Systemic Policy Adviser's Report - 2003
No Smoking Policies
Dual Diagnosis Issues
Mental Health Care and Treatment in Jails
Mandatory Inquests
Personal Needs Allowance
Searches — Person and Property
Consent and Capacity Board Appeals to Superior Court
Use of Handcuffs and Security Guards in Mental
Health Units
Police Record Searches
Seclusion and Restraint
Lack of Transparent Complaint Processes
Voluntary Patients on Locked Units
Recovery, Self-advocacy and Empowerment
Role of the Systemic Policy Adviser
The role of the Systemic Policy Adviser (SPA) is to promote the PPAO's provincial and local systemic advocacy agenda, to provide support, advice and consultation to Patient Advocates and Rights Advisers and to respond to inquiries from the general public, patients, families, health practitioners and other stakeholders. As well, the SPA takes the lead in responding to issues of concern raised by consumers, PPAO staff and other stakeholders. In these efforts, the SPA consults with and receives input from PPAO staff who have direct and first hand contact with our clients and our various stakeholders. The SPA also works with PPAO staff to develop position papers on a variety of issues and proposed government legislation. The SPA seeks out opportunities to advance patient rights and to further the vision, mission and mandate of the PPAO. Position papers are posted on the website so that they are available to those interested in knowing where the PPAO stands on a particular issue. It is interesting to note that often the PPAO is able to articulate the issues and concerns from the patients' perspective and this can be very different from the submissions of other parties. However, we also note that at times there are similarities between our recommendations and those proposed by other groups and service providers. Following are some examples of the range and diversity of issues that the policy adviser was involved with during 2003.
Many of the mental health facilities across Ontario began either implementing smoke free policies or started discussions this year. One facility not only banned smoking in enclosed areas but also on hospital grounds which goes far beyond anything imagined. Although the hospital reported the implementation to be "100% successful" that assessment was that of the administration, and not that of most of the patients nor the Advocates working at that facility. The policy not only goes far beyond what patients in general hospitals and other health care settings experience but it appears that since the client population has a "mental illness" the institution made a "best interest" decision on their behalf. However, many patients found it difficult to adapt to such forced withdrawal from cigarettes, especially when they did not voluntarily make the choice to quit smoking but instead are forced to quit abruptly.
Given the focus on smoking issues the PPAO prepared a position paper on this topic which enshrines several key principles including: choice, consultation, discretion and cessation. To learn more about these principles, from an advocacy perspective visit the PPAO's website at www.ppao.gov.on.ca.
It became evident in 2003 that community placements for individuals with a dual diagnosis are almost non-existent and that the Ministry of Community and Social Services and the Ministry of Health and Long-Term Care were not working in unison for the benefit of this client population. Regrettably, this has "stranded" inappropriately many individuals with a dual diagnosis in mental health facilities as no community placement or housing is available for them. This is tantamount to forced hospitalization of clients with a dual diagnosis well beyond the necessary or intended period of hospitalization. Despite having received the appropriate mental health treatment and being ready for discharge, many clients with a dual diagnosis remain in hospital, against their will waiting for community placements. In many cases the hospital has no legal authority to hold these clients but they are also painfully aware that to discharge them would mean to put them at significant risk of harm. However, it does expose the hospitals to some risk and liability as they are holding clients without the legal authority to do so.
In other cases the group homes and housing placements where the clients originally came from have refused to take these clients back once they have been admitted to a mental health facility. This has resulted in some clients losing their home simply because they required mental health care and treatment. This is unfair and an injustice that the two Ministries can no longer ignore given its human cost and their commitment to de-institutionalization and community living. Many of these clients and their families have filed complaints with the Ontario Ombudsman but it does not appear that these efforts will result in an investigation that will break the funding deadlock or lack of coordination between the Ministry of Community and Social Services and the Ministry of Health and Long-Term Care.
Mental Health Care and Treatment in Jails
In 2003 the PPAO received several complaints from inmates and families about access to quality mental health care and support services in provincial correctional facilities. Although outside the mandate of the PPAO, information was provided and each individual was referred to the office of the Ombudsman. The PPAO, as part of its systemic advocacy initiatives wrote to the Ombudsman highlighting the concerns expressed by families and inmates and requested that the Ombudsman conduct an "own motion investigation."
