NAHO CONFERENCE 2009

NAHO CONFERENCE 2009

A Pilot Project for A Pilot Project for Mental Health Mental Health

Service Treatment Service Treatment Provision for Provision for

Residential School Residential School SurvivorsSurvivors

AUTHORS: Dr Bob Chaudhuri (1); Tom AUTHORS: Dr Bob Chaudhuri (1); Tom Terry(1); Robert Thomas(2); Brian Walmark (2)Terry(1); Robert Thomas(2); Brian Walmark (2)

AFFLIATIATIONS (1): Northern Ontario School of Medicine AFFLIATIATIONS (1): Northern Ontario School of Medicine (NOSM)(NOSM)

AFFLIATIATIONS (2): Keewaytinook Okimakanak AFFLIATIATIONS (2): Keewaytinook Okimakanak (Northern Chiefs Council)(Northern Chiefs Council)

Canada's Indigenous population is a vulnerable group in the Canada's Indigenous population is a vulnerable group in the health care system, with specific mental health and healing health care system, with specific mental health and healing

needs that are not widely being met.needs that are not widely being met.

Indigenous peoples face certain historical, Indigenous peoples face certain historical, cultural-linguistic, socioeconomic, and system cultural-linguistic, socioeconomic, and system barriers to access to mental health care that barriers to access to mental health care that government, health care organizations, and government, health care organizations, and social agencies must work to overcome. social agencies must work to overcome.

Current health indicators undermine Canadian Current health indicators undermine Canadian Indigenous health status, including mental Indigenous health status, including mental health.health.

To address some of theseTo address some of these

inequities in health andinequities in health and

health care, some Indigenoushealth care, some Indigenous

health organizations havehealth organizations have

recently developed servicesrecently developed services

to mental health that includeto mental health that include

traditional cultural approachestraditional cultural approaches

to healing.to healing.

However, Indigenous health and However, Indigenous health and

healing information and practices arehealing information and practices are

practically non-existent through thepractically non-existent through the

mainstream health care system, whichmainstream health care system, which

is dominated by Western approaches.is dominated by Western approaches.

An Indigenous paradigm of health has been An Indigenous paradigm of health has been successfully employed by Indigenous peoples for successfully employed by Indigenous peoples for thousands of year prior to the arrival of Europeans thousands of year prior to the arrival of Europeans and colonialism. and colonialism.

This study seeks to create new and different This study seeks to create new and different methods of treating First Nations people linking methods of treating First Nations people linking traditional Indigenous healing practices and traditional Indigenous healing practices and western practices using a community mental western practices using a community mental health care delivery system as well as health care delivery system as well as teleconferencingteleconferencing

It should be noted that teleconferencing is an It should be noted that teleconferencing is an antiquated term . In reality we mean antiquated term . In reality we mean videoconferencing (Internet Protocol IP) videoconferencing (Internet Protocol IP)

The focus of this research is to investigate the successes and The focus of this research is to investigate the successes and challenges by this new delivery system, which offers both challenges by this new delivery system, which offers both Indigenous and Western forms of healing to clients in mental Indigenous and Western forms of healing to clients in mental health service agencies, and to get descriptive information from health service agencies, and to get descriptive information from

their clients about success of such an approach.their clients about success of such an approach.

The KO Indian Residential The KO Indian Residential School Survivors Program - School Survivors Program -

IRSSP IRSSP • The mental health treatment services delivery model The mental health treatment services delivery model

for a pilot project (the KO Indian Residential School for a pilot project (the KO Indian Residential School Survivors Program - IRSSP) being jointly proposed by Survivors Program - IRSSP) being jointly proposed by the Sioux Lookout First Nations Health Authority the Sioux Lookout First Nations Health Authority (SLFNHA) NODIN Child and Family Intervention (SLFNHA) NODIN Child and Family Intervention Services and by Keewaytinook Okimakanak (KO), the Services and by Keewaytinook Okimakanak (KO), the Northern Chiefs Council, a tribal council serving six Northern Chiefs Council, a tribal council serving six first nations in Ontario’s far north. first nations in Ontario’s far north.

