The Last Word

Lost in transition: Emerging adults and their families face many challenges

2012-01-03T13:00:00Z

Shelly Ben-David

Parents hope their children will grow up to be successful members of society. A parent's worst nightmare is seeing their child winding up homeless, without prospects of career or family. I'm not a parent, but as a social worker who over the years has worked with young adults with severe mental illness, as well as their parents, I have witnessed the desperation that parents feel when their child is at risk for severe mental illness.

]]> For two years, I have been working at the Center of Prevention and Evaluation (COPE) research clinic at the New York State Psychiatric Institute, which follows adolescents at risk for developing psychosis. I have worked with young adults who are on the cusp of their first psychotic break and listened to their stories -- some hopeful, many others filled with confusion, sadness and feelings of alienation.

Adolescence is a period of major development, when many biological, psychological and social changes occur. Developmental psychologist Erik Erikson defined adolescence as a stage that involves grappling with identity formation and role development. The task of the teenager is to individuate from family and become a member of wider society. In the stage that follows adolescence, young adults seek companionship and love and consider parenthood. But at COPE, I see young adults who because of their symptoms and their difficulty achieving developmental milestones -- finding work, establishing relationships, living on their own -- experience a sort of prolonged adolescence.

For many teenagers and young adults struggling with severe mental illness, achieving these developmental milestones is a big struggle. Research shows that mental health problems increase during adolescence, when more complex disorders like psychosis begin to emerge. As these individuals reach young adulthood, plans for separating from family, establishing meaningful relationships and finding a vocation become difficult because these young adults often rely on their families to take care of them.

At the same time, they also face the transition from child-serving to adult-serving health care systems, with their rigid age boundaries. This health care transition often coincides with developmental transitions and increases the chances that youth with mental health problems will get lost in the transition between systems of care. How are families, particularly those from a lower socio-economic background, able to financially provide care for their children, especially if there are no programs to ease the transition to adult services?

In the United States, many children and adolescents with disabilities qualify for supplementary security income (SSI). But in order too continue to qualify for benefits as an adult, those who received SSI as children must go through a process of "redetermination" of eligibility. Johnson and colleagues interviewed youth and their families who had gone through this process and found limited understanding about the process of redetermination and the steps required. Families and young adults also expressed a lot of confusion about the different types of benefits they could receive. The findings, published in a 2007 issue of Policy Research Brief from the University of Minnesota, also showed that health care providers and school counsellors also had limited knowledge about this transition in support.

Educating families and health care providers can make the difference in determining whether young people can keep their status and financial and medical support as they transition into adult health care systems. SSI benefits are necessary for families living on limited means -- they need the money to pay for rent, treatment and basic living expenses. One common fear for young adults, as well as their families, is that if they work, they may lose their SSI benefits. This fear is a disincentive to employment, so these young adults are less likely to get work and integrate into society, thereby failing to achieve important developmental goals.

I was first introduced to the phenomenon of psychosis as a first-year undergraduate when I volunteered at the Center for Addiction and Mental Health in Toronto. I ran yoga and meditation groups with patients, many of them young adults, in the early psychosis unit. I remember thinking how scary it must be to be a psychiatric inpatient. Yes, these young people were there to get help, but I wondered what happened after they left the hospital. Were they able to resume their lives?

In a study published in 2007 in the Journal of Behavioral Health Services and Research, Pottick and colleagues found that for transition-age youth with mental health problems, the rate of admission to outpatient services declined, while the rate for inpatient admission increased dramatically. As more youth are hospitalized and treated in an inpatient setting, they are at increased risk of trauma and misdiagnosis, as well as inordinate reliance on antipsychotics, with their marked side-effects.

At the COPE clinic, where I work with adolescents at risk for psychosis, we strive to normalize and de-stigmatize what the young adults we see experience. We provide clinical services for young adults and their families, in the hope that if they do become psychotic, they will have a more positive outcome and trajectory to recovery. We need better collaboration and co-ordination between adolescent and adult systems of care so that young adults facing the transition don't fall through the cracks during one of the most important developmental periods of their lives.

Shelly Ben-David is a licensed social worker for the State of New York. She is also research co-ordinator at the Center of Prevention and Evaluation at the New York State Psychiatric Institute/Columbia University.

Demolishing stigma: It takes more than an urban village

2011-09-15T13:00:00Z

Wayne Skinner

What should an academic health sciences centre do if it had the opportunity to redevelop a historic 27-acre site? For the Centre for Addiction and Mental Health (CAMH) in Toronto, the answer was to build an "urban village." Equipped with that appealing phrase to represent the concept and the strategy, CAMH has embarked on one of the most ambitious redevelopments of a health care campus in the world today.

]]> In 1850, the original 200-acre site on Queen Street was opened as one of the most progressive developments of that time. The Provincial Lunatic Asylum, as it was called, was more or less self-sufficient, growing much of its own food. It was a walled facility, and the thought of being brought there surely a fearful prospect, despite the efforts of pioneers to humanize care. The task of moving from the model of madness as moral malady to mental illness started then, and continues today. Over the years, the institution grew to become the largest psychiatric hospital in Ontario. But as the city grew around the hospital, it became less self-sufficient. It remained a place of confinement and protection in a world that continued to be phobic about mental suffering.

This 1972 photo depicts the controversial demolition of the Provincial Lunatic Aslyum, while its replacement, the Queen Street Mental Health Centre, was under construction. Courtesy of the Archives, Centre for Addiction and Mental Health, Toronto.

I was introduced to 999 Queen St., as it was called by then, in 1971, when as a social sciences student I went to work there. It changed my life. Two years later, I was a graduate student in social work at the University of Toronto, and my career has focused on addiction and mental health ever since.

Back then, I worked in the original building, a massive structure that showed its age, but that also revealed magnificent proportions and a classic design that deserved to endure. Instead, the building was demolished, replaced by a set of four buildings connected by an enclosed walkway in the mid-'70s, fronted by an administration building in the functional ugly style that prevailed through much of the mid-20th century.

Tearing down that old building would have probably not been permitted today. Its destruction would be the equivalent of destroying the equally noble building that the Toronto General Hospital moved to on College Street in 1910. Now revitalized, it serves as the hub for a set of new medical science buildings. Is there something in the way we look at things that makes us want to preserve a historic medical building and tear down a historic psychiatric hospital? I suspect so, and I suspect that our approach to that space on Queen Street still reveals a problematic relationship between contemporary society and mental illness.

Formerly a wing of the Toronto General Hospital, this heritage building now houses the MaRS Centre, an innovative new hub for medical and related research.

Urban architecture and landscape design, as evidenced by other developments in North American cities, is inclined towards ecological values. Around the University of Toronto, for example, streets have been redesigned to expand pedestrian space, and others have been closed off to vehicles. Such changes reflect the urban village concept.

CAMH's strategy is to integrate the new site with the surrounding neighbourhood by extending existing streets to create new city blocks in order to create a safe, welcoming setting for care in which the institutional stigma long associated with the property is eliminated. But it is hard to understand how transposing what was once a contiguous, very green 27-acre campus into a few new city blocks is supposed to break institutional stigma. Although there are gestures in the redevelopment that recognize the past -- most importantly, saving parts of the wall -- the greater effect of this design is division, erasure and forgetting.

Perhaps the greater opportunity is to imagine a true urban village that proclaims the whole campus as a site dedicated to mental health. This is how the great institutions in health care represent themselves -- by standing out as something positive, even though they have histories of medical treatment that seem as barbaric as does the history of psychiatric care. Psychiatrist Dr. Vivian Rakoff recently noted that it reflects a lack of historical understanding to evaluate the well-intentioned actions of past generations through the lens of today's more advanced knowledge. I hope that future generations will remember our efforts with such a wise gaze.

Artist's rendering of three new buildings at the heart of the Centre for Addiction and Mental Health's new urban village in Toronto.

Even more important, we need to challenge ourselves to do the best we can with the knowledge and resources we have. So much of the CAMH redevelopment has been successful. The ability to excite and recruit private and corporate donations has been remarkable. New and improved purpose-built buildings are being constructed. But is there a tradeoff? Are we paying an unfortunate price? Imagine not a lattice of streets that will draw more vehicular traffic and divide a campus that could otherwise be remarkably and distinctly unified. Imagine instead a place that not only provides the best care, but that can become a model environment, where buildings and landscape stand out and cohere to create a welcoming community of sanctuary and health.

The goal of redevelopment can be more than making the site look like any other set of city streets which just happen to hold Canada's largest mental health and addiction facility. The site needs to be a space that proclaims itself as a place of caring, learning, healing, recovery and community. That is a different mission than trying to fit in. It is about standing out and leading the way. It is about showing pride of place. That is what great institutions do.

Wayne Skinner is deputy clinical director of the Addictions Program at the Centre for Addiction and Mental Health in Toronto.

Do community treatment orders work?

2011-06-14T16:55:55Z

Ann-Marie O'Brien

Community treatment orders (CTOs) are part of a complex landscape of law, policy and practice. Defining and measuring their effectiveness depends on who you ask; policy makers, practitioners and the people who fall under CTOs all present different perspectives. CTOs do not exist in a vacuum. Many factors affect how, when and with whom they are used, including the availability and willingness of physicians and the mental health infrastructure to support them. Ten years after the introduction of CTOs in Ontario, there exists only a handful of studies to inform opinions on their usefulness. Many important questions remain unanswered.

]]> The purpose of CTOs as defined in the Ontario legislation is to provide a comprehensive plan of community-based treatment or care and supervision that is less restrictive than being detained in a psychiatric hospital. They are meant to provide the support people need to maintain wellness outside of institutional care, thus reducing use of inpatient services. It seems reasonable, then, to gauge the effectiveness of CTOs by measuring their impact on hospitalization rates. Every Canadian study that has used this measure has found CTOs to reduce use of hospital inpatient beds. However, some critics note the limitation of this measure. They argue that within the context of ever decreasing hospital inpatient resources, staying out of hospital does not in itself indicate wellness. Simply closing hospital beds will decrease their use.

There is another possible way to measure success. CTO legislation is developed within unique cultural and socioeconomic contexts. In Ontario, like in many other jurisdictions, the legislation was motivated by an act of violence by a person whose symptoms of illness were untreated. Given the association of this legislation with random acts of violence committed by people with untreated mental disorders, it would be reasonable to evaluate CTOs by measuring their impact on violence. This question has yet to be examined in Ontario.

CTOs knit together the minimal presumed necessities for mental health and well-being of individuals with serious mental disorder: treatment (usually and sometimes exclusively medication) and medical supervision. CTOs in Ontario, unlike in other jurisdictions, are physician directed, not court ordered. One challenge of determining whether CTOs work is distinguishing between the effectiveness of the CTO and the effectiveness of the treatment. One measure of effectiveness would be the impact of CTOs on compliance. All studies that have examined compliance have found a positive association between CTOs and compliance.

The introduction of CTOs has affected agencies such as the Psychiatric Patient Advocate Office (PPAO) and the Office of the Public Guardian and Trustee. In 2009, the PPAO reported having received 2,198 requests for rights advice for CTOs -- a six-fold increase since 2002. It would be interesting to know what additional funding these agencies have received to keep up with the increased demand for services. What is the impact of this funding -- or lack of funding -- on individuals subject to CTOs? To what extent have recent changes in legislation been driven by increased demands for rights advice and diminished resources to keep up with those demands?

Historically, mental health services have been divided between inpatients (voluntary and involuntary) and outpatients. Once outside the institution, people were more or less on their own. The introduction of CTOs has created a new set of mental health service users--involuntary outpatients. The PPAO, in its 2009 annual report, reported that almost 70 per cent of CTOs were consented to by substitute decision makers. How have our practices been adapted to serve involuntary outpatients? Many community-based practitioners are unprepared for this new reality. When CTO legislation was passed, significant funds were channeled to community-based mental health agencies to hire case managers to provide services to people on CTOs. Currently, the number of people on CTOs has far surpassed the number of case managers originally funded to serve involuntary outpatients. From a practice perspective, what lessons have been learned from the past 10 years?

The most fundamental question is, How do CTOs affect the lives of the individuals who are subjected to them? These people are a challenging population to engage for scientific enquiry. Beyond meeting the very broadly defined legal criteria for CTOs, these individuals have different clinical presentations and diverse socioeconomic realities. Their perceptions of CTOs are as varied as they themselves are as individuals. Some are completely indifferent to the CTO; they are resigned to the lack of power they have over their illness and reluctantly comply with the CTO. They make no connection between treatment compliance, symptom reduction and improved quality of life in the form of stable housing and meaningful employment.

Others feel persecuted by the requirements of the CTO. They express feelings of powerlessness, oppression, hopelessness and, often, anger. They deeply resent having to comply with treatment because they, too, don't see the connection between treatment compliance, symptom reduction and improved quality of life. These people frequently engage the Consent and Capacity Board in their pursuit of justice.

Another group of people have remarkable stories of recovery that began with involuntary treatment. Some regain capacity to make treatment decisions, and some make the connection between compliance and improved quality of life. What we still need to better understand is the combination of factors that contribute to these positive outcomes.

Anne Marie O'Brien is a CTO coordinator at the Royal Ottawa Mental Health Centre. She is adjunct faculty at the Carleton University School of Social Work.