The Ombudsman responded to the PPAO in writing advising that his office had in their 2001-2002 Annual Report reported on an investigation into the placement and treatment of an inmate with special needs and that the Ministry of Public Safety and Security had agreed to implement the recommendations proposed by the Ombudsman. The PPAO remains concerned about access to mental health care and treatment in provincial correctional facilities, the lack of formal rights advice where there is a finding of treatment incapacity and access to crisis intervention services for those inmate who may be at risk of harming themselves.
The PPAO is concerned about the number of patient deaths following admission to mental health facilities, immediately following discharge or when a person is denied admission to a mental health facility. We are also concerned that in many of these cases inquests are not held, despite urging from advocates, family members and other stakeholders.
In October 2002, the PPAO and the Chief Commissioner of the Ontario Human Rights Commission wrote independently to the Chief Coroner, Dr. James Young to express concern with respect to section 10(2) of the Coroners Act. The section states that when a person dies while resident or in-patient in a psychiatric facility the Coroner has the discretion to decide whether an inquest ought to be held. Alternatively, Section 10(4) of the Act states that "the Coroner shall issue a warrant to hold an inquest" when an individual dies while in the custody of a peace officer or correctional institution. From our perspective, and from the perspective of the Ontario Human Rights Commission, the Act as it is presently written provides a different level of protection and scrutiny for individuals who are being held by law in psychiatric facilities. We think that this needs to change!
The PPAO has asked that the Act be amended to require a formal inquest in the event of a death of an involuntary patient in a psychiatric facility. On January 7, 2003 the PPAO wrote to stakeholders, including consumer-survivor organizations across Ontario informing them of the PPAO's position on mandatory inquests and asking them to write to the Chief Coroner of Ontario if in support of this position. Several groups wrote to the Coroner in support of the PPAO's position and since that time the PPAO has met with the Coroner's Office to provide additional information about our issues and concerns.
The PPAO continues to work on this systemic advocacy initiative and to advance the position that mandatory inquests for involuntary patients are essential. Updates will be posted as they become available.
During 2003 the PPAO continued with its systemic advocacy initiative of supporting clients in their efforts to have the Personal Needs Allowance increased from $112.00 to at least $160.00 per month. Many of the patients, families and advocates believed that with a new government there would be renewed interest in this subject and with it brought the hope that after more than a decade without an increase there would be a substantial increase to reflect the actual cost of living and increased consumer prices. The PPAO will continue to support its clients in this endeavour.
Searches — Person and Property
It seems that 2003 was the year in which the search for contraband became a big issue. This led to many searches of both person and property and at times without there being any probable cause or justification for the searches. Some searches did not even meet the legal threshold set out in the law. Clients often reported after these searches the destruction of property, that personal strip searches did not afford them the dignity and respect that they deserved and that at times staff appeared to use searches for punitive reasons. In each of these cases clients were encouraged to talk to a lawyer to ensure that their legal and civil rights were not violated.
Consent and Capacity Board Appeals to Superior Court
As a rights protection program, we have a responsibility to help remove as many barriers as possible that deny our clients access to justice. The PPAO contacted the Superior Court of Justice in January of 2003 to request a review of the requirements for access to the Court from decisions of the Consent and Capacity Board (CCB). We have asked that the appeal process be revised to make the process more accessible, particularly in respect of unrepresented appellants, given the liberty and bodily integrity interests at stake. Consultations with stakeholders are underway to develop a standard Notice of Appeal for such appeals.
Use of Handcuffs and Security Guards in Mental Health Units
In 2003 the PPAO noticed a trend by mental health facilities towards the use of security guards in the supervision, restraint and surveillance of individuals with mental illness. More alarming is the use of handcuffs when dealing with clients' disruptive behaviour or where the security officer reasonably believes that it is necessary to prevent injury to any party. Although they are intended to be used as a "last resort" some clients have reported that they have been used inappropriately both in general mental health units and in forensic programs. The PPAO has serious concerns as to the legal authority for security intervention in this matter and that there is no assurance that minimal force is applied, that there is no accounting for a client's past history of trauma, violence or victimization, nor is there any accounting for the impact on the therapeutic relationship between the client, the team and the health care facility.