• This pilot project combines the resources ofThis pilot project combines the resources ofMultiple First Nation partners and communities.Multiple First Nation partners and communities.Unfortunately, the Legacy of Residential SchoolsUnfortunately, the Legacy of Residential SchoolsAnd Intergenerational trauma has had a largeAnd Intergenerational trauma has had a largeEffects in NorthWestern Ontario among otherEffects in NorthWestern Ontario among otherPlaces in Canada.Places in Canada.

IRSSPIRSSP

• The project will facilitate both The project will facilitate both counselling and community supports counselling and community supports for Indian Residential School survivors for Indian Residential School survivors in the KO First Nation communities of in the KO First Nation communities of Deer Lake, Fort Severn, Keewaywin, Deer Lake, Fort Severn, Keewaywin, North Spirit Lake, and Poplar Hill.North Spirit Lake, and Poplar Hill.

• Both traditional and western methods Both traditional and western methods for Mental Health treatment of “Post-for Mental Health treatment of “Post-Colonial” or Residential School Colonial” or Residential School Trauma survivors will be employed.Trauma survivors will be employed.

KO COMMUNITY MAPKO COMMUNITY MAP

IRSSPIRSSP

• The overall purpose of the KO Indian The overall purpose of the KO Indian Residential School Survivors Program Residential School Survivors Program (IRSSP) is to: (IRSSP) is to: – 1. 1. Provide appropriate and sufficient Provide appropriate and sufficient

community-based therapy.community-based therapy.– 2. Support services to promote healing 2. Support services to promote healing

from IRS trauma for survivors and from IRS trauma for survivors and families within their home community.families within their home community.

– 3. KO is in charge of facilitating the funds 3. KO is in charge of facilitating the funds for this program.for this program.

IRSSPIRSSP• Unfortunately, we have learned the hard way that Unfortunately, we have learned the hard way that

conventional models of mental health treatment conventional models of mental health treatment services delivery for survivors of Residential services delivery for survivors of Residential Schools from remote northern Ontario First Schools from remote northern Ontario First Nations have generally resulted in client Nations have generally resulted in client recidivism. recidivism.

• As well, high costs associated with the conventional As well, high costs associated with the conventional models of service delivery have meant that service models of service delivery have meant that service delivery must be highly structured to control costs. delivery must be highly structured to control costs. High travel costs mean reduced access to client High travel costs mean reduced access to client services. services.

• Examples of how the KO IRSSP video-enabled Examples of how the KO IRSSP video-enabled therapy and traditional healing would address some therapy and traditional healing would address some of the existing service delivery challenges are:of the existing service delivery challenges are:

Comparison of Existing Model with proposed KO IRSSP Community-Comparison of Existing Model with proposed KO IRSSP Community-Based ModelBased Model

Existing Service Delivery Existing Service Delivery ChallengesChallenges

KO Model to Address ChallengesKO Model to Address Challenges

-High cost of travel: financial; -High cost of travel: financial; social/family; personal/spiritual social/family; personal/spiritual

-Less therapy-related travel with more -Less therapy-related travel with more community-based services mean more community-based services mean more effective use of resourceseffective use of resources

and greater access to services by more and greater access to services by more

IRS survivors.IRS survivors. -Gaps in existing community based -Gaps in existing community based support 24/7support 24/7

- KO Project provides connection and - KO Project provides connection and continuity with client, treatment plan continuity with client, treatment plan

and therapist or traditional healer.and therapist or traditional healer. -Existing ‘fee-for-service’ (FFS) model is -Existing ‘fee-for-service’ (FFS) model is too similar to Residential Schools. Very too similar to Residential Schools. Very challenging for clients from remote challenging for clients from remote settings, who need to be very self-settings, who need to be very self-motivated and in an urban or road motivated and in an urban or road access community for realistic chances access community for realistic chances of success.of success.

