A Podcast about Mental Health and Addictions

Episode 6: Québec

Episode 6: Network of Psychological Health Scouts (QC)

April 28, 2021 – Québec is implementing a network of psychological health scouts throughout the province. Their team of 150 social and community workers will reach out to all of Québec, including the most vulnerable people in society to increase the resilience and adaptability of individuals and the community. The team members aim to gain the trust of citizens and promote psychological health by strengthening community mobilization and citizen participation so that no one is left behind.

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Loretta O’Connor: Welcome to the sixth episode of the Promising Practices podcast series. This podcast is an initiative of Canada’s Premiers. The goal of the series is to share the promising practices that are underway in each province and territory. In each episode, we introduce you to experts in the field and tell you about innovative practices and programs. The Premiers' goal with this podcast is to reduce the stigma associated with mental illness and addiction issues and to foster a more focused and collaborative approach among provinces and territories. I will now turn it over to the Premier of Québec, M. François Legault.

Premier François Legault: Bonjour tout le monde! I'm very happy to contribute to this project. This is an opportunity to share our vision about mental health. This issue has been a priority for our government since our election. But things have changed in the past year with the pandemic. It's been very difficult for a lot of people, and it will continue to affect us even after the crisis. I'm especially thinking of young people. We've had to make difficult decisions to fight the virus, but I'm proud to say that Québec was able to keep its schools open during much of the pandemic. The pandemic has created or worsened many mental health problems. That's why over the past year, we've made record investments in mental health. We're doing what's necessary to help each other. Our Minister for Health and Social Services, Dr. Lionel Carmant, will talk about innovative projects on this issue. I would like to thank him as well as the whole team who made this project possible. Thank you.

This is a translation of a podcast that was originally recorded in French.

Minister Lionel Carmant: Hello. I’m very pleased to have this opportunity. First of all, thank you for the invitation, which I accepted with great pleasure. This is a very interesting and relevant initiative which provides a variety of participants from across Canada with the opportunity to share innovations or promising and inspiring practices.

Mental health, addiction and homelessness issues in rural, remote and Northern communities are of concern to all of us. To better support people dealing with these issues, we must reduce the stigma associated with them. This is why a number of initiatives are being deployed in Québec, such as public awareness campaigns on mental disorders, addiction and homelessness, including Nuit des sans-abri or the Night of the Homeless, Addiction Prevention Week, and raising awareness in the Health and Social Services network about hiring and supporting employees with mental disorders or associated symptoms.

Also included are plans to reduce the judicialization of people dealing with these problems. Our focus must be on the principle of the pre-eminence of the individual. This means promoting and supporting the defence of human rights and the exercise of citizenship. What we are essentially talking about is the importance of housing, social involvement, work, studies, etc. Above all, we must encourage and support the participation of individuals and their families in the delivery, planning and organization of services. We must also promote the practice of peer-support and recognize experiential knowledge. It is very important to use practices that are recognized to be effective in regard to contact strategies in adaptability programs in which the Health and Social Services network actively participates.

We also developed a support program for mental health justice, including a drug addiction treatment program through the Québec Court system. We also have a strategy for accessing health and social services for people who are homeless or at risk of becoming homeless.

Remote, rural and Northern communities face some unique challenges. Care and services must be adapted to better meet the needs of the population. We also experience the added challenge of hiring and retaining staff, a challenge that is compounded by the remoteness of these communities. Of course, one of the preferred avenues is the development of virtual care and services, whether it be video-evaluation, video-consultation or video-appearance. We must provide access to the different communities of practice, for example, the Community of Medical Practice in Addiction and the Centre for Expertise and Collaboration in Concurrent Disorders.

To reach vulnerable people, the focus must be on continuity and proximity. Outreach services need to be accessible and local community organizations must be included in the continuum of mental health care and services and must be offered in the language of those who want to receive these services. We pay particular attention to transitions, for example, from youth services to adult services and when leaving youth centres, detention centres and hospitals. It is so important to develop innovative outreach services to reach people who are not using traditional services. For example, in Québec we have Aire ouverte, a network of integrated services to reach young people aged 12 to 25 in their own environment.

In addition, we are working on the development of alternative justice programs, for example the Justice and Mental Health Support Program. I place great importance on the fluidity of these services, based on a step-by-step model of care. We are working on Québec’s Program for Mental Disorders and the prioritization of forensic psychiatry services. We are emphasizing the deployment and consolidation of outreach services and the networking between community partners and the Health and Social Services network. This is so important -- for example, having an increased presence of Integrated Health and Social Services Centre workers in mental health dependency, within emergency housing resources for people experiencing homelessness.

In order to meet everyone’s needs, we are working to adapt to all cultures. Consultations with First Nations and the Inuit were held at the end of January 2021 as part of the development of the next mental health and homelessness action plans. The issues raised will definitely be taken into consideration in the work that is underway. In addition, there will be ethno-cultural mental health consultations in April. We are also assessing the possibility of applying a diversity analysis to the Interdepartmental Action Plan on Mental Health, as well as to the Homelessness Plan. We are considering the co-development of programs, services and tools with communities along with the cultural adaptation and inclusion of ancestral beliefs. We will also be deploying training on Aboriginal realities within different Québec institutions. I will be listening with great interest to the exchanges between Dr. Généreux and Dr. Bleau. I will have the opportunity to return at the end of the podcast to share my thoughts and impressions with you. See you soon!

Dr. Pierre Bleau: Hello everyone. My name is Pierre Bleau. I am a psychiatrist, and Québec’s National Director of Mental Health and Forensic Psychiatry Services, and I am fortunate today to be able to speak with Dr. Mélissa Généreux, a public health specialist. Hello Mélissa.

Dr. Mélissa Généreux: Hello Pierre.

Dr. Bleau: Mélissa, if you don’t mind, we are going to talk today about a restructuring measure announced in November 2020 by Minister Carmant, Associate Minister of Health, and made at his request, which was to deploy throughout Québec and in the community a network of mental health scouts. I believe this is something that you can personally relate to, as you have been involved with this idea for several years and, in fact, we called upon your services to help in the deployment of this network of mental health scouts in Québec. Tell us about your experience with this.

Dr. Généreux: First of all, I really want to acknowledge this incredible initiative. We are very lucky in Québec and I am grateful to be a part of the development and implementation of this initiative. I would say that it impacts me in many ways because as you said, I am a public health physician, but I was also Director of Public Health for the Eastern Townships region from 2013 to 2019. It’s a bit unique, because I was appointed on July 2, 2013. I was very young, 33 years old, I was very happy to become the director for my region, but I had no idea that four days later, I would be called in the middle of the night to be told that the unthinkable had happened. That is, the town of Lac-Mégantic had experienced a huge tragedy, the train tragedy that you’ve all heard about. And I’ll tell you that it completely changed the course of my career and my whole perspective as a public health physician. Of course, then and there, much like what we are doing with the pandemic now, we put out the fires, and dealt with the emergency. But in the weeks and months that followed, we began to see on the ground that the morale of the population was really not at its best. We were interested in documenting the situation because we wanted to know: was it just our impression, or was the morale of the population really lower than it was before the tragedy? We undertook population surveys and we were able to document that things were not going well. As a result, we developed a new model. We listened to the local people who asked us to develop an approach to mental health that was more in touch with the people of the community, a much less clinic-centred approach and more of a community approach. We learned a lot and I’m happy to see that today, this very rich experience will serve all of Québec in the context of another crisis which, of course, is the health crisis related to the pandemic.

Dr. Bleau: It’s important to mention this, Melissa. Because intuitively, when you’re a clinician, you have data, and in a few moments, we can talk about the data you’re managing, the research you’re conducting on psychological distress during COVID, during the pandemic that we’re all experiencing. But it’s important to mention that it’s not because the psychological distress of the population is increasing that this necessarily translates into clinical needs. As clinicians, we all think that distress is increasing, so we should have more specialized psychological services to help us, but that is not what you saw in Lac-Mégantic and that is also what struck us. When we had to decide, what it was we were going to establish, we said to ourselves that perhaps it should not be done through clinical services. Maybe it’s not what the population currently needs.

Dr. Généreux: I think that in medical training, basically, we have to admit that we have been driven to deal with illness – psychological health or psychological health disorders – in a clinical way. We want to take charge, we want to offer the right treatment, whether it’s medication or psychotherapy. In Lac-Mégantic, when we saw that there were many symptoms of post-traumatic stress, indications of depressive symptoms, of anxiety, that was our first reflex. And what we realized, what really opened our eyes, was that while there were more and more problems, or symptoms indicating problems in terms of psychological health, we noticed that people were seeking consultations less and less often. And when asked, “Is it because there are not enough services available? Do you need us to add more psychologists, psychiatrists, or more GPs?” They said no, no, no. There are many reasons for that, but first of all, you don’t necessarily feel sick. You don’t necessarily want to go into the system, officially, to wear the label. There may still be some stigma attached to mental health, but it’s mostly that people were saying the situation we were exposed to, that’s what was abnormal. I don’t consider myself abnormal, I just consider myself reacting the best way I can to the ups and downs. And yes, sometimes I have lows that can be quite difficult … bad times…, but I don’t feel like going to counselling. In the end, I just want to feel good in my everyday life. Once we understood that, we said to ourselves why not move the resources, when we were ready to add resources in the hospital or in the clinic, why not move them so that these resources could be more actively engaged in the community, to try to reinvigorate the community a little bit and thus offer people opportunities to get involved as citizens, to mobilize, to reconnect with each other, to give some meaning back to their lives. I think that we were right, because we have truly seen some very, very interesting results in Lac-Mégantic these last few years.

Dr. Bleau: That’s kind of what caught our attention. At least for me, as a clinician and having done research on mass trauma, to see that distress does indeed increase, and that we need to get closer to people. That’s reflective of the challenge that we took on, to apply what you observed in Lac Mégantic, to the pandemic. You are also at the heart of research on the emotional distress of the population. I would like you to share with us some of the similarities and how glad we are to be able to benefit from this experience in the future.

Dr. Généreux: Well, it’s interesting because at first glance, can we really consider that a railroad disaster and a pandemic have any similarities? Many people might say that they are completely different situations. They would be right in some respects. On the other hand, in terms of the disruption it causes in all our spheres of society, I think we can all agree that a pandemic is a traumatic event, as disruptive as the railway tragedy was, but obviously on a smaller scale in terms of the Lac-Mégantic community. And it is really under this premise that, as early as February 2020, my research team and I, at the University of Sherbrooke, were already preparing a grant application with this scientific basis, as we were anticipating that the pandemic, which was not even a pandemic at the time, we were anticipating that this great world health crisis was going to have major repercussions, but this time on the scale of the entire planet, since we are talking about a global crisis. Through the grant we obtained from the Canadian Institutes of Health Research, we were able to create population-based surveys. We were able to measure the state of psychological health of the entire population in Québec, and elsewhere in Canada as well, and in seven other countries around the world, as far away as New Zealand. We undertook a very broad survey and it is fascinating, and also disturbing, to see that no matter where you are on the planet, including Canada, the psychological response is quite negative, as we could have anticipated. So, Canadians, Québecers, everyone on the planet, many are reporting symptoms of either depression or anxiety. I’m not saying that these are people who have a disorder, who need to be taken care of, but there is still a quarter of our adult population, at this time, who report symptoms compatible with a generalized anxiety disorder, for example, or a major depression. It’s pretty telling.

Dr. Bleau: It’s important to say this, because when we look at other pandemics over the last one hundred years, it’s not necessarily true that distress has been transposed into what we might call a prevalence of mental illness or more serious pathologies, but distress is still at the heart of our concerns. So, given the responsiveness and agility, with regard to the project to establish a network of mental health scouts, I would like you to tell me how things went when you introduced the project in Lac-Mégantic specifically, and also what we are doing now. Because I think it’s important to see that it’s not a clinical intervention, it’s more of a way to identify needs. And this is a notion that we’re less comfortable with in medicine because we didn’t learn this in school. In fact, our entire health care system, one might say, is based on a model of pathogenesis, that is to say, of understanding the disease, but here the approach is different. Here we have taken an approach with a concept that people are less familiar with in the clinical environment, an approach of salutogenesis. Tell us about this approach, about these scouts. What do they do concretely in the field?

Dr. Généreux: To begin with, I think it’s important to emphasize salutogenesis as being at the heart of this approach. Salutogenesis, as its name implies, is the opposite of pathogenesis. It’s about being interested in adopting a perspective according to which we try to understand what causes well-being rather than pathogenesis, which aims to better understand what causes disease. What we want is to see how we can create more well-being, more psychological health and even physical health at the community level. And for that, it forces us not only to look at the risk factors and the problems, but also to see where the strengths are in our community, where our assets are, our resources, and how we can make the most of them. I would say that in Lac-Mégantic, quickly and quite intuitively, we realized that we had to do this because in our initial surveys, what we found was that seven out of ten adults in Lac-Mégantic, two years after the tragedy, were still reporting manifestations of post-traumatic stress, such as nightmares, being startled at nothing, and avoiding at all costs anything that reminded them of the railway tragedy. 7 in 10 is major. And that’s when we said to ourselves that we had to think differently. We couldn’t simply say that Lac-Mégantic is a tragedy, the culmination of a problem. It’s simply untrue. There are many people who are mobilized, or who have the desire to rally together. Perhaps it might be enough to better connect them with each other. What we did was to ask the Ministry of Health and Social Services at the time to develop what we call today an outreach team, which is the origin of our network of scouts, which will now be established throughout Québec. This outreach team is a team that works within the Health and Social Services network, but whose entire practice is done in the community and not in a clinical setting. For example, we can have social workers, social work technicians, and it’s a bit like street work. We can have community organizers, who are there to set up or encourage the setting up of community mobilization projects. All this was quickly implemented in Lac-Mégantic. We started going door to door, reaching out to people to say, “Hey, we’re here, and you know what? We don’t want to do the work for you. We want to accompany you. We want to make you realize how rich your community is, how full of resources. We just need to bring them to light a little more, connect them, network them.” And the magic happened by itself. I saw cases, Pierre, of people who were living in isolation, and suffering from loneliness, that we didn’t see, they were not people that we heard about in clinics. They didn’t go to clinics despite the fact that they were not doing well. People who had lost their jobs, who were probably drinking too much, who had separated, in short, who had had difficult years following the tragedy and who, by a simple invitation to reconnect with their community, to get involved in a committee that aims to organize an activity of some kind, have regained a little taste of being citizens again, have found a meaning to everything that had just happened, even though at first glance it doesn’t make sense, a railroad tragedy destroying an entire downtown. So really, by breaking the solitude, by offering people the chance to get socially involved in different activities, whether it be art, culture, sports, social facilitation of any kind, we really managed to save lives. And it is on this basis that we were inspired to propose the network of scouts that is currently being created throughout Québec.

Dr. Bleau: Which is good, because when we talk about scouts, many people will think, and some will say, that it already exists. We have scouts, we also call them spotters. We know the concept. In terms of prevention, suicide prevention for example, or even for older populations, when we rolled out this new project, most people around us referred to what we had set up, and said that it already exists. But what is important, and why we called them mental health scouts, is that we wanted to give them a toolbox that responded to a psychological prescription and not do what we were already doing, which was to meet social needs. So, you’ve come to talk to us about the social prescription. This social prescription is at the heart of the data. In salutogenesis, we talk about the principle, the feeling of coherence, of giving meaning to what people have experienced and allowing them to go and find what they need to make sense of it and regain their health. It is a gamble that intuitively seems commonplace or ordinary, but that shows a very great power, especially that of going into the community and not asking the community to come into clinics more often or to engage in more hospital-centric models.

Dr. Généreux: It is important to emphasize this, because it is the whole spirit behind the scouts network. Yes, of course, by being more in touch with the population, we may identify people who are in distress, who should have received a consultation or counselling a long time ago, who may not be ready to do so, but whom we can progressively bring towards care or a clinical consultation, people who have needs that are a little more intense and who require clinical support. But honestly, in Lac-Mégantic, we didn’t see this too often. I would even go so far as to say that what we observed was the opposite. It was people who were being followed by social workers in the clinic who were referred to us. For example: “Listen, it seems to me that my patient would benefit from getting involved. He has some talents. It seems to me that to reconnect, to break his solitude, that would probably be a win-win for his development, his well-being. More than pills, for example, or a weekly follow-up with me.” Or sometimes it’s a combination of both, of course. So yes, I would say that sounds very social. And yet, my basic training is like that of any other doctor. But when you see the fairly convincing results from, for example, someone who decides to take up photography, I’ve heard that several times as we did projects in Lac-Mégantic. This is just one example, but people who decide to say, “I’m going to participate in a photography project where through my lens, through the art of photography, I’m going to take pictures of things that speak to me and then I’m going to explain what those pictures say to me, I’m going to put a voice to it” and through that, we invite people to express, to put words to something that is difficult to express, to put order in their own mind, to make sense of all that has happened. And I’m telling you, it can have as much, if not more of a therapeutic effect than clinical care. I’m not saying one is better than the other, but certainly they are complementary.

Dr. Bleau: In fact, our objective was also to link this network of mental health scouts with the network we work with – in order to see the added value and also to see how one would influence the other. Because at the beginning, the challenge was that the clinical network was telling us, “Sure, we’re going to do the same thing with more money.” Our goal is really to change the culture of care, to change the approach to a more social prescription, to reconnect psychologically with one’s community, to find a meaning to life, to make sense of what happens in a pandemic. It is not easy, but each person ultimately feels less isolated. At the end of the day, they re-establish strong social ties and this also reflects the Minister’s objectives in terms of mental health, to be closer, to be more community-based. I think this is what we observe, and this is what we wish to implement.

Dr. Généreux: Yes, and I would say that in addition to that, our research is quite persuasive in this regard: that people who feel lonely or who have a weaker sense of belonging to their community at this time are among those who are most at risk of having a negative psychological response in times of pandemic – so more anxiety, more depression. And on the contrary, those who feel well surrounded, supported, connected to their community are the very people who have protective factors around them, which protect them against all the adversity that we face. I might even say that now, we’re talking about a pandemic. But beyond the pandemic, there will be other issues, other forms of adversity – for example, climate change, extreme weather events, or it could be an economic crisis – when we know that things aren’t easy, and that they might stay that way. It could be a tragic event in a small community. So, in short, adversity, we’re not immune to that as a society, unfortunately. And I think that having a much stronger social fabric, a social fabric in which the health network participates, of which the health network is a part, that this can enhance our ability to face the pandemic and the post-pandemic, but also all the future forms of crises that we may experience in different communities throughout Québec.

Dr. Bleau: This is so important because, as you mentioned, we are paying more and more attention to climate tragedies, to all kinds of tragedies. In Québec, we are used to witnessing blow after blow in the spring from flooding incidents, from our rivers that are overflowing. We can imagine that the involvement, the training of people with psychological first aid is a notion that we must apply in our first toolbox strategy. And we are in the process of developing several levels of monitoring. We can always improve this aspect. In fact, what we would like to see in this context is that we can make these measures permanent, that we can ensure that this concept of salutogenesis becomes an intrinsic part of our care model, our intervention model.

Dr. Généreux: Absolutely, and I’m thinking once again, I’m preaching for my choir because in Lac-Mégantic, that’s very similar to what happened. In one year, we laid the foundations; we created links and came up with new ideas. We were in creative mode, in innovation mode. That’s really important. And my team could tell you better than I could how stimulating it is to say to yourself, “This morning, this week, this month, I am working for what is most important. I am working for the community.” So, if we need to revise our model, if there are new ideas that come to the table, we will adapt. If the clinical network shares with us certain emerging problematic findings, we will adjust. We are constantly reviewing, always, to be as useful as possible to the community. And I would say that, yes, it does colour the approach in the clinical setting because they are much more aware of what is going on in the community through the eyes and ears of our team in the field. It’s really a great synergy that has been created and I would say that we can see the benefits of that because even before the pandemic, we, the outreach team, had already been working for a few years. And when the pandemic arrived, it was difficult in Lac-Mégantic, like everywhere else. But the difference is that our community resilience, thanks to the outreach team and all the projects that followed, was already very well developed. And we saw that the community pulled together quickly in a caring way. We set up a lot of projects in response to the pandemic, projects that are still in development today, and still being implemented. There are really great things being created. This is proof that when we have the right structures in place and that the clinical network is part of it, as well as the community, municipal and school networks, and all of these wonderful people together, this is where the magic happens, the innovation, the creativity, and that is when we are truly responding to the needs of the community.

Dr. Bleau: In any case, Dr. Généreux, you can certainly say now that you are speaking for Québec, because we are fortunate in Québec to be able to witness the deployment of this innovative project, a change of culture, a change of direction, also greatly supported by this vision that our Associate Minister for Health has, a vision that is much more supportive of support, community support, and of developing a closeness with people. I think that this also responds to the mandate that I had as National Director, to enhance the whole aspect of community intervention. And we do hope that the pandemic is behind us, but with a structuring project like this, we think that the future could be better with our interventions.

Dr. Généreux: Personally, I like to think that nothing happens for no reason. It’s a terrible tragedy, what has happened with the pandemic, but it allowed us to grow faster than I could have hoped. I am really proud that in Québec, we were able to set up such a great project. I am really pleased for Québecers. I think that this project was compelling even before the pandemic. It will be just as compelling afterwards and for years to come. I tell myself that at least we have accomplished that. It is something that can be sustained, that can bring a lot of resilience to the whole of Québec. I think we are lucky to have that.

Dr. Bleau: In any case, I thank you for your fine work, your help, your support, the research, and the intuition to have started this. And you are right to mention it, it is important to say that through tragedies there are opportunities. Of course, it’s not the first thing that we grasp, but we still have to be able to seize or have the resilience to seize those opportunities. I think that here in Québec, we have set up something that will help us in the years to come, that will help our community to be better. And as we discuss it today in this podcast, the aim is to share with the rest of Canada that this initiative could be done on a Canada-wide scale and it would certainly be an added value for all the communities in Québec and in Canada.

Dr. Généreux: I believe very strongly that everyone in Canada could benefit.

Dr. Bleau: Thank you very much, Melissa.

Dr. Généreux: It was a pleasure.

Dr. Bleau: Goodbye everyone.

Minister Carmant: Thank you Dr. Généreux and Dr. Bleau. Those very relevant exchanges teach us a great deal about these crucial issues, and they stimulate our thinking. I am always very proud to see all that is being done in Québec in this field. I was particularly interested in the discussion on the scouts network that we have deployed in Québec. We have a lot to be proud of. I really hope that this will inspire my colleagues in other provinces and territories. I am very pleased to be able to count on the expertise of Dr. Généreux, who conducts surveys in several countries. Her analysis has allowed us to draw certain conclusions and also to improve our practices. I find the concept of salutogenesis very interesting and inspiring. We need to look at what’s working well in our society and share this with those who have mental health needs. This is really a solution for the future, in the coming years. I hope to see similar initiatives take root across the country. Remember, we need to reach out to people. Fifty percent of people with mental health problems do not seek help. We need to be creative in our approaches to reach them.

Thank you for listening and giving us your undivided attention today. It was a pleasure to talk about mental health with you. Thank you also to Dr. Généreux and Dr. Bleau for sharing their expertise with us.

Premier Legault: Thank you to Minister Carmant and to Drs. Bleau and Généreux. I invite you to listen to the next episode of this podcast, which will be in Prince Edward Island. We'll learn more about an initiative to help farmers and their families. Thank you for listening.


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