Best Practices in Mental Health Reform: Discussion Paper

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5. Phase II Findings: Best Practice Examples

The Phase II situational analysis compiled 13 Canadian examples of best practices in mental health reform selected from provincial and territorial nominations. The selection was conducted in collaboration with the Advisory Network on Mental Health which is composed of senior mental health provincial and territorial government officials from across Canada and Health Canada representatives. Four programs/strategies selected for site visits were reviewed in Section I of the report while Section II contained descriptions of nine other initiatives. The report concluded with a discussion of lessons learned, characteristics which facilitate innovation and general considerations for implementation of best practices.

The site visits afforded an opportunity for an in-depth examination of each of four initiatives that included observation and meetings with different stakeholders.

• The Mental Health Commission of New Brunswick is an example of a successful system reform effort based on an aggressive re-engineering of governance and fiscal mechanisms. Among key ingredients for success were the creation and management of an integrated funding envelope, regionalisation, and adoption of a mental health policy committed to reallocating resources from institutions to the community.
• The Seven Oaks Project in Victoria, British Columbia provides a regional alternative to long term hospitalization in a psychiatric hospital in a highly staffed community-based residential setting. This pilot initiative was implemented as part of a 10-year project to downsize the Riverview psychiatric Hospital and to develop alternatives in the care of a difficult-to-manage group of long stay patients.
• The Consumer/Survivor Development Initiative is a project of the Ontario Ministry of Health that directs resources to, and fosters the development of new consumer groups across the province. The result has been the formation of 36 consumer-run projects involved in a range of activities from self-help and advocacy to operating businesses and providing sensitization training to mental health professionals.
• In Halifax, Nova Scotia, the Connections Clubhouse is a comprehensive psychosocial rehabilitation program which incorporates in one program a number of the best practice approaches outlined in the Phase I Review. As a multi-service agency and through linkages and partnerships with every facet of the community, this program is striving to provide fully integrated and seamless support to its members. The program is committed to a participatory philosophy. _***

Nine less intensive reviews describe programs that range from offering core services and supports to implementing strategies for system-wide change. The following seven programs offer examples of core services:

• The Assertive Community Rehabilitation Program in Brockville demonstrates a successful implementation of case management following a Program in Assertive Community Treatment (PACT) model, with the added dimension that the program is sponsored by a hospital and is staffed by re-deployed and trained hospital staff.
• The Phoenix Residential Society in Regina, Saskatchewan offers a residential and treatment program for persons with mental illness and substance abuse problems. Staff have training in both psychiatric rehabilitation and addictions treatment, and program services combine assertive community treatment, housing and vocational services.
• A crisis response program in Winnipeg in which a social service agency with a provincial infrastructure plays a key role in service delivery and program dissemination.
• The British Columbia Housing/Mental Health Program demonstrates how a mutually beneficial partnership between two government ministries has been able to increase housing stock and provide persons with serious mental illness with more opportunities for independent living.
• AMI-Québec is a family self-help initiative that has expanded from a nucleus of four families to an organization that offers support to families through education, support groups, telephone support, various networks including one for siblings, and advocacy.
• The Community Approach to Skills Development Training program is operated by CMHA in Lethbridge, Alberta. This employment preparation program allows students to learn skills in a normalized setting at the training work site.
• Five communities in the Northwest Territories have implemented a pilot project to hire their own mental health workers. This approach to providing care in an under-served area has reduced the need for residents to leave the community to obtain services, and has allowed the community to become involved in defining and implementing a program to meet its mental health needs.

Two programs offer examples of system-wide projects:

• The Manitoba Training Initiative represents an explicit commitment by government to training and skill development to facilitate mental health reform. Training has been incorporated into university and college programs for various health professions, and courses are offered to community mental health workers as mandatory and optional continuing education programs.
• The goal of the CMHA National Office New Framework for Support project is to encourage a new way of thinking about the capacities and potential of consumers, and how their role as full citizens can be enhanced. Implementation activities have focused on promoting the Framework in order to change mental health policy and practice in governments and communities across Canada.

5.1 Lessons From the Situational Analysis: What Facilitates Change?

While the situational analysis examined a diverse selection of Canadian initiatives, there was remarkable consistency in the tools and strategies used to facilitate change and innovation. A summary of these follows:

• Clearly articulated philosophy and principles typically underlie the specific innovations that have been implemented. Psychosocial Rehabilitation offers a value and attitudinal base for many of the programs that have been described. The Framework for Support has broadened thinking about the components of community support and the capacities of consumers. This survey of the field supports the importance of drawing on conceptual bases such as these to articulate a common language and set of values as a basis for major change.
• A wide range of stakeholders were meaningfully involved in the planning and operation of innovative programs. An openness to input from multiple perspectives increases opportunities for collaboration and problem solving and fosters creation of an explicit vision of the future which is shared by various stakeholders.
• Political will is a special dimension of system change. In order for radical, widespread changes in funding and policy to occur and be maintained, it is critical that elected governments endorse and support the reforms. Influence can be exerted by advocacy groups, professional groups issuing position papers, academics, senior ministerial staff and elected officials who are acting on personal experiences and convictions.
• Infrastructure support is another essential element with powerful consequences. Many of the innovations described could not have happened without the active assistance of the larger organization within which the program resides.
• It is possible to successfully reallocate funds and personnel from institutional to community care. Many innovative programs are funded with dollars that have become available through the downsizing of inpatient care within provincial hospitals. With enlightened program managers and appropriate opportunities for training, hospital clinical and support staff can become excellent community workers.
• When support extends beyond health services to involve agencies from other sectors, it becomes possible to better address the broad range of needs among those with severe mental illness. It also expands the resource base that is available for community support and allows persons with severe mental illness to participate in a broader range of community activities.
• With concerted action, stigmatizing attitudes can be changed and resistance to change overcome. Positive experiences with the integration of persons with severe mental illness in the community are a powerful means of reducing stigma and promoting reform.
• The enthusiasm and dedication of skilled program directors, staff and volunteers is essential for making the programs work. Program directors are not only good managers, their demonstrated willingness to take risks and ability to inspire and lead others make innovation possible. Both professionally trained staff and trained non-professionals have valuable roles. The contribution of expertise that comes from the experience of being a consumer or a family member is another critical ingredient.
• The Canadian Mental Health Association - National Office is an important force in promoting a common set of principles through the diverse provincial and territorial mental health reform efforts, especially in encouraging formation of partnerships between mental health and other health and social service agencies (in recognition of the range of supports and resources that all citizens need), and in emphasizing consumer involvement in planning, management and evaluation of services and supports.

Erratum
***This paragraph of Best Practices in Mental Health Reform: Discussion Paper 1997 which begins "In Halifax, Nova Scotia ..." may be subject to misinterpretation. The intent was to clarify that there is insufficient research evidence about the clubhouse model per se to support it as a "best practice". Unfortunately, it could be read as a qualification of the authors selection of the New Connections Clubhouse as a Canadian example of a best practice program. This is not the case. The selection was based on the authors judgement that this program contains many elements of the best practices that are supported by research evidence. The authors of the Discussion Paper were impressed with the New Connections Clubhouse program and have included it as an exemplary application of the knowledge that has accumulated about how to serve persons with serious and persistent mental illness.