. Good afternoon, everyone.
Thank you very much to the members of this committee for giving me the opportunity to share my experience with you.
I want to quickly introduce myself. You've already heard my name, Cornelia Wieman. I'm originally a member of the Little Grand Rapids First Nation in Manitoba. I'm also a survivor of the sixties scoop. In 1998, I finished my training in psychiatry, and at that time I was the first woman to become an aboriginal psychiatrist in Canada.
The discussion that I hope we're going to have today will be partly based on my experience and the areas I've worked in over the past 20 years or so in the areas of mental health and health generally.
I spent eight years working as a psychiatrist in a community-based mental health clinic on the Six Nations of the Grand River territory. Then I moved to Toronto and spent about seven years in research at the University of Toronto. I co-directed the indigenous health research development program at the University of Toronto, and also the national Network for Aboriginal Mental Health Research, based out of McGill University.
From 2001 to 2002, I was a member of the suicide prevention advisory group. This is one of the key things I want to present to you with this afternoon. This was a group of individuals representing Canada nationally. We examined the issue of first nations youth suicide very comprehensively and released a report entitled “Acting On What We Know: Preventing Youth Suicide in First Nations”.
If you haven't seen a copy of that report, I can send the clerk the link to the pdf. It was a joint project between Health Canada's first nations and Inuit health branch and the Assembly of First Nations.
Since that time, I've moved back into the clinical realm. This time I have had quite a bit of experience working with urban aboriginal populations, mainly in Toronto, providing mental health services through the YWCA Elm Centre, which is a housing first model. This means that they will take women who are homeless or vulnerably housed, 50 aboriginal women suffering from mental health and addictions, and 100 other women who are not aboriginal. I was part of a mental health support team that worked with those women to try to improve their mental health but also maintain their housing in that building.
I've been working at the Centre for Addiction and Mental Health in Toronto since March of 2013. As part of our programming here at CAMH, we have an aboriginal services program. We serve people with mental health and/or addictions. We offer in-patient residential substance abuse treatment, outpatient substance abuse treatment, and outpatient psychiatric care.
In January of this year, I took a position at McMaster University one day a week to work as a faculty adviser to the aboriginal students health sciences program. The major goal of that program is to increase the number of aboriginal health professionals gaining entry into and graduating from McMaster University, which is very relevant to some of the recommendations from Canada's Truth and Reconciliation Commission that I've also included in my handout.
I know I have to be brief. I will talk mainly about the recommendations that came out of the suicide prevention advisory group, which were grouped into four major areas.
The first area was called “Putting Forward an Evidence-Based Approach to Prevention” of suicide. That advocated for continued support for research initiatives around the country, both in aboriginal communities and in partnership with aboriginal communities and academic institutions, such as universities, to increase what we know about indigenous suicide and work on solutions.
I know that previously at this committee, you heard a presentation from Alain Beaudet, who is the president of the Canadian Institutes of Health Research, and the Institute of Aboriginal Peoples' Health, whose scientific director is Malcolm King. I won't go into too much detail, except to say that when we talk about evidence-based approaches, we don't just mean a western framework for doing research. This can also include community-based initiatives and de-colonized approaches to understanding suicide. A lot of the time, there's difficulty obtaining funding for suicide research that communities want to do because, for whatever reason, it doesn't meet the academic standard that's put forward in a western framework.
The second major area was entitled “Toward Effective, Integrated Health Care at the National, Provincial and Regional Levels”. I suppose this is the area where I have the most experience. We need to learn about the best practices and models for delivering exemplary health care to aboriginal communities. I had the great fortune of working in the Six Nations of the Grand River, which you may or may not know is the largest first nations community in the country. When I worked there, it had a population of 11,000 to 12,000 people living on reserve, and almost the same number living off reserve.
I can't speak on behalf of the Six Nations community, but I do know that through the care that we delivered, our goal was always to try to provide services that would be equivalent to, or exceed, what someone would be able to obtain at a community mental health clinic in any urban or rural clinic, anywhere across the country. I believe we did that.
They have much more data on outcomes and things like that. I cannot speak to that because I don't work there anymore and they own their own data. I do know that, generally, people's outcomes were much better for being in contact with our service and being followed. We had lower rates of admission to hospital and lower rates of suicide than what you would expect when you look at first nation suicide rates across the country, which are generally thought to be two to four or five times the Canadian national average.
A major issue in mental health care is providing sustainable funding for mental health services and healing centres, on reserve, in rural areas, and in urban areas. Again, some of the recommendations from the Truth and Reconciliation Commission also speak to this.
For example, when you look at the budget for non-insured health benefits for the year 2013-14, the total expenditures for the entire budget were just over $1 billion. Pharmacare takes up 40.5% of that budget. There's a lot of money that's spent on pharmacare, as well as medical transportation to get people to and from their appointments. “Other health care” only accounts for 1.4% of that budget, which amounts to about $14.2 million. That other health care is deemed for short-term crisis intervention and mental health counselling benefits to address at-risk situations.
