:• 26 of our 33 branches provide court support/diversion services or

are in the planning/development stages.Program Statistics:• Peel Court Support Program (2004/2005)

– 61 individuals were diverted from the CJS to the MHS– 399 consultations were made to family and service providers

• Peterborough Court Support Program (2004/2005) – assisted 91 individuals in providing court support – 22 individuals were diverted from the CJS to the MHS

• Ottawa Court Support Program (2004/2005) – assisted 46 individuals with serious mental illness involved in the

CJS Court Support/Post-Charge Diversion

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Court Support and Post Charge Diversion

• CMHA Training Sessions– Many CMHAs across the region are delivering

information/training sessions to increase awareness– Peterborough Pre-Charge Diversion Program

• Since June 2005, CMHA Peterborough has delivered four half-hour training sessions to the local Peterborough Lakefield police involving close to 130 police officers.

• Since September 2005, the branch has delivered presentations to all court personnel, as well as hospitals, other community service agencies, east central corrections center, and east central probation services.

Court Support/Post-Charge Diversion

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Court Support and Post Charge Diversion

– Mental Health Court Support Workers Workshop• In October, 2005, the Ministry of Health and Long-term Care

(Mental Health and Addiction Branch) and CMHA Ontario organized a two day training session for all court support workers across the province.

• Approximately, 130 participants were involved representing CMHAs across the region and other mental health agencies.

– Windsor Justice Program• In July 2005, CMHA Windsor/Essex provided a training

workshop for staff at the Windsor Jail• In December, 2005, CMHA Windsor/Essex provided a joint

training session on mental illness for staff at the Windsor Jail and area Probation officers.

Court Support/Post-Charge Diversion

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Court Support and Post Charge Diversion

• Service Agreements– Many CMHA branches have established service

agreements with other mental health agencies, hospitals, correctional services, and police.

– Considering many of the programs are new, a large majority of the service agreements between agencies are currently informal working partnerships. As programs develop and evolve service agreements will become more formalized.

Court Support/Post-Charge Diversion

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Court Support and Post Charge Diversion

• Best Practices– Research on pre-trial court diversion practices

support three themes:• Creating awareness among lawyers and court staff, who may

not be aware of mental health issues• Implementing formal case finding procedures to identify

mentally ill offenders in need of services• Diversion programs are only successful if adequate

resources exist in the community Source: Hartford et al, 2004

Court Support/Post-Charge Diversion

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Conclusion

• Everyone in Ontario is affected by mental illness.• People with a mental illness are more likely to be the victims, rather

than the perpetrators of violence.• Learning the facts about violence and mental illness is an important

first step in building realistic attitudes. • Next Steps:

– Build relationships and partnerships with local mental health agencies, hospitals and police.

– Attend workshops and training sessions on mental health/illness.• Remember to treat the person experiencing a mental health crisis

with respect and dignity at all times.• Working together is the key to successful outcomes.