Editorials do not necessarily reflect the views of CAMH

The great Ritalin debate: It's not overprescribing, it's bad prescribing

2011-03-14T13:36:06Z

Ted Ridley

"You're not going to tell me to put my child on Ritalin!" The alarm in the mother's voice is palpable, her reaction familiar to child and youth mental health workers. The clinician has just reviewed this mother's account of her son's persisting and worsening academic performance, his inability to maintain relationships with family, friends and teachers, his repeated abandonment or rejection from community activities. The standardized behaviour checklists completed by parents and teachers coincide with the interview findings, and rate him above the 95th percentile for ADHD symptoms. But the boy's mother has rejected medication before it has even been suggested.

]]> Browsing the Internet uncovers a disturbing array of allegations, ranging from cynical to hysterical, that might explain this reaction: stimulants are condemned as dangerous, addictive, unnatural and overprescribed. The prospect of "zombie" children medicated for the sole purpose of keeping them quiet in class and making teachers' lives easier is probably the top myth that parents recite.

Detractors dismiss ADHD as merely a label for behaviour that others find challenging. Internet sites abound promoting "alternative" therapies and natural or holistic remedies, few of which are evidence-based or free, and many of which are entirely spurious.

Adversaries of medication management point to the increasing volume of stimulants produced in recent years as evidence that they are overprescribed, and to the many prescriptions that are never refilled as a sign that the medications were fraught with intolerable side-effects and probably not helpful to begin with. The implication or outright accusation is that medical practitioners are too casual in diagnosing ADHD.

Controversy over the use of medication to treat mental health conditions is probably at its most intense when children are involved, and parents are understandably apprehensive about starting and maintaining their kids on a psychoactive medication. Few possess the knowledge or clinical expertise to recognize the reductionist quality of these views, and most are uninformed of the significance of the long-term risks of failing to treat ADHD effectively.

Reliable estimates of ADHD prevalence continue to rise toward double digits, although its detection in primary care settings amounts to a small fraction of this group. Assessment is usually initiated at a point of crisis, and often on the urging or insistence of the child's school.

In the mental health community, appreciation of ADHD as a complex, dynamic and chronic condition is growing, but its dimensions are not widely understood. Symptoms may not be universally obvious or consistently impairing, and the inattentive-type ADHD symptoms often elude earlier detection but add significantly to the condition's complexity.

Some symptoms diminish over time; most vary in intensity from one set of circumstances to another. Children and youth without ADHD can also be distractible, reluctant to tackle boring academic tasks, even inappropriately impetuous and exuberant. The fact that a child with ADHD can sometimes persist with a task for a reasonable interval or earn a high grade on a test fuels the parent's scepticism that maybe he doesn't have the dreaded disorder after all.

But the complaint that physicians recommend medication after a brief office visit and what seems to parents as an inadequate assessment has some merit. Practitioners may be familiar enough with ADHD to provide a confident diagnosis fairly quickly and recognize that the child is unlikely to succeed without medication, but failing to address parents' misgivings can undermine success.

Even if the parent overcomes her reluctance and hesitantly agrees to try medication, the day inevitably arrives when she forgets to administer it. The absence of a complaining phone call that day from the child's teacher supports the hope that he outgrew the condition or perhaps never really had it in the first place. By the time his impairments resurface, perhaps weeks or months later in the midst of another crisis, the link between symptoms and the medication that helped manage them may be lost.

If the child has traits of oppositional defiant disorder, the most common concurrent condition, parents often capitulate to their resistance to taking medication. Given that overall prescription medication compliance for all conditions is relatively low, it's not surprising that adherence to a medication about which there is ambivalence and anxiety would be even lower.

Results of the Multimodal Treatment Study of Children with ADHT (MTA), the largest controlled study of ADHD treatments, failed to identify any treatment as having an enduring superior effect. Although medications showed initial significant benefit compared to other modalities, follow-up studies failed to demonstrate lasting advantage in the group treated with medications over the non-medicated group. The reasons for this deserve further study, but they do not negate the value of medication management.

The more accurate view is not that psychostimulants are overprescribed, but that too often they are not effectively prescribed.

The expectation to identify and manage uncomplicated ADHD in primary care settings is challenging but critical to manage what is essentially a chronic, impairing and under-detected condition. CADDRA (Canadian ADHD Resource Alliance) publishes comprehensive guidelines for physicians, comprising a five-visit protocol to complete a thorough screening and workup before initiating a trial of medication. Regular follow-up monitoring and review are essential.

Front-line professionals in child and youth mental health regularly work with children who have ADHD and their families in various therapeutic capacities. Their potential to collaborate in optimal multimodal ADHD management through detection and screening, parent and patient psychoeducation and monitoring remains largely untapped.

Ted Ridley is a child/youth mental health counsellor with the Hamilton Family Health Team in Hamilton, Ont.

Editorials do not necessarily reflect the views of CAMH

Can housing first work if there isn't enough affordable housing?

2011-01-04T13:00:00Z

Stephen Gaetz

In recent years, "housing first" has emerged as a key response to homelessness in North America. With its growing popularity in Canada comes increasing interest in understanding how the approach works, different program models and its effectiveness for specific populations. One key factor that undoubtedly shapes the success of any housing first program is the nature and supply of affordable housing.

]]> Pathways to Housing project in New York in the 1990s, is that people do better moving forward with their lives if they are first housed. This is as true for homeless people and those with mental health and addiction issues as it is for anyone. According to Pathways to Housing, "The Housing First model is simple: provide housing first, and then combine that housing with supportive treatment services in the areas of mental and physical health, substance abuse, education, and employment." This approach differs from what has been (and arguably still is) the orthodoxy of our Canadian response to homelessness; in that "treatment first" approach, people who are homeless should be placed in emergency services until they are "ready" for housing (having received access to health care or treatment) or until housing is available.

Research quite convincingly demonstrates the general effectiveness of housing first over treatment first. In a 2000 study, Tsembaris and Eisenberg demonstrated that 90 per cent of people in the Pathways program remained housed five years later. A growing body of research shows that people with mental health and addiction issues do very well with a housing first approach, spend fewer days in hospital and are cheaper to support. (To see the research, visit www.homelesshub.ca/housingfirst.)

Housing first is most effective when, first, people are rehoused rapidly, minimizing time spent on emergency services. Because resources are scarce, priority should be given to high-needs clients, including families and those with mental health and addiction challenges. Second, ongoing and appropriate support must be provided for those who need them (and many don't). Those with addiction issues should have access to harm reduction-based housing, if that is what they prefer. Finally, where possible, clients should have input into the kind and location of their housing. While providing shelter and supports is central to housing first, the approach works best when it helps people nurture supportive relationships and become meaningfully engaged in their communities.

As housing first grows in popularity, it is applied in new ways and in different contexts. One challenge of implementing the approach is the ability to deliver appropriate housing support in the context of a housing shortage. I have often wondered what would have happened if the City of Toronto had attempted to implement its Streets to Homes program in the late 1990s, when rental vacancy rates were routinely below one per cent, compared to the last five years, when vacancy rates have hovered between three and four per cent.

In a tight rental market, one of the first things to go is the notion of consumer choice. One criticism of housing first is that people are often given housing in remote areas of town, far removed from services, poorly served by transit, and where people struggle to connect. Women fleeing violence may be placed in neighbourhoods that are not safe. The outcome is often isolation, continued marginalization and a compromised ability to accesses necessary services and supports. In the long run, this can undermine stability and security of tenure.

Different approaches to housing first take on the challenge of affordable housing supply in distinct ways. In Montreal, all levels of government working with the non-profit sector have sought to address the supply problem with an ongoing investment in social housing, with pathways to that housing for people who are homeless. The Streets to Homes program in Toronto relies almost exclusively on the private market, and rather than use rent subsidies, it has developed a system to fast track people so they can access other government benefits and supports. With a waiting list of more than 75,000 for social housing and with modest targets for expanding its affordable housing supply (up to 1,000 new units annually--though these targets are not being met), Toronto relies on the private rental market, making its housing first program vulnerable if the affordable housing supply shrinks.

In Calgary, the affordable housing supply has shrunk drastically over the past 10 years, while rents have skyrocketed. In rolling out its housing first model, the Calgary Homeless Foundation takes a systems approach, coupling its adaption of housing first with an investment in affordable housing (3,000 units built over the past three years) and with rent supports for people living -- or choosing to live -- in the private rental market.

The best approach to housing first, then, is to treat it not as a program or service tied to an agency, but rather, as part of a broader and more strategic response to homelessness; one that focuses on prevention by ensuring an investment in an affordable housing supply, and by requiring other sectors (mental health and corrections come to mind) to play their part in diverting people from homelessness through more effective discharge planning strategies. It is only by ensuring a sufficient supply of affordable housing that one of the central tenets of housing first -- consumer choice -- is protected.

Stephen Gaetz is the associate dean of research and professional development in the Faculty of Education at York University in Toronto, and founder of the Homeless Hub, a Canadian clearinghouse for homelessness research.

Editorials do not necessarily reflect the views of CAMH

Where is the recovery in chronic disease management?

2010-09-23T13:00:01Z

Raymond Cheng

The power of language in health care is an understated one. For those of us who pass our days as stakeholders, whether on the front lines, during policy discussions or in meeting rooms, jargon is the lifeblood of rhetorical discourse. But do we ever consider its effect on those people who use services and programs?

]]> Take the term "chronic disease management," for example, for a little deconstructing. I think I know what this means from my perch as a policy wonk. On the surface, it has to do with presenting a model of care that involves teamwork among professionals in a clinical or community setting to help service users cope with a health issue. Ideally, it would help stabilize or improve their quality of life. Sounds great, right?

But to most people, "chronic disease management" sounds as unpalatable as that cough mixture that boasts in commercials about how awful it tastes. "Chronic" connotes "a problem you'll have until you die." "Disease" means "you're ill and will always be." "Management" states in no uncertain terms that "someone else is going to do it for you; please lie back and enjoy the show." Do these three words reflect the values and ethical expectations of our health care system?

Personally, I think these words are empowering only to cloak the medical model when it comes to asserting for a share of health care dollars. "Chronic disease management" may unwittingly entrench the power of spending money on illness. Omitted by implication are the values of promoting wellness and self-care. There appears to be little room for a dialogue that considers whether pre-empting the conditions to which the individual's health is susceptible (e.g., the social determinants of health -- good food, proper housing, social supports) is a direct causal factor in turning on the switch on the disease and setting off the need to partake of chronic disease management. Most importantly, in such a setting, one feels very much alone in combating the health problem without the overt presence of peers to confide in or with whom to share firsthand experiences and insights about making healthier choices.

In the case of mental illness and addiction, the concept of chronic disease management is particularly complex. Coming as I do from a consumer/survivor perspective, I bridle at the idea that individuals with a mental health diagnosis have a chronic disease that needs to be managed.

Certainly, as part of a recovery-based focus on living with mental health or addiction problems, it is necessary to take care of one's physical health. Diabetes, obesity and other issues that reduce life expectancy are an unfortunate reality for people with mental illness and addiction. Proactive monitoring and proper care are indisputably good strategies to help people work towards their life goals.

However, as someone who has seen recovery in action from all walks of life, as someone who has seen it take many forms, across different time spans, with different languages, cultures and racialized populations, I like to think that I am more open-minded than most about the ebb and flow of the mental health diagnosis in each individual. Focusing on the chronic disease model of care and committing to funding the "sick" without an exit strategy, and more importantly, not asking individuals what they want, may not be the optimal way to go.

When it comes to mental health, taking preventative measures to reduce symptoms, time in emergency rooms and hospitalizations is a sound and practical approach to maintaining wellness. WRAP (Wellness Recovery Action Plan), Pathways to Recovery and PACE (Personal Assistance in Community Existence) are programs being taught to individual consumer/survivors.

But it is within the dynamics of a group or a one-to-one relationship that personal self-initiative, teamwork and cost-effectiveness come together as a proven best practice -- that of peer support.

Peer support has the rich potential to complement and be integrated into the chronic disease model. The idea of the sole courageous mental health consumer working in isolation outside of formal care to overcome a label through self-discovery is an earnest vision that is best aligned with group activities that build on collective strengths -- experiential knowledge, problem solving and non-judgmental feedback in a safe and confidential environment, where hugs are valued over OHIP cards (Ontario's government-run health plan).

The Ontario Peer Development Initiative, a provincial umbrella of more than 60 consumer/survivor initiatives, peer support groups, patient councils and alternative businesses, has been funded by the Ontario Trillium Foundation to create the Peer Support Core Essentials Training program -- created by peers, for peers. This project has distilled the very best wisdom of almost two decades into a manual that will create certified trainers. The same potential lies untapped for people with substance use issues as well.

Now, more than ever, is the right time for practitioners of the chronic disease model to work with practitioners of the recovery and peer support model. As someone with lived experience, away from my desk and computer keyboard, I only wish for the best sustained quality of life. It can best come from a mutual collaboration and respect for both models.

"Be well" is a wise greeting that a colleague of mine appends to her e-mails as a salutation. I hope that one day the mental health and addictions system integrates this message into its way of doing business.

Raymond Cheng is an advocacy and policy co-ordinator at the Ontario Peer Development Initiative.

Editorials do not necessarily reflect the views of CAMH.

Reaching beyond gendered responses to address male victimization

2010-06-08T18:10:25Z

By Ramona Alaggia

Abuse and violence have long been constructed along gender lines, with the dominant framework emphasizing male perpetrators and female victims. Although most sexual crimes are committed by men, this should not discount the reality that males, especially in childhood, are as vulnerable to sexual victimization as females. Reported rates of child sexual abuse have long been regarded as the "tip of the iceberg," with Canadian rates of female victimization estimated at about one in four for girls before age 18 and about one in six for boys. However, recent studies suggest that prevalence rates of sexual abuse of boys have been significantly underestimated and may be closer to those of girls.

]]> Disclosure for all children is difficult, but it might be more complicated for boys because of societal attitudes that boys are expected not to be in positions of weakness and because boys are most often sexually abused by men. Research shows that disclosing same-sex abuse is threatening for most males.

From a feminist perspective, women and children historically have been vulnerable to sexual exploitation and violence because of their disempowered position in society and their relational and economic dependence on men. Males in childhood are treated in the same devalued position as women and female children. While trends are slowly shifting in gender relations, we still see generations of men exhibiting serious effects of childhood victimization that include depression, aggression, low self-esteem, addiction, anxiety and sexual dysfunction that persist into adulthood. Unfortunately, these problems manifest in ways that often result in men ending up in the criminal justice system, often for violent crimes.

Male victimization in cases of childhood sexual abuse raises important questions of gender symmetry, as there might possibly be as many boy victims as girl victims. However, significant gender differences still clearly exist when examining perpetrators, since studies consistently show that there are many more male than female perpetrators of child sexual abuse.

Domestic violence is another area of controversy where male victimization is being debated in terms of gender symmetry. Gender symmetry centres on notions that males and females are equally victims of childhood sexual abuse and intimate partner violence, and that there are as many female as male perpetrators of all forms of abuse. While clinical research indicates that women are most often the victims of intimate partner violence, population studies now claim that men are just as often victims, especially in younger couples. These results are somewhat skewed, as they are derived from sociological studies that rely on college and university samples in which developmental and alcohol factors may account for mutual couple violence. When shelter and child welfare clients are investigated, the overwhelming numbers of victims are women.

The consequences of violence are also more profound and enduring for female victims on emotional and financial dimensions, and especially in regards to safety. Homicide victims of intimate partner violence in North America are predominantly women and children. Canadian census data also indicate that women are significantly more likely than men to suffer serious injuries with life-long repercussions as a result of domestic assaults. Abused women who are forced to flee relationships are more frequently left in financial ruin and alienated from their cultural communities and extended families. The consequences of domestic violence are more serious and far-reaching for women in all areas of functioning.

Gender symmetry and its relationship to intimate partner violence is a murkier issue. Many researchers and clinicians are sceptical of how women's use of violence is measured because self-defence by women and the use of violence in retaliation for long-term abuses are counted. Critics argue that these acts are qualitatively different and should not be lumped in the same category of men's violence perpetrated for control and subordination. It is further asserted that if shelters for men did exist, they would be grossly underused because significantly fewer men are abused and fear for their lives, and men have more access to financial resources to leave relationships in ways other than turning to shelters.

Male victimization has entered the arena of identity politics to claim their status as a marginalized group who are not readily identified or accepted as victims of sexual and relational violence. With this emergence come agendas for the creation of and access to resources. Men's advocacy groups claim that if services such as shelters existed for abused men, they would be filled. Men who were sexually abused as boys assert that when men disclose, there are almost no survivor services for therapy to recover from their victimization. Male survivor groups have formed in the United States and have been successful in creating service networks and raising awareness of the prevalence of male child sexual abuse; for example, they have exposed the extent of sexual abuse by clergy, which has forced the Roman Catholic Church to start to acknowledge these historic violations and to take action to prevent further abuses.

In the final analysis, what should not be lost to these debates is that regardless of gender, violence has serious effects. No one should be assumed to be free from risk. These issues should be explored with anyone seeking psychosocial counselling and need to be addressed through compassionate dialogue and effective treatments.

Ramona Alaggia holds the Chair in Children's Mental Health at the Factor-Inwentash Faculty of Social Work at the University of Toronto.

Editorials do not necessarily reflect the views of CAMH.

Psychiatrists fighting stigma: Doing more harm than good?

2010-03-03T21:28:18Z

By Jan Wallcraft

Madness has been stigmatized for centuries. The madhouses and asylums of yore simply removed the "mad" from society, often permanently. Nathaniel Lee, a 17th-century English playwright who spent five years in the notorious Bedlam asylum, said: "They called me mad, and I called them mad, and damn them, they outvoted me."

]]> Lee was one of the few whose voice was heard. For most, their exclusion was complete. The French philosopher Michel Foucault described the emergence of psychiatry at the end of the 18th century, silencing the voices of the mad and ending dialogue between "reason" and "madness," and establishing the language of psychiatry as a "monologue of reason about madness."

The tide turned, and asylums began to close in the mid-20th century. But stigma and social exclusion remained. Sociologist Irving Goffman wrote his seminal work on stigma, based on research with asylum inmates. Since then, many studies have shown that the public and even mental health professionals hold stigmatizing attitudes towards people with mental illness. These studies have led to calls to eliminate stigma.

Answering the call recently have been psychiatric organizations that have launched high-profile anti-stigma campaigns. Their logic is that if mental illnesses are seen as "brain diseases," for which people with mental illness cannot be blamed, stigma will reduce. But the stigma remains. People deemed mentally ill are still disadvantaged in employment and health care, and die younger. Schizophrenia is the most stigmatized, due to fears of violence, but depression, anorexia nervous and suicidal behaviour are also targets - as is addiction.

Psychiatrists claim that diagnoses are scientific descriptions of diseases, necessary to ensure correct treatment. Many professionals, including some psychiatrists, disagree, arguing that diagnoses are concepts, not diseases, which have acquired spurious solidity. In physical medicine, a disease is identified by physical signs as well as reported symptoms. In psychiatry, there are no physical signs, and the patient's own view is marginalized. Psychiatric diagnoses are simply labels for types of behaviour, adding nothing to the understanding of experience, cause or cure.

Psychiatric diagnosis may in fact itself be to blame for the stigma of mental illness. Sociologists developed labeling theory, stating that negative cultural definitions of mental illness affect treatment outcomes. In their 1991 book From Mental Patient to Person, Peter Barham and Robert Hayward quote one person with mental illness, illustrating the negative effect of labeling: "You wake up every morning and you think, 'Oh God, I'm a schizophrenic!' If the doctor hadn't told me, I'd just have woken up and thought, 'Well, I'm just going through some sort of illness and I'll probably get over it.' But once you get diagnosed you start thinking all sorts from different corners about the illness and it just gets worse and worse."

Negative assumptions are found inside hospitals too. One woman, Kate, shares her experience on the web site of Time to Change, a UK-wide initiative to fight the stigma of mental illness: "My main experience of Mental Health discrimination was actually within the mental health system itself! Nurses and psychiatrists assumed anything I said was not real (because I was mad), expected everyone to conform to the established routine ... and expected to solve people's problems by giving them drugs and labelling them as insane... I have always upheld that if you put ANY human being through enough stress, contradictions and devaluing, they will develop 'symptoms.'"