I know from checking the meeting schedule of this committee that you've already heard from the first nations and Inuit health branch. I believe you heard from Keith Conn around that.
There's been a long-standing issue of insufficient funding for both western-trained mental-health professionals, and traditional healing, which typically isn't reimbursed in the way that say, physicians, social workers, or psychologists are reimbursed. That, in itself, is an issue as well, because traditional healers spend a lot of time working with people in their communities, and a lot of the time, the work that they do is on a volunteer basis.
In its recommendations, the Truth and Reconciliation Commission also stressed the value of aboriginal traditional healing practices. Because I am aboriginal by background, I think I've had a natural tendency to be open to including traditional healing practices in the patients that I see, but other psychiatrists may not be.
That leads me into talking briefly about a health and human resources issue across the country. I checked the data from the Canadian Psychiatric Association. There are 4,770 psychiatrists across the country. I know of three other aboriginal psychiatrists who are practising in the country. There have been four of us for some time. I know of two aboriginal psychiatry residents who are in the process of completing their training, which brings us to a grand total of six. When you divide six by 4,770 you get 0.01%.
The reality is that virtually all psychiatric care across this country to aboriginal people is provided by non-aboriginal psychiatrists and other health professionals. I have questions about why we're training aboriginal family physicians, but why psychiatry, in and of itself, is seeming to be an unattractive specialty to attract aboriginal medical students to choose upon graduation.
In my work at McMaster in trying to recruit aboriginal students into the medical program, for example, we would really like to continue this pattern. Again, this is another major recommendation of the Truth and Reconciliation Commission. Because the majority of care is provided by non-aboriginal health professionals, there's a great need to train health professionals in cultural safety, so that they're providing culturally relevant care.
I'll end there and hope we have a really good discussion.
Going back to the suicide prevention advisory group report, the fourth major area that I didn't get to was recommendations around strengthening youth identity, resilience, and participation in cultural activities. I've seen a couple of articles on that in the news over the last couple of weeks. I think in the western provinces there have been a couple of studies released that indicate that incorporating traditional and cultural activities into the daily life of a community is helpful for their mental health. Some of you may be familiar with the seminal work that's been presented by Michael Chandler and Christopher Lalonde in British Columbia that talks about lower rates of suicide in communities that have at least one facility dedicated to traditional and cultural practices.
The way I have always operated as a mental health professional is that I have been open to patients or clients participating in both areas if they wish. I would treat them as a psychiatrist, because I'm trained as a psychiatrist; but as a first nations person, I would also be open to sharing the care with a traditional healer. I understand some of the difficulties around traditional healing: engaging them, engaging the elders, and how they're compensated. It's still an issue that needs to be sorted out, and probably individually for each community. When I worked at Six Nations, there was also some controversy around who may call themselves a traditional healer. We relied on respected individuals in the community to point these folks out to us so we could establish a working relationship with them.
Understandably, some traditional healers were very hesitant about working with a western-trained psychiatrist. I think the point to learn is that these types of good collaborative working relationships take time to establish. The western medical model wants to move things quickly, and wants to see someone, assess a person, diagnose them, make a plan, and that's sort of it. I had to relearn a lot of my training when I finished and started working in a community on reserve to learn how to work at that community's pace. It ended up being fruitful in establishing that type of relationship.
Even though it requires effort and commitment on both parts, if there's mutual respect present, then I think it can do nothing but provide optimal care for aboriginal people living in a variety of communities, not just on reserve, but here in downtown Toronto as well. CAMH is progressive in the sense that we have two elders, two traditional healers, who are attached to the aboriginal services program here as well. Someone can see a western-trained psychiatrist, or a social worker, or a nurse, but they can also see a traditional healer for ceremony and counselling if they wish. I haven't visited the site over the last little while, but I believe they're putting a sweat lodge on the grounds of the Centre for Addiction and Mental Health, which would be terrific for the people undergoing the residential treatment.
I don't know if that answers your question. I think we need to appreciate that aboriginal people are asking for this as part of their mental health care. It's up to the health care providers to be open to that. There's a challenge, however. I know in Ontario—I can only speak for the Province of Ontario—without going into too much detail, Ontario's doctors are at odds with the provincial Minister of Health, and there's been a lot of chatter around—
To start, one of the major issues in working with people in communities is trust. There have been decades upon decades of mistrust between indigenous people and all types of other folks in this country of Canada, but specifically involving health providers.
This is my area of expertise. People may have had previous poor experiences with health care providers when they felt their needs weren't listened to, or they may have been as far out on the spectrum as being overtly mistreated by health care providers. One only has to look at the example of Brian Sinclair, the man who came to the emergency department at the Winnipeg Health Sciences Centre. He was an aboriginal man. He sat in the emergency room for 34 hours and died without even being seen. Trust is a major issue.
