CAMH has been in the news lately, getting a lot of attention on the subject of staff safety. Nobody wants violence of any kind happening here. But an interesting feature of “violence” is that those with social power tend to define it. For instance, why aren’t conditions of extreme poverty, causing hunger and homelessness discussed as “violence”? Unions, quite correctly, speak out on behalf of their members’ well-being. CAMH, as an organization, addresses safety through policy and creating an environment for practice. But what is violence in the experience of clients of CAMH? The issue of violence at CAMH from a client perspective is about an inclusive understanding of everyone’s right to be done no harm, which includes respect for people’s rights and liberties.
When interviewing clients about their experience of abuse in psychiatric institutions, I found that to some clients, procedures that are legal in the mental health system can feel like abuse, especially if coerced or if consent was given without adequate information about risks having been provided. To a few clients, rights violations and even criminal abuse seem acceptable because they believe it is what they deserve – sometimes because they felt it benefited them, sometimes because they had always been told that punishment is no more than they deserve.
There is violence that can happen anywhere when someone lashes out, in any work place or residence, and CAMH is both. What this issue of harm occurring at CAMH does NOT mean is that people with mental health issues are any more prone to violence than anyone else (with rare exceptions). However, one must consider that any group of people jammed into a limited space with a bunch of strangers, often with little access to fresh air or exercise, already having a bad time, and often against their will, are going to get very stressed. It’s a natural response, and being in a hospital does not suspend a person’s basic human needs.
The best way to address clients’ struggle with their needs not being met is to meet them. Research indicates, in fact, that meeting clients’ self-identified needs leads to better outcomes than meeting service providers’ ideas of client needs.
The Empowerment Council has been advocating for more programming that meets client-identified needs.
Counselling for abuse and other trauma is a crying need, and even more urgent in an environment where so many factors can trigger trauma in survivors, and most mental health and addiction clients are trauma survivors. There are capacity challenges in the mental health system, which is sometimes a problem of what gets funded and what does not, as well as being a problem of just not enough funding.
Funding systems in Ontario provide almost no therapy for people who can’t afford to spend over $100 an hour outside the hospital, and inside the hospital there is very limited availability of therapy that addresses abuse and other trauma. Thanks to some of us who have been persistent voices on the topic, there is an effort to have trauma informed care at CAMH. TIC is not the provision of services to address trauma, it is about being sensitive to manifestations of trauma and avoiding triggering people who are survivors (which is most of the clients of the system). This is helpful to avoid further traumatization. But therapy specifically to address abuse and trauma is what many clients also need – in CAMH and in the community.
The EC has been working productively with CAMH Education for several years on a curriculum for staff that is about creating a safe, respectful, trauma-informed environment. The first Prevention and Management of Aggressive Behaviour training curriculum for staff was about how to respond to incidents to de-escalate them, and how to learn from clients how to help when a person has a crisis. The latest curriculum, just being piloted, is about how to create an environment that avoids crises and violence from developing at all. In addition to being informed by trauma, the focus of PMAB-Revised is on clients rights and empowerment, recovery principles and is more client centred and family sensitive. It includes staff taking care of their own emotional state, accepting client emotions as natural and healing rather than a cause for alarm, using de-escalation instead of restraints, using an alternatives toolkit geared to the individual client rather than a dose of heavy medication or isolation. It reflects much of what clients have said they want staff to understand. Some of this education has already been delivered, some is about to be piloted.
This education supports and is supported by a policy that aspires to eliminate restraint use. This policy was influenced by recommendations made by EC and adopted by CAMH. From the perspective of a client on the receiving end, restraints and excessive isolation are violence. For this reason we need to do everything possible to safely avoid their use.
Clients’ unmet need for more programming of all kinds has been greatest during evenings and weekends, when there is often nothing for clients to do. The combination of boredom, restriction and stress is never good. The EC has been raising this concern for many years. We are glad to appreciate that CAMH is now taking action on this front. Evening programming has begun and will expand, hopefully, to be followed by weekend programs. WRAP (Wellness Recovery Action Plan), an empowering client centred approach to self care, will be part of what is offered.
These initiatives are progressive and responsive to some of the substantial advocacy issues that EC has been expressing on clients’ behalf. Therapy for trauma survival is still needed. We’re hopeful that evening and weekend programming will include access to fresh air and exercise. Creating an environment of respect, where clients’ self-identified needs are addressed, also benefits staff, and meets CAMH values. We’re all in this together. But clients, it must always be remembered, are in the most vulnerable position of all.
About The Empowerment Council The Empowerment Council exists to represent clients. CAMH clients elect a Board from amongst themselves to whom the EC staff (also current or former clients) is responsible. We use the direction and knowledge from numerous client discussions and consultations to guide us. Our role at CAMH is to advocate for clients on a systemic level, to try to stretch our tiny organization to do the most good for the most people.