- IRSS clients best served & have the - IRSS clients best served & have the greatest chance of success in treatment greatest chance of success in treatment when both therapy & after-care when both therapy & after-care activities are based in the client’s home activities are based in the client’s home community, where the natural, most community, where the natural, most culturally-appropriate and most culturally-appropriate and most effective client supports exist. Family, effective client supports exist. Family, survivor peers and community context survivor peers and community context

are required for client successare required for client success - Non-conformity with accepted - Non-conformity with accepted characteristics of successful treatment characteristics of successful treatment for IRS Survivors (family-based, trans-for IRS Survivors (family-based, trans-generational)generational)

-Therapy models / treatment planning -Therapy models / treatment planning will conform to unique specialized will conform to unique specialized

requirements for successful IRSS txrequirements for successful IRSS tx

Comparison of Existing Model with proposed Comparison of Existing Model with proposed KO IRSSP Community-Based ModelKO IRSSP Community-Based Model Continued Continued


ContinuedContinued

KO Model to Address KO Model to Address ChallengesChallengesContinuedContinued

-Existing Local Mental Health -Existing Local Mental Health Workers often lack clinical Workers often lack clinical experience, have little or no training, experience, have little or no training, provide little if any case provide little if any case management, maintain a high management, maintain a high caseload, respond primarily to crisis caseload, respond primarily to crisis needs/situations, do not maintain needs/situations, do not maintain regular schedule of client consults, regular schedule of client consults, and suffer from lack of staff support.and suffer from lack of staff support.

- Local IRSSP Coordinators will be - Local IRSSP Coordinators will be trained to a minimum standard in trained to a minimum standard in basic counselling (NODIN) and basic counselling (NODIN) and TGTM, will be supported to complete TGTM, will be supported to complete required case management functions, required case management functions, and will work with and provide and will work with and provide support for Survivors and families on support for Survivors and families on long-term and inter-generational long-term and inter-generational

effects of residential school traumaeffects of residential school trauma

Comparison of Existing Model with proposed Comparison of Existing Model with proposed KO IRSSP Community-Based ModelKO IRSSP Community-Based Model Continued Continued

-Failures in past with IRS Survivors -Failures in past with IRS Survivors are due to lack of aftercare/follow-are due to lack of aftercare/follow-through on Plans (resulting in high through on Plans (resulting in high system and community/family costs system and community/family costs

due to recidivism)due to recidivism)

-KO IRSSP Local Coordinators will -KO IRSSP Local Coordinators will coordinate/facilitate after-care and coordinate/facilitate after-care and follow-up at the community level to follow-up at the community level to ensure access to and utilization of ensure access to and utilization of local supports. Specialized social local supports. Specialized social supports available only in home supports available only in home community. community.

-Existing FFS model is appropriate -Existing FFS model is appropriate for more immediate acute social for more immediate acute social needs and not residential school needs and not residential school traumatrauma

-KO IRSSP model specialized to -KO IRSSP model specialized to address long-term individual, address long-term individual, collective and intergenerational collective and intergenerational aspects of trauma and treatment aspects of trauma and treatment planningplanning

- NODIN stressed – responding to - NODIN stressed – responding to acute needs/crisisacute needs/crisis

- immediate acute needs met locally - immediate acute needs met locally or w/NODINor w/NODIN

- IRS trauma was collective. - IRS trauma was collective. Treatment must have collective Treatment must have collective component.component.

-KO IRSSP develops integrated -KO IRSSP develops integrated treatment plans which may indicate treatment plans which may indicate unique and innovative approaches to unique and innovative approaches to utilize local supports / family / utilize local supports / family / Committees Committees


ContinuedContinued

KO Model to Address KO Model to Address ChallengesChallenges

ContinuedContinued

IRSSPIRSSP• Telemedicine-enabled therapy, traditional healing and Telemedicine-enabled therapy, traditional healing and

support services for Residential School Survivors from support services for Residential School Survivors from the KO First Nations will be cooperatively developed the KO First Nations will be cooperatively developed and initially supervised by a mental health professional and initially supervised by a mental health professional (the IRSSP Pilot Coordinator) at the KO Office in (the IRSSP Pilot Coordinator) at the KO Office in Balmertown. Balmertown.

• Regional coordination of program development, Regional coordination of program development, community consultation and IRSS Committee community consultation and IRSS Committee development, assistance to Chiefs & Councils in development, assistance to Chiefs & Councils in assigning support responsibilities to local worker(s), assigning support responsibilities to local worker(s), program promotion, training, approvals and billing for program promotion, training, approvals and billing for overall therapy and traditional healing services through overall therapy and traditional healing services through NIHB, worker support and advocacy, and coordination NIHB, worker support and advocacy, and coordination of evaluation activities, will be the responsibility of the of evaluation activities, will be the responsibility of the KO IRSSP Pilot Coordinator.KO IRSSP Pilot Coordinator.

IRSSPIRSSP• Local IRSSP Program responsibilities will include Local IRSSP Program responsibilities will include

establishing a local support network amongst establishing a local support network amongst survivors, local promotion of IRSSP and supports, survivors, local promotion of IRSSP and supports, providing and/or facilitating referrals, coordinating providing and/or facilitating referrals, coordinating client services (both local via tele-medicine or other client services (both local via tele-medicine or other and NODIN), client and group advocacy, facilitating and NODIN), client and group advocacy, facilitating and encouraging client follow-through on treatment and encouraging client follow-through on treatment plans. plans.

• Providing (or facilitating access to) emergency Providing (or facilitating access to) emergency counselling if needed between clinical sessions, and counselling if needed between clinical sessions, and participating in evaluation activities. participating in evaluation activities.

• These responsibilities will be fulfilled by existing These responsibilities will be fulfilled by existing local mental health workers who will be tasked with local mental health workers who will be tasked with additional responsibilities under this IRSS Program. additional responsibilities under this IRSS Program.

IRSSPIRSSP• The mental health Single Agreement for Service The mental health Single Agreement for Service

Model will provide the general template for Model will provide the general template for collaborative treatment. collaborative treatment.

• Essential face-to-face consults with therapists Essential face-to-face consults with therapists normally accessed by video-technology will occur normally accessed by video-technology will occur early on in the treatment process -- either up-front early on in the treatment process -- either up-front or after the first few therapy sessions – and will or after the first few therapy sessions – and will occur in the client’s home community context via a occur in the client’s home community context via a community visit by the therapist. community visit by the therapist.

• As well, consults with traditional healers will As well, consults with traditional healers will include a face-to-face consult early on in the include a face-to-face consult early on in the treatment process (via a community visit), and will treatment process (via a community visit), and will then progress to regular video-enabled consults for then progress to regular video-enabled consults for a majority of the treatment sessions.a majority of the treatment sessions.

IRSSPIRSSP• IRSSP therapy and traditional healing services may be IRSSP therapy and traditional healing services may be

accessed by IRS survivors and their families in a number of accessed by IRS survivors and their families in a number of ways:ways:

• 1)1) Direct contact with the IRSSP Local Direct contact with the IRSSP Local Coordinator by the survivor or family member(s);Coordinator by the survivor or family member(s);

• 2)2) Direct contact with KO Health Services or Direct contact with KO Health Services or KOTM, which informs the Pilot or the Local Coordinator;KOTM, which informs the Pilot or the Local Coordinator;

• 3)3) Direct contact with the KO IRSSP Pilot Direct contact with the KO IRSSP Pilot Coordinator, who will contact the Local Coordinator;Coordinator, who will contact the Local Coordinator;

• 4)4) Contact at-a-distance with related crisis and Contact at-a-distance with related crisis and support contact lines, which will then contact the IRSSP.support contact lines, which will then contact the IRSSP.

• IRSSP therapist and traditional healing services will require IRSSP therapist and traditional healing services will require “prior-approvals” from NIHB. Prior-approval will be applied “prior-approvals” from NIHB. Prior-approval will be applied for once a referral is made to IRSSP staff. When necessary, for once a referral is made to IRSSP staff. When necessary, IRSSP staff will assist the IRS applicant in completing the IRSSP staff will assist the IRS applicant in completing the necessary forms to apply for ‘prior-approval’. The next slide necessary forms to apply for ‘prior-approval’. The next slide will define the necessary information required for ‘prior-will define the necessary information required for ‘prior-approval’.approval’.

IRSSPIRSSP• The necessary information for “prior approval” in The necessary information for “prior approval” in

the application includes:the application includes:• a)a) a letter from the Chief/Council recognizing a letter from the Chief/Council recognizing

the person as a Traditional Healer/Elder, and that the person as a Traditional Healer/Elder, and that they welcome the Elder to the community on such they welcome the Elder to the community on such and such a date;and such a date;

• b)b) name and address of the Elder/Healer;name and address of the Elder/Healer;• c)c) confirmation from the Elder/Healer that confirmation from the Elder/Healer that

there is an appointment with former IRS there is an appointment with former IRS student(s) - dates and times scheduled or that the student(s) - dates and times scheduled or that the person is attending a healing event;person is attending a healing event;

• d)d) if there is a community healing event - date if there is a community healing event - date and agenda of the event;and agenda of the event;

• e)e) name, address, phone #, date of birth and name, address, phone #, date of birth and DIAND # (band number) of the former IRS student DIAND # (band number) of the former IRS student plus names and dates of birth of family members;plus names and dates of birth of family members;

• f)f) if the person is a family member of a if the person is a family member of a survivor, the actual survivors personal survivor, the actual survivors personal information, ie. DOB, DIAND#, School attended;information, ie. DOB, DIAND#, School attended;

• g)g) travel dates, for accommodation - dates travel dates, for accommodation - dates requested.requested.

IRSSP Treatment IRSSP Treatment ProcessProcess

..

• When this information is received, travel When this information is received, travel arrangements will be reviewed and the arrangements will be reviewed and the applicant will receive an IRS prior approval applicant will receive an IRS prior approval number from the NIHB office (which may number from the NIHB office (which may take seven working days to process). take seven working days to process).

• Once the video-session or community visit Once the video-session or community visit has occurred, an invoice is submitted to has occurred, an invoice is submitted to NIHB including the prior-approval number NIHB including the prior-approval number (IRS###), as well as a statement (IRS###), as well as a statement identifying all expenses with attached identifying all expenses with attached original receipts for accommodation, original receipts for accommodation, transportation, and a written and signed transportation, and a written and signed confirmation of attendance for each day of confirmation of attendance for each day of travel.travel.

• Once treatment plans are approved by Once treatment plans are approved by NIHB, prior-approvals may apply to NIHB, prior-approvals may apply to multiple consults as part of the overall multiple consults as part of the overall plan.plan.

IRSSP KOTM best IRSSP KOTM best practices (1)practices (1)• Counselling environment, successful client engagement and Counselling environment, successful client engagement and

confidentiality issues during video therapy sessions and confidentiality issues during video therapy sessions and remote sessions with a traditional healer will be addressed remote sessions with a traditional healer will be addressed by applying existing guidelines / protocols established by by applying existing guidelines / protocols established by KO Tele-Medicine (KOTM) over the last five years. KOTM KO Tele-Medicine (KOTM) over the last five years. KOTM serves 26 remote First Nations communities in Ontario’s far serves 26 remote First Nations communities in Ontario’s far north.north.

• These practises are articulated in the following KOTM These practises are articulated in the following KOTM documents:documents:

• Telecounseling Consultation Information SheetTelecounseling Consultation Information Sheet – a – a client information sheet which describes KOTM and client information sheet which describes KOTM and Telecounselling, as well as providing detailed information Telecounselling, as well as providing detailed information for clients on “What Happens During a Telecounselling for clients on “What Happens During a Telecounselling Appointment”, “What About Privacy / confidentiality?”, Appointment”, “What About Privacy / confidentiality?”, “What are the Potential Risks?”, the Benefits to “What are the Potential Risks?”, the Benefits to Telecounselling, as well as what other options are available.Telecounselling, as well as what other options are available.

IRSSP KOTM best IRSSP KOTM best practices (2)practices (2)• Protocol for Telepsychiatry Consults – Protocol for Telepsychiatry Consults – a a

program delivery tool for KOTM staff to ensure program delivery tool for KOTM staff to ensure sensitive, confidential, effective and proper sensitive, confidential, effective and proper consults, and covering topics such as background consults, and covering topics such as background noise, other persons in the clinic area, technical noise, other persons in the clinic area, technical issues related to equipment operation, as well as issues related to equipment operation, as well as other service delivery aspects required for other service delivery aspects required for successful consults such as Oaths of Confidentiality successful consults such as Oaths of Confidentiality for staff and necessary consent forms for clients.for staff and necessary consent forms for clients.

• IT User GuideIT User Guide – providing technical instruction for – providing technical instruction for use of phone and video suite equipmentuse of phone and video suite equipment

• Privacy and Confidentiality Policies sectionPrivacy and Confidentiality Policies section from the KOTM Policy and Procedures Manual from the KOTM Policy and Procedures Manual

• Protecting Your Personal Health Information – Protecting Your Personal Health Information – KOTM client information brochureKOTM client information brochure

Timeline and EvaluationTimeline and Evaluation• The evaluation / assessment of video-enabled The evaluation / assessment of video-enabled

therapy and traditional healing services through therapy and traditional healing services through the KO IRSSP will be on-going and result in a final the KO IRSSP will be on-going and result in a final report at the end of the Pilot period (March 2010), report at the end of the Pilot period (March 2010), and for each subsequent year of service delivery. and for each subsequent year of service delivery.

• Outside evaluators will work collaboratively with Outside evaluators will work collaboratively with IRSSP staff to determine the scope and focus of the IRSSP staff to determine the scope and focus of the assessment activities and design an evaluation assessment activities and design an evaluation plan. Evaluative tools will be administered at the plan. Evaluative tools will be administered at the end of most IRSSP activities, including all video-end of most IRSSP activities, including all video-enabled sessions and any formal support enabled sessions and any formal support functions/events held in each First Nation. functions/events held in each First Nation.

• As well, staff and Committee training will be As well, staff and Committee training will be evaluated by participants for relevancy, evaluated by participants for relevancy, appropriateness and usefulness. appropriateness and usefulness.

• Quantitative analysis of statistics, together with Quantitative analysis of statistics, together with projection of costs for same level of service/activity projection of costs for same level of service/activity if not video-enabled, will provide some relative if not video-enabled, will provide some relative measure of cost effectiveness when compared to measure of cost effectiveness when compared to existing models which support client travel away to existing models which support client travel away to urban settings for therapy or healing services in urban settings for therapy or healing services in isolation from family and peer supports. isolation from family and peer supports.

IRSSP Implementation IRSSP Implementation WorkplanWorkplan

July 2009 – March 2010July 2009 – March 2010• Summary Objectives/Activities to be Summary Objectives/Activities to be

completed:completed:– Program DesignProgram Design– Establish local IRS Support CommunitiesEstablish local IRS Support Communities– Community ConsultationsCommunity Consultations– Hiring – the appropriate coordinatorsHiring – the appropriate coordinators– Confirming Traditional HealersConfirming Traditional Healers– Training – include case management, Training – include case management,

confidentiality, basic counselling, crisis confidentiality, basic counselling, crisis interventionintervention

– Program PromotionProgram Promotion– Service DeliveryService Delivery– Program Planning – Year 2Program Planning – Year 2– Program Evaluation/AssessmentProgram Evaluation/Assessment

Current KO Mental Health Current KO Mental Health ClientsClients

• KO Mental Health Office reports that KO Mental Health Office reports that the present KO mental health client list the present KO mental health client list (all 5 FNs) totals 78 individuals (all 5 FNs) totals 78 individuals

• 39 of which are direct IRS survivors 39 of which are direct IRS survivors • 18 are inter-generational victims, and 18 are inter-generational victims, and

the remaining the remaining • 21 (primarily children) present other 21 (primarily children) present other

MH issues.MH issues.• Once in operation, the IRSSP will Once in operation, the IRSSP will

increase # on listincrease # on list

Community Front Line Community Front Line WorkersWorkers

QuestionsQuestions

• Thank youThank you

• Acknowledgments to Krystal Kohar.Acknowledgments to Krystal Kohar.

Documents

NAHO CONFERENCE 2009