CMHA Ontario Presentation to the Amalgamated Transit Union

1. CMHA Ontario Presentation to the Amalgamated Transit Union March 10, 2006 Our Mission and Vision►

2. 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►

3. Our Values • Social Justice • Individual and collective responsibility • Access to appropriate and adequate supports • Self-determination • Community integration • Integrity • Partnership • Excellence • Accountability • Creativity What We Do►

4. What We Do • Knowledge Transfer • Policy Research and Development • Education and Training • Mental Health Works What is Mental Illness?►

5. 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►

6. 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) Mental Illness in Numbers ►

7. 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 ►

8. Mental Illness in Numbers • 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). Overview of Mental Disorders ►

9. Overview of Mental Disorders Anxiety Disorders Mood Disorders Schizophrenia Concurrent Disorders Personality Disorders Anxiety Disorders ►

10. 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 ►

11. 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 ►

12. 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 ►

13. 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 ►

14. 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 ►

15. 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 ►

16. 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 ►

17. 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 ►

18. 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 ►

19. 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 ►

20. Responding to Crisis Situations Hallucinations Delusions Suicidal Behaviour Panic Attacks Excited Delirium Recognizing Hallucinations ►

21. 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 ►

22. 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 ►

23. 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 ►

24. 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 ►

25. 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 ►

26. 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 ►

27. 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 ►

28. 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 ►

29. 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 ►

30. 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 ►

31. 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 Response Do’s and Don’ts Crisis Services in Ontario ►

32. Crisis Services in Ontario Types of Crisis Services Resources and Contact Information Pro-active Steps Types of Crisis Services ►

33. 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 ►

34. 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 ►

35. 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 ►

36. Mental Illness and the Criminal Justice System CMHA Diversion Programs Justice Funding Crisis Response/Outreach Services Court Support and Post Charge Diversion Mental Illness and the CJS ►

37. Mental Illness and the CJS 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 CMHA Diversion Programs ►

38. CMHA Diversion Programs • 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. Justice Funding►

39. 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►

40. 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►

41. Crisis Response/Outreach Services 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►

42. 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►

43. Crisis Response/Outreach Services 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 ►

44. Crisis Response/Outreach Services 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 ►

45. 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 ►

46. 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. Crisis Response/Outreach Services►

47. 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. Crisis Response/Outreach Services►

48. Crisis Response/Outreach Services • 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) Court Support/Post-Charge Diversion►

49. 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►

50. 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