Report: Four Decades of Mental Health Policy in Ontario, Canada

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Administration and Policy in Mental Health, Vol. 31, No. 1, September 2003 ( 2003)

REPORT

FOUR DECADES OF MENTAL HEALTH POLICY IN ONTARIO, CANADA Kathleen Hartford, Ted Schrecker, Mary Wiktorowicz, Jeffrey S. Hoch, and Crystal Sharp

As in jurisdictions throughout North America, mental health care in Ontario— Canada’s largest and most industrialized province—has shifted from the hospital to the community. This report summarizes four decades (1959–2000) of mental health ‘reform,’ with emphasis on the recurrence of

a number of themes and on the long delays between recommendation and implementation. This paper was prepared as part of an intensive study (in progress) of the impacts of psychiatric de-institutionalization in one region of Ontario, motivated by the apparent absence of any coordinated research attention to what happens to people as they move from the hospital to the abstraction known as ‘the community.’ Canada is a federation that has gradually become more decentralized over the past several decades. Canada’s system of public health insurance began in 1957 on the basis of 50/50 cost sharing for hospital insurance between the federal government and the provinces. The federal contribution has gradually declined since 1977, and its current value is a matter of ongoing controversy. This is because provinces now receive a single federal transfer payment, but they are not required to use the funds for any specified purpose. Health insurance is administered by the provinces, which determine standards of care and decide what services will be covered, subject to somewhat ambiguous constraints in national legislation (the Canada Health Act) that sets out the principles for public

Kathleen Hartford, R.N., Ph.D., is a ScientistEpidemiologist at the Lawson Health Research Institute in London, Ontario, Canada. She is also Associate Professor, Faculty of Health Sciences and Faculty of Medicine & Dentistry, University of Western Ontario. Ted Schrecker, M.A., is a Research Associate in the Saskatchewan Population Health and Evaluation Research Unit in Saskatoon, Saskatchewan, Canada. Mary Wiktorowicz, Ph.D., is Assistant Professor in the School of Health Policy & Management at York University, Toronto, Ontario, Canada. Jeffrey S. Hoch, Ph.D., is Assistant Professor in the Departments of Epidemiology and Biostatistics, Family Medicine and Psychiatry, at The University of Western Ontario. Crystal Sharp, M.A., MLIS, is with CD Sharp Information Systems Ltd., London, Ontario, Canada. Address for correspondence: Associate Professor Kathleen Hartford, R.N., Ph.D., School of Nursing and Department of Epidemiology and Biostatistics, The University of Western Ontario, 375 South Street, A220 NR, London, Ontario, Canada N6A 4G5. E-mail: Kathleen.Hart [email protected].

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 2003 Human Sciences Press, Inc.

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Administration and Policy in Mental Health

health insurance. Within the provinces, policy-making authority tends to be highly centralized because of political party discipline and the fusion of executive and legislative powers, which is characteristic of Cabinet-parliamentary government. Municipalities have only limited powers and revenue sources; county governments have no legislative or revenue-raising powers and no responsibilities in the mental health area. Until 1985, the province was governed for more than forty years by the Progressive Conservative Party. Then the province’s politics became more volatile, with control of government shifting to the centrist Liberals and (in 1990) to the social democratic New Democratic Party before the Conservatives returned to power in 1995 on an aggressive platform of expenditure restraint, balancing the province’s budget, and income tax cuts.

THE POLICY LEGACY At the end of the 1950s, the primary locus of care for Ontarians suffering from mental illness was the large Provincial Psychiatric Hospital (PPH). These institutions housed 1,000 to 5,000 patients, often in obsolete and inadequate buildings in remote locations, and were valued as sources of local employment as much as for their therapeutic effect (Simmons, 1990, pp. 107–109). In 1962 there were only 545 beds in Ontario’s general hospital psychiatric units, as against 11,362 in the PPHs. When the federal government first offered to share the costs of public hospital insurance with the provinces in 1957, PPHs were already well established as government-run institutions, and general hospitals were ineligible for federal funds if more than 10% of their beds were assigned to psychiatric care. The effect was to create a two-tier pattern in which psychiatric units in general hospitals were “the preferred alternative of the psychiatric profession” (Simmons, 1990, p. 78), while the PPHs were predictably bur-

dened by overcrowding, understaffing, and underfunding. As long ago as 1959, proposals (Dymond, 1959) drafted for a then-new Minister of Health called for greater emphasis on services at the community level, establishment of psychiatric units in general hospitals, and some form of community care for “convalescent patients.” Similar recommendations were made in 1962 by a (national) Royal Commission on Health Care—a fact that is not surprising in view of the small, closed nature of the mental health policy community at the time (Simmons, 1990, p. 103). Expressions of concern about the state of mental health services and suggestions for reform were recurring features of the Ontario policy landscape during the ensuing two decades. For example, in 1969 the Ontario Council on Health, an appointed advisory body to the Minister, observed that the mental health system still lacked a coordinated long-range planning program for health services and related facilities (Ontario Council on Health, 1969). A decade later, an ad hoc Council Committee on Mental Health Services (Ontario Council on Health, 1979) criticized the Ministry for not making mental health a priority, for a lack of necessary information and of interministerial coordination, and for “totally inadequate” aftercare services. The Committee “joined a long list of individuals and organizations which had, since 1963, recommended that the Department of Health divest itself of responsibility for the provincial psychiatric hospitals” (Simmons, 1990, p. 185). Not only did reviews of mental health policy fail to generate any systematic policy response, the reviewers themselves were sometimes greeted with active hostility. For example, a Task Force on Mental Health Costs appointed by the Minister of Health in 1969 focused on divestment of PPH administration because of provincial concerns that PPH costs might rise to the levels associated with general hospitals—a tacit acknowledgment that funding ar-