For the folks I worked with on the reserve, it took a lot of time. It took months of my working in that community for people to come forward and feel comfortable in coming to see me because, even though I'm first nations myself, I was presented to the community as “This is going to be our psychiatrist who is working in the community”, and people have a lot of hesitancy about psychiatry. It resonates some of the trauma they may have experienced through the sixties scoop, through being in child protective services, or through the legacy of residential schools, in that psychiatrists have the special ability to involuntarily hospitalize people if necessary, or treat them against their will in very extreme cases, as you know. So because there is that quite vast difference in power, it takes a lot of time and a certain temperament to be able to sit there and be patient and allow the patient to trust you. You have to gain that trust not only through your words but through your actions.
On non-aboriginal health care professionals, for example, I have seen colleagues especially when I was at McMaster University, where there is a psychiatrist whose name is Gary Chaimowitz, who has provided psychiatric services to communities on the west coast of James Bay for something like 20 years. He goes regularly. He is committed to those communities, and the communities know that, so there is trust that has developed.
I'm not saying it has to take 20 years, but psychiatrists who might visit a community are probably not going to function that well in that community if they expect to see 30 people in one day and just get people in a revolving door, every five minutes, and hand them prescriptions. It takes patience.
I think from the point of view of aboriginal people who are trained as psychiatrists, we are almost non-existent. We're one-thousandth of 1% of the number of psychiatrists in Canada. So we're not going to meet any goal anytime soon, but it is an important question. We are graduating across the country a fair number of aboriginal individuals in medicine. We do much better in the western provinces, with British Columbia, Alberta, Saskatchewan, and Manitoba doing a much better job in that respect than the rest of Canada.
We do pretty well in Ontario to a certain extent—better than we did in the past—but by and large, graduates of medical school choose to specialize in family medicine. I'm always curious as to why people don't choose psychiatry, because the mental health needs of our communities are so great. I don't think there has ever been a study done on this. I'd like to do a survey of graduates and find out why it is that they don't pick psychiatry as a choice. It may have something to do with the fact that many aboriginal medical school attendees are mature students with families and family medicine training can be completed in two years following medical school, whereas psychiatry residency takes five years.
I don't know if that's part of it, and I also don't know if, again, it's because of that dynamic where as psychiatrists we can do things that are involuntary. We can hospitalize people against their will. We fill out form 1 certificates to hold people against their will. I don't know whether or not there's a reluctance to engage in that kind of health care where you have that kind of power, so to speak, over your patients and that it seems kind of paternalistic, or whatever it is.
What I would very much like to see as a solution, however, is psychiatry training programs across the country having a sub-specialty in rural and remote mental health care, including delivering services to first nations, Inuit, and Métis communities across this country. I think that may go a long way to attracting some aboriginal graduates of medical school into that form of training, but it also would train a cadre, so to speak, of psychiatrists who upon finishing their residency training would be willing to work in these communities and provide services where they're so desperately needed.
I think you've touched on another important factor for suicide, which is that we know that kids, young people, are at lower risk of suicide if they have what we call forward thinking, so they can see themselves at some point in the future doing something. Whether that's being a mother, a father, a student, an employee, they have to be able to see themselves at least at some point in the future, and then we know they have something to hold on to.
The challenge that we face—and I'll be the first to admit that there is no easy set of solutions to this—is how to help and support indigenous young people across this country to develop a sense of identity for themselves that is consistent with their tradition, their culture, and their values, but also functional in contemporary times. Do you know what I mean?
For example, I am about to turn 52 years old. I'm a child of the sixties scoop, and I can honestly tell you that I did not feel strong in my identity until I was probably in my mid-twenties to mid-thirties. It took that long for me to feel comfortable in both, such that I could be a strong first nations woman and yet be a psychiatrist and function in a very difficult job and be who I am in my life, a wife, a mother, whatever.
That's the challenge, and I don't necessarily think there is an easy answer, but I think one way to go about it that I touched on briefly is to invest much more heavily in sharing stories of resilience with our young people. All of the resilience literature, whether it has to do with indigenous people or not, says that if somebody has at least one strong person in their life that they can relate to and they have a good relationship with, or they share a story with, that, in and of itself, can foster resiliency.
We need to hear stories like my own, and I don't mean that in an arrogant way at all. If you talk to indigenous people across the country who are recognized as achievers, no one will tell you a story that it was just smooth sailing, that they were just born and they went on to greatness without a hitch. That is not the case at all. I think everyone has a very complicated and rich story of struggle, and yet ultimate achievement. If we shared these types of stories with our young people, I think they could relate to pieces of themselves, see themselves in that, see possibilities for themselves in the future, and ultimately it would result in them flourishing as contributing, valuable members of Canadian society.