The PPAO strenuously advocated that such measures not be taken and that mental health care be delivered in a "hands free" environment by trained and regulated health care professionals, not security staff. The message conveyed to the public through the use of security personnel is that this client population is one to be feared and that security guards are there to protect the public and others. This is the wrong message to send as it reinforces the stigma and discrimination experienced by those with a mental illness.
The PPAO wrote to the Ontario Human Rights Commission expressing concern about the disclosure of personal information relating to mental illness through police records searches. The PPAO is concerned that the non-criminal "contact" information regarding persons with mental illness is being disclosed as a result of police records searches requested by potential employers, volunteer groups, sports clubs and other organizations that provide services to children or vulnerable persons. The PPAO is concerned that any "contact" with police, including when they take someone to the hospital on a Form 1 (Application for Psychiatric Assessment), is included on these searches as a "contact with police." The person is then put in the unenviable position of having to either tell the other party about the circumstances of that police involvement or simply abandoning the employment or volunteer opportunity. Such policies make successful re-integration into the community almost impossible for clients who have received treatment and who have recovered such that they are seeking out such opportunities.
The Human Rights Commission responded to the PPAO that "such a practice might be discriminatory against persons with mental illness and impede their successful re-integration into the community and their pursuit of life and career aspirations as responsible citizens". The Commissioner wrote to the Minister of Public Safety and Security outlining the nature of the PPAO's complaint and that such practices were "having a discriminatory effect in criminalizing persons with mental illness." It has become clear to the PPAO that there is a need to standardize the information that is both collected and released by police forces across Ontario, given the potentially devastating effects of release of non-criminal contact with police on re-integration into the community. Some police forces are sensitive to the impact of the release of this information but others are not. The government must move to standardize the process across the province and to remove discriminatory processes and rules for those who have a mental illness.
Some of PPAO's clients continue to report that the use of seclusion and restraint is still too commonplace in Ontario's mental health facilities. The PPAO in its 2001 report on the use of seclusion and restraint in Ontario's Provincial Psychiatric Hospitals made more than twenty best practice recommendations on how to minimize restraint use and move towards the provision of mental health care in a "hands free," restraint free environment. The PPAO encourages mental health facilities to develop rigorous reporting and documentation requirements for all restraint use and to develop a committee that reviews each restraint to ensure that it is in keeping with the standards set out in mental health legislation and that no other least intrusive alternative was available. For a copy of the PPAO's report on the use of seclusion and restraint contact the PPAO's central office at 1-800-578-2343.
Lack of Transparent Complaint Processes
Many mental health facilities across Ontario lack a clear and transparent complaints process that is accessible to clients and families when they have a complaint about the hospital or the care and treatment that they received. This has resulted in PPAO staff being involved in complaints, at times prematurely, simply because the hospital does not have a complaints process in place. The PPAO encourages mental health facilities and programs to implement complaint processes that are transparent, easy to navigate and accessible to all. Such complaint processes will heighten accountability to consumers and allow facilities to review policies, procedures and develop best practices with respect to quality of care and treatment.
Voluntary Patients on Locked Units
Although not a new issue, Patient Advocates noticed an increase in the number of locked units in psychiatric facilities where voluntary patients are receiving their care and treatment. As a rights protection agency, the PPAO finds this trend to be troublesome given that the liberties, movement and freedoms of voluntary patients should never be restricted. The PPAO encourages mental health facilities to review their practice of keeping voluntary patients on locked units and taking appropriate action to rectify this situation.
Recovery, Self-advocacy and Empowerment
In 2003 everyone was talking about empowerment and client participation, from funders to families to the clients themselves. It was discussed as a "model" and as the best thing going. However, some clients started to report that recovery was being defined by their teams, that empowerment was a phantom as there is no power sharing between the system and the client and that there just was enough information about self-advocacy and how to be successful at it. The PPAO began to explore the linkages between these concepts and to examine the interconnectedness of each of these concepts. The PPAO quickly realized that in order for the mental health system to be reformed that there needs to be a careful examination of these concepts, from the clients' perspective and with the system being willing to surrender power to those that they are intended to serve. PPAO staff made several presentations on these concepts, the linkages between them and challenged treatment teams and facilities to review everything they do with clients to ensure that they are not dis-empowering them but instead supporting them to achieve their full potential by being involved in all decisions that affect their care, life and treatment. It is only when we empower people that they will be able to embark on their unique journey of wellness and recovery.