K. Hartford, T.Schrecker, M. Wiktorowicz, J.S. Hoch, and C. Sharp

rangements for PPHs would not support adequate levels of care. However, since the Task Force was not provided with necessary statistics by provincial bureaucrats after repeated requests, its work ended prematurely and only an interim report (Ontario Department of Health, 1970) was issued (Simmons, 1990, p. 146). In language that sounds remarkably contemporary, in 1983 a Ministry-mandated review conducted by academic psychiatrist Gilbert Heseltine advocated “a mental health care system . . . which directs energy and resources toward providing services outside the hospital so that hospitalization occurs only when dictated by treatment or behavioural needs,” and “the provision of alternative settings for treatment and care in the least restrictive and disruptive settings which are as close to the patient’s or client’s home as practical” (Heseltine, 1983, p. 205, as cited in Provincial Community Mental Health Committee, 1988, p. 30). Recommendations like these raised the question of what would constitute ‘home’ for patients once the locus of care shifts to the community. Some of the answers became clear by the late 1970s. The shortage of housing and support systems, so that formerly hospitalized patients lived in poor quality and unregulated housing, was a matter of frequent public comment and legislative questioning. The provincial government seemed slow to acknowledge responsibility for addressing the problem, even when faced with highly critical reports on the situation of discharged psychiatric patients in Toronto (the province’s capital and largest city) by consultants and outside observers (Simmons, 1990, pp. 168–175, 191–194). Heseltine’s 1983 report found that the number of articles focusing on mental health issues in Toronto’s two major daily newspapers nearly tripled between 1979 and 1981. For the most part, they reported on the lack of community-based care and affordable housing for the deinstitutionalized population, the meager welfare payments available for former inpatients, and the

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political wrangling over responsibility for providing income support and housing. Despite the lack of systematic efforts to reorganize mental health services, the number of beds in PPHs rose from 11,362 in 1962 to 15,257 in 1965, then fell to 6,504 in 1975, and to 4,948 by 1980. Only a small part of this decline was offset by the opening of psychiatric units in general hospitals; the total number of hospital beds assigned to psychiatric patients in Ontario peaked at 219 per 100,000 people in 1965, falling to 81 per 100,000 in 1980. The decline partly reflected rapid advances in the technology of psychiatric treatment—specifically, the introduction of neuroleptic drugs. Partly, as well, it resulted from institutional changes starting in 1964, when the Homes for Special Care Program transferred thousands of elderly and/or developmentally disabled people who were considered not to be in need of treatment to other institutional settings or to privately run nursing homes (Allodi, 1973, p. 281; Simmons, 1990, pp. 109– 120). However, the lack of data on admissions and readmissions tracked by patient makes it extremely difficult to assess accurately the relative significance of various contributors to deinstitutionalization over the period in question. To some extent, the data problem continues to this day.

THE ‘RIGHTS REVOLUTION’ The decline in the number of hospital beds for psychiatric patients was accompanied by substantial change in the legislative framework providing for involuntary hospitalization. Ontario’s Mental Health Act (MHA) of 1967 for the first time established the patient’s own safety or the safety of others, rather than the patient’s welfare, as the basis for compulsory psychiatric examination or committal (Sharpe, 1979). Another innovation involved the creation of regional review boards to hear appeals from patients who had been hospitalized against their will. However, the legislation contained no provision for ap-

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peal to the courts (Chandrasena & Smith, 1986, p. 643). Concerns about the vagueness of criteria for involuntary hospitalization, along with the ongoing interest of the Canadian Mental Health Association and the personal involvement of a new (in 1977) Minister of Health, led to further proposals for what became the landmark MHA amendments of 1978 (Simmons, 1990, pp. 228– 236). The central feature of the changes, which were controversial at the time, was a substantial tightening of criteria for both initial psychiatric assessment and committal. Henceforth, these would be permitted only on the basis that a person’s mental disorder had resulted or would result in “serious bodily harm” (to the patient or others) or “imminent and serious physical impairment of the person” (Revised Statutes of Ontario 1990, Chapter M.7, Sections 15–20). With very minor modifications, these remained the Ontario criteria for involuntary hospitalization until the end of the 1990s. Because psychiatrists perceived the new criteria as unduly restrictive, the changes provoked immediate criticism (Miller, 1979; McCormick, 1981), of a kind that continued over the ensuing two decades (cf., O’Reilly, 1998). An involuntