NAHO CONFERENCE 2009

OTTAWA, ON

A Pilot Project for Mental

Health Service Treatment

Provision for Residential

School Survivors

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

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

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

Canada's Indigenous population is a vulnerable group in the

health care system, with specific mental health and healing

needs that are not widely being met.

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

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

To address some of these

inequities in health and

health care, some Indigenous

health organizations have

recently developed services

to mental health that include

traditional cultural approaches

to healing.

However, Indigenous health and

healing information and practices are

practically non-existent through the

mainstream health care system, which

is dominated by Western approaches.

An Indigenous paradigm of health has been

successfully employed by Indigenous peoples for

thousands of year prior to the arrival of Europeans

and colonialism.

This study seeks to create new and different

methods of treating First Nations people linking

traditional Indigenous healing practices and

western practices using a community mental

health care delivery system as well as

teleconferencing

It should be noted that teleconferencing is an

antiquated term . In reality we mean

videoconferencing (Internet Protocol IP)

The focus of this research is to investigate the successes and

challenges by this new delivery system, which offers both

Indigenous and Western forms of healing to clients in mental

health service agencies, and to get descriptive information from

their clients about success of such an approach.

The KO Indian Residential School

Survivors Program - IRSSP • The mental health treatment services delivery model for a pilot

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

• This pilot project combines the resources of

Multiple First Nation partners and communities.

Unfortunately, the Legacy of Residential Schools

And Intergenerational trauma has had a large

Effects in NorthWestern Ontario among other

Places in Canada.

IRSSP

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

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

KO COMMUNITY MAP

IRSSP

• The overall purpose of the KO Indian

Residential School Survivors Program (IRSSP) is

to:

– 1. Provide appropriate and sufficient community-based

therapy.

– 2. Support services to promote healing from IRS trauma for

survivors and families within their home community.

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

IRSSP

• Unfortunately, we have learned the hard way that conventional models of mental health treatment services delivery for survivors of Residential Schools from remote northern Ontario First Nations have generally resulted in client recidivism.

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

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

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

Existing Service Delivery Challenges KO Model to Address Challenges

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

personal/spiritual

-Less therapy-related travel with more community-

based services mean more effective use of resources

and greater access to services by more IRS survivors.

-Gaps in existing community based support 24/7 - KO Project provides connection and continuity

with client, treatment plan and therapist or

traditional healer.

-Existing „fee-for-service‟ (FFS) model is too similar

to Residential Schools. Very challenging for clients

from remote settings, who need to be very self-

motivated and in an urban or road access

community for realistic chances of success.

- IRSS clients best served & have the greatest chance

of success in treatment when both therapy & after-

care activities are based in the client‟s home

community, where the natural, most culturally-

appropriate and most effective client supports exist.

Family, survivor peers and community context are

required for client success

- Non-conformity with accepted characteristics of

successful treatment for IRS Survivors (family-

based, trans-generational)

-Therapy models / treatment planning will conform

to unique specialized requirements for successful

IRSS tx

Comparison of Existing Model with proposed KO IRSSP

Community-Based Model Continued

Existing Service Delivery Challenges

Continued

KO Model to Address Challenges

Continued

-Existing Local Mental Health Workers often lack

clinical experience, have little or no training,

provide little if any case management, maintain a

high caseload, respond primarily to crisis

needs/situations, do not maintain regular

schedule of client consults, and suffer from lack

of staff support.

- Local IRSSP Coordinators will be trained to a

minimum standard in basic counselling

(NODIN) and TGTM, will be supported to

complete required case management functions,

and will work with and provide support for

Survivors and families on long-term and inter-

generational effects of residential school trauma

Comparison of Existing Model with proposed KO IRSSP

Community-Based Model Continued

-Failures in past with IRS Survivors are due to

lack of aftercare/follow-through on Plans

(resulting in high system and community/family

costs due to recidivism)

-KO IRSSP Local Coordinators will

coordinate/facilitate after-care and follow-up at

the community level to ensure access to and

utilization of local supports. Specialized social

supports available only in home community.

-Existing FFS model is appropriate for more

immediate acute social needs and not residential

school trauma

-KO IRSSP model specialized to address long-

term individual, collective and intergenerational

aspects of trauma and treatment planning

- NODIN stressed – responding to acute

needs/crisis

- immediate acute needs met locally or

w/NODIN

- IRS trauma was collective. Treatment must have

collective component.

-KO IRSSP develops integrated treatment plans

which may indicate unique and innovative

approaches to utilize local supports / family /

Committees

Existing Service Delivery Challenges

Continued

KO Model to Address Challenges

Continued

IRSSP

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

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

IRSSP

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

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

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

IRSSP

• The mental health Single Agreement for Service Model will provide the general template for collaborative treatment.

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

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

IRSSP

• IRSSP therapy and traditional healing services may be accessed by IRS survivors and their families in a number of ways:

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

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

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

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

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

IRSSP• The necessary information for “prior approval” in the

application includes:

• a) a letter from the Chief/Council recognizing the person as a Traditional Healer/Elder, and that they welcome the Elder to the community on such and such a date;

• b) name and address of the Elder/Healer;

• c) confirmation from the Elder/Healer that there is an appointment with former IRS student(s) - dates and times scheduled or that the person is attending a healing event;

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

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

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

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

IRSSP Treatment Process.

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

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

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

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

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

• These practises are articulated in the following KOTM documents:

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

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

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

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

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

• Protecting Your Personal Health Information – KOTM client information brochure

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

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

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

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

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

IRSSP Implementation Workplan

July 2009 – March 2010

• Summary Objectives/Activities to be completed:– Program Design

– Establish local IRS Support Communities

– Community Consultations

– Hiring – the appropriate coordinators

– Confirming Traditional Healers

– Training – include case management, confidentiality, basic counselling, crisis intervention

– Program Promotion

– Service Delivery

– Program Planning – Year 2

– Program Evaluation/Assessment

Current KO Mental Health Clients

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

• 39 of which are direct IRS survivors

• 18 are inter-generational victims, and the remaining

• 21 (primarily children) present other MH issues.

• Once in operation, the IRSSP will increase # on list

Community Front Line Workers

Questions

• Meegwetch, Thank you

• Acknowledgments to Krystal Kohar.