In a recent article in the New York Times Magazine adapted from his new book Crazy Like Us: The Globalization of the American Psyche, Ethan Watters suggests that "we treat people more harshly when their problem is described in disease terms" and that "a brain made ill through biomedical or genetic abnormalities is more thoroughly broken and permanently abnormal than one made ill though life events."

The Royal College of Psychiatrists in the United Kingdom ran the Changing Minds campaign from 1998 to 2003, aimed to reduce stigma by increasing awareness about mental illness and offering modern understandings of anxiety, depression, anorexia, schizophrenia and personality disorders. But critics saw the campaign as an attempt to increase public take-up of psychiatry, saying the College had ignored evidence that labeling itself causes damage. Similarly, in the United States, psychiatrists have been criticized for campaigning to convince the public that millions more people, even babies and children, are in need of psychiatric help. Removing the stigma of mental illness, they argue, will simply help psychiatrists and drug companies to widen their empire.

Recently, the World Psychiatric Association began to campaign against the stigmatization of psychiatry and psychiatrists. Dr. Norman Sartorius has admitted that diagnoses are problematic, calling for more care in the use of labeling. He argues that diagnoses can be misunderstood by non-medical professionals and especially by the public, where they feed into negative stereotypes.

However, if we take the psychosocial medicine route, currently eclipsed by biomedicine, we move away from categorical diagnoses and start to see each person's unique problems, life history and needs and wishes, and can build solutions around these. People can regain the capacity to help themselves and one another. Those in the best position to re-educate the public and the professionals are the patients and former patients themselves.

Dr. Jan Wallcraft is a Visiting Fellow at the Universities of Hertfordshire and Birmingham in the United Kingdom.

Editorials do not necessarily reflect the views of CAMH.

Does treatment for Internet addiction miss the mark?

2010-01-05T18:01:58Z

By Hilarie Cash and Cosette Dawna Rae

According to the National Institute on Drug Addiction, the most effective way to treat addiction is to treat comorbid psychological problems concurrently. This is certainly the case at reStart: Internet Addiction Recovery Program in Washington. Some argue that programs designed for Internet addiction are too narrowly focused and that pathological use of computers is only a symptom of other problems. We argue that Internet addiction may reflect other issues, but that is a legitimate, specific disorder in itself that requires targeted treatment.

]]> It is not uncommon for people with a technology-related behavioral addiction to report depression and anxiety, but it is not always clear whether these co-morbid conditions are the cause or the result of an impulse control disorder. Other co-morbid conditions that we commonly find as we work with people on an in-patient or out-patient basis are Asperger's syndrome, social anxiety disorder, attention deficit disorder and attention-deficit/hyperactivity disorder.

The first phase of treatment involves an in-depth assessment and evaluation. By taking a thorough individual and family history we can begin to formulate ideas about co-morbid conditions. Our clinical experience has been that after several weeks away from video games and the Internet, our clients generally begin to improve. Depression and anxiety begin to lift.

Many of our clients come to us after having seen other mental health professionals who did not deal directly with the addiction, choosing, instead, to see the addiction as a manifestation of other problems that needed to be addressed first. We also hear from clients and their caregivers that many therapists have dismissed the possibility of a behavioural addiction, and in some cases, have actually encouraged individuals with excessive use patterns to continue their problematic behaviour. This failure to treat the process (behavioural) addiction directly, as one would deal with a chemical addiction, is, in our opinion, reminiscent of the early days of chemical dependency treatment when co-morbid conditions went untreated until someone was "clean and sober." Perhaps it is because so many professionals in the mental health field are not trained to recognize, assess or treat technology-related behavioural addictions that this situation persists, despite growing evidence that Internet addiction disorder (IAD) is a new and fast-growing disorder.

The following case study illustrates our approach.

Bill (not his real name) was a 17-year-old client whose family had been living on the East Coast. He appeared to have been a well-rounded kid who played the cello, participated in sports, socialized with friends and did well in school. Bill's world turned upside-down when his father left the family and maintained little contact with his children. Bill's mother moved with her children to a new state to be closer to relatives. It was at this point that Bill began playing video games. The games were clearly an escape from the pain of losing his father, friends and all that was stable and familiar to him. His mother tried, ineffectively, to control his excessive gaming. Prior counselling proved ineffective as Bill's video game use, depression and anxiety intensified. When his mother sought our help, Bill, who was about to turn 18, was flunking out of high school and refused to participate in any meaningful family activities, including meals and chores. He was unwilling to communicate with his mother. The only time he left the house was to visit friends with whom he could game.

Bill only agreed to come to reStart after a family intervention, where he was given the choice to either come to reStart or leave the house. He decided to join our program. His assessment identified him as depressed and anxious. The treatment plan we developed for him involved, among other things, teaching him about the nature of addiction and preparing him to re-enter a life that would involve moderate use of computers, helping him understand and express his feelings about what had happened with his parents and helping him develop real-world social skills and constructive skills for managing his emotions.

Over the course of the program, Bill made progress in all areas. When he left, he was much more socially confident and engaged, he was not depressed, and he had a relapse-prevention plan in place. He reported that the mindfulness training he had received had been the single most useful tool he had acquired.

It seems that the underlying problem is not whether Internet addiction treatment centres are too narrowly focused, but whether individual providers are skilled in assessing, evaluating and treating technology-related behavioural addictions along with other co-morbid conditions.

Hilarie Cash, Ph.D, and Cosette Dawna Rae, MSW, LSWAIC, are co-founders of reSTART: Internet Addiction Recovery Program in Washington.

Editorials do not necessarily reflect the views of CAMH.

Do you think programs designed for Internet addiction are too narrowly focused? Is pathological use of computers only a symptom of other problems, such as depression and social anxiety disorder?

Share your thoughts below.

Poor access to disability supports perpetuates cycle of poverty

2009-10-16T13:05:43Z

By Ruth-Anne Craig

In the summer 2009 issue of CrossCurrents, Dr. Richard Warner argues that disability benefits create disincentives to employment. He makes some valid points about his study comparing disability earnings and employment income in the United States. He also makes good points about the importance of high-quality vocational rehabilitation programs for people with mental illness whose goals are employment-related. However, his argument oversimplifies the complex problems associated with mental health and employment.

]]> While it is true that disability policy requires restructuring as a whole, the situation in Canada is extremely tenuous for people with a mental illness disability. The problem lies mainly in access to disability initiatives, which ultimately creates dependence on provincial assistance programs. Provincial welfare has commonly been referred to as the program of last resort, and was originally conceived as a temporary income replacement. Approximately 70 per cent of unemployed individuals with a psychiatric disability subsist on social assistance payments and live in poverty. According to the National Council on Welfare, in the 10 provinces, the yearly income of an individual with a disability can be as low as $7,851. All welfare incomes in the provinces were below two-thirds of the low income cut-off line. The poverty gap for individuals with a disability was larger than the amount of income they received in each of the provinces. This cycle of poverty, combined with the overwhelming stigma attached to mental illness and lack of accommodation in the workplace, creates the biggest barriers for people with mental illness and reduces opportunities for quality employment.

Yet research indicates that most people with a psychiatric disability want to work, and since mental illness affects people from all occupations, why is it that so many highly qualified individuals never realize their former earning potential in the competitive labour market after being diagnosed with mental health problems? The answer lies in our nation's deficit approach to mental health and mental illness and our lack of a comprehensive recovery and strengths-based mental health initiative that considers the complex and unique needs of people with mental illness. Our income support programs are not designed for this disability population.

In Canada, there are three federal income security programs connected to disability - the Canada Pension Plan Disability (CPP-D), Employment Insurance (EI) and the Disability Tax Credit (DTC). All these programs are contributory, which means that individuals who have been employed for a specific period of time have contributed or are eligible for credit when filing their income tax returns. Only those who have had steady employment are eligible for Canada Pension Plan disability benefits or Employment Insurance sickness benefits. This poses a problem for people with mental illness, who often have sporadic or cyclical patterns of employment. Mental illnesses like schizophrenia or mood disorders often arise in late adolescence or early adulthood, interrupting education, with lifelong effects on occupational success. More than 50 per cent of CPP applications are denied benefits because of insufficient earnings.

Applying for EI poses the same dilemma. There are no safeguards to help those who have entered the labour market to maintain their attachment to work when periods of unemployment occur due to problematic mental health symptoms. But initiatives could be developed to alleviate the problems with EI and EI eligibility. The duration of EI sickness benefits could be extended. The current 15 weeks do not always allow sufficient time and opportunity for rehabilitation. Like CPP-D, the qualifying period for EI eligibility needs to be modified. Returning EI to its pre-1996 status by readopting a 360-hour qualifying period for benefit eligibility will assist many people whose disabilities are cyclical in nature, as well as those for whom part-time work is the only alternative because of mental health symptoms and medication side-effects.

Accessing disability income support programs has become a major problem for people with mental illness because the eligibility criteria and definition of disability are not framed within a recovery perspective. This means that a person must be permanently unemployable and unable to pursue any employment to qualify. But many people with mental illness have the potential to work. Because of this, medical professionals are often reluctant to fill out forms for CPP-D or the Disability Tax Credit Assessment form. Unable to access these programs, people with mental illness are forced to apply for provincial assistance programs. Once in this system, it is extremely difficult to escape the cycle of poverty and demoralization offered by this meager subsistence.

Many more people with mental illness could be employed given appropriate workplace accommodation. The federal government has acknowledged its responsibility for a national mental health strategy by creating the Mental Health Commission of Canada. This strategy should include a substantial fund to work with provinces and territories to expand supported education and training programs, supported employment programs that help people achieve success in the competitive labour market, and training and resources for employers to implement workplace accommodations. These supports would greatly enhance the opportunity for people experiencing mental illness who have steady employment, as well as those who wish to enter the labour market. Stigma associated with mental illness, one of the biggest barriers to employment, can be addressed through workplace health education regarding the extent and impact of mental illness and workplace stress.

Meaningful work is important to people with mental health issues. Being employed has implications that reach much further than economic security. Employment is a determinant of health, opening the door of recovery for many people struggling with mental illness. We must do whatever we can to keep the door unlocked, so that more people have the opportunity to pass through it.

Ruth-Anne Craig is executive director of the Canadian Mental Health Association, Manitoba Division.

Editorials do not necessarily reflect the views of CAMH.

Should inpatient psychiatric wards be gender segregated?

2009-07-22T14:21:17Z

by Kathy Hegadoren

Historical references conjure up negative images of crowded insane asylums, where men and women segregated by gender were housed for years or decades. Then came the enlightened age of social psychiatry, where social determinants of mental health came to the forefront, prompting re-examination of gender-based segregation of inpatients. If men and women were going to rejoin the "outside world" in a socially acceptance manner, the institutional environment needed to become more "normalized." This ushered in the movement to establish mixed-gender inpatient units. ]]> Fast forward to the age of deinstitutionalization, where the average lengths of stay began to precipitously fall and where community services were deemed more humane, naturalistic and therapeutic. Large mental health hospitals began to close and inpatient treatment was mostly provided within large urban tertiary care hospitals. Where the average length of stay was four to six weeks, therapy groups could focus on interpersonal skill development and social learning in formal and informal ways. There was an inherent belief that developing communication and self-reflection skills was enhanced or at least made more socially appropriate by a more naturalistic framework of mixed male/female groups.

But the average length of stay continued to fall. Hospital closures, increased recognition of mental health emergencies, the emergence of "crisis beds," day programs and partial hospitalization programs and the development of specialized programs all contributed to shorter lengths of stay. (Currently the average length of stay in many general psychiatry inpatient units is five to seven days.) Group therapy was no longer about systematically developing relational skills because there was not enough time. More and more inpatient stays focused on assessing acute symptoms, modifying drug regimens and providing more individualized therapy targeted at the immediate crisis or circumstance.

Another theme has emerged over the past decade. Recognition has grown that many female inpatients have histories of interpersonal violence. Although psychiatry was slow to respond, it is not surprising that female inpatient units are overrepresented by women with such experiences. It is well recognized that trauma can result in pervasive, long-term impacts on mental health that do not fit neatly into a single DSM-IV category. Relational problems, emotion regulation issues and a fundamental mistrust of others are common. Indeed, women with histories of childhood interpersonal violence often reflect the most complex clinical presentations: They are not stable longitudinally; they respond poorly to drug therapies; they are heavy users of mental health services with limited success and they require long-term multi-modal, highly specialized treatments. Extended time in specific outpatient trauma programs interspersed with short inpatient stays for crisis intervention is typical.

Short average lengths of stay and increased recognition of the relational problems that can arise from histories of trauma have led some to argue for gender-segregated inpatient units. They posit that women will feel safer and will not be triggered as much, especially by men who may have aggressive outbursts or inappropriate social behaviors. Female-only units would provide a therapeutic environment where women could progress on their journey towards wellness.

But before we set out on this course, we need to carefully examine the evidence that this change in policy would actually achieve better care for female inpatients. Some data suggest that men and women do better with different types of psychotherapy, which supports the notion of gender-specific group therapies. Research about adult sequelae of child abuse does suggest that men and women interpret and react to these experiences differently and thus likely need different therapeutic targets. There is growing belief that treatment programs, especially the psychotherapy-based components, may need to consider gender as a determinant of content. In the past, many trauma-related resources had a female bias, almost by default. In terms of childhood interpersonal violence, men are often reluctant to disclose such experiences. More needs to be done to address gender differences in therapies targeted at the profound consequences that can result from interpersonal violence. However, that does not necessarily translate to segregated inpatient units.

Indeed, many questions remain. Will these female-only units be just for women who have experienced violence? Although trauma is overrepresented in the psychiatric population, not all inpatients have experienced it. Will women without trauma feel as comfortable if the main therapeutic focus is trauma? Antepartum and postpartum inpatient units are gender-specific services for women, but are they truly gender-sensitive? I would say they are not.

Moreover, is it true that an all-female unit would be more therapeutic or safer from triggers that evoke powerful emotional and physical reactions? Could not the behaviour of other female inpatients also serve as triggers? Would all staff have to be female? For women with histories of violence, the core issues are often around control, trust and interpersonal relationships. These issues can lead to misinterpretation, ambivalence and conflict from any interaction, regardless of gender. Past family dynamics may have involved conflicts with mothers, such that an all-female staff will not ensure feelings of safety, validation and trustworthiness. Moreover, agency policies, processes regarding admission and discharge, rules of who can be admitted and how long patients can stay may not be totally responsive to the needs of women with trauma.

The historical reasons for desegregation made therapeutic sense at the time and prompted profound improvements in inpatient psychiatric care. More recent developments in psychiatric service delivery have raised questions about the current validity of those reasons. Before we embark on a path to resegregate, we need to be sure we are fully aware and prepared to deal with all the implications.

Kathy Hegadoren is a professor in the Faculty of Nursing at the University of Alberta and a Canada Research Chair in Stress Disorders in Women.

Editorials do not necessarily reflect the views of CAMH.

Message in a bottle: Wet shelters embody true harm reduction approach

2009-03-25T15:55:29Z

by Tomislav Svoboda

In the winter of 1996, Eugene Upper, Kompani Mirsalah-Aldin and Irwin Hardy froze to death on three separate nights in the streets of Toronto. A coalition of poverty and housing activists led by street nurse Cathy Crowe and human rights lawyer Peter Rosenthal advocated for an inquest. A coroner's inquest determined that in addition to homelessness, uncontrolled heavy alcohol use and severe mental illness were implicated in the deaths. The jury recommended that a 24-hour in-shelter harm reduction program including in-shelter provision of alcohol be implemented in the shelter system. A 12-hour municipally run shelter was designated as the program site. Front-line staff led by Arthur Manuel developed the Annex Harm Reduction Program within this shelter, which included an in-shelter drinking program despite senior administration statements that such a program was neither necessary nor feasible.

]]> The program aimed to provide shelter for homeless men who avoided shelters or who were repeatedly barred from other shelters due to difficult behaviours related to alcohol use, severe mental illness and other factors. From the front-line perspective, these were individuals who were not being helped by numerous hospitalizations, incarcerations, court appearances and police pickups. Annex staff adopted a harm reduction approach in the strict sense, supporting clients in their use of alcohol in a variety of ways, including serving alcohol as part of a managed alcohol program and storing alcohol for clients, building staff-client relationships and accepting difficult behaviours in a supportive shelter environment.

Two shelter-based programs in Canada have now adopted the Annex model. These managed alcohol programs in Ottawa and Hamilton, Ontario, serve alcohol up to 11 hourly drinks a day as an alternative to drinking beverage and non-beverage alcohol on the street. The drinking programs are part of more comprehensive programs that include multidisciplinary health care, social work, shelter, meals and other supports.

Despite being embraced by front-line advocates as providing ongoing benefits to clients, shelter-managed alcohol programs continue to be highly controversial and are subject to ongoing criticism by community leaders and commentators. During a recent Toronto City Council budget review, Annex staff were questioned about providing alcohol and cigarettes to clients. In 2004, city council had requested that staff report back on harm reduction alternatives to providing alcohol to shelter clients.

Although numerous studies have evaluated harm reduction as an approach to assist homeless opiate-dependent individuals, there has been little discussion in the medical or addiction literature about this approach for those pejoratively called "skid row alcoholics." The plight of the homeless sub-population these programs serve, although well known, is not well described in the scientific literature, making this population more vulnerable to misconceptions in public and professional debates. Front-line service providers recognize them as "frequent flyers"; they have been called "million-dollar men," reflecting their intense use of emergency rooms, ambulances, prisons and other services that do not address their underlying problems.

Various interrelated moral and empirical imperatives motivate the shelter-based managed-alcohol programs, including removing class-based application of law; not denying services because of alcohol use; reducing harms by removing clients from dangerous environments and providing services otherwise not available; and applying interventions appropriate to the stages of change. In our society, if you are poor and without a home it is illegal to drink; but if you have financial means and a home you can drink as much as you want. Without shelter-based managed-alcohol programs, a poor person without a home is subjected to a state of prohibition; drinking is forbidden in parks, shelters or hospitals. A person will be denied access to emergency shelter, hospital care and other social services if he or she wishes to drink while using these services.

Good data suggest that applying action- or maintenance-oriented approaches to those who are in pre-contemplation will fail; yet these misapplied approaches underlie policies that link shelter, hospital and financial assistance care to successful abstinence. The managed-alcohol shelter programs have been described as "safe drinking sites," leveraging empirical understanding from the heavily studied "safe injection sites" that are increasingly show-ing benefit over abstinence-based approaches.

With the expectation that the first three imperatives and argument by analogy would not be sufficient to dissuade unfair bias against these programs, studies were conducted to determine whether managed-alcohol programs provide greater benefit than the usual abstinence-based care. A preliminary study conducted by Joyce Burnstein at Toronto Public Health suggested that deaths among clients who stayed at Seaton House, Toronto's largest shelter for men where the Annex program resides, dropped after starting the program. Three peer-reviewed studies have shown benefits from managed-alcohol-type programs: Thornquist and colleagues in Academic Emergency Medicine in 2002; Podymow and colleagues in the Canadian Medical Association Journal in 2006; and a 2006 University of Toronto PhD dissertation on the Annex program all found large drops in emergency room visits, detox unit visits and police interactions and incarcerations and increased time spent in shelter out of harm's way for those enrolled in managed-alcohol programs.

Many questions remain unanswered, and managed drinking programs continue to be controversial. For now, in the minds of many front-line care providers and hardened alcohol-dependent individuals, these programs are a better alternative to a life filled with mouthwash, rubbing alcohol, street assaults and blackouts, ambulance pickups and incarcerations.

Dr. Tomislav Svoboda helped to develop the Annex program. He is a community medicine specialist and clinical director at Seaton House and an associate scientist at the Centre for Research on Inner City Health at St. Michael's Hospital in Toronto.

Editorials do not necessarily reflect the views of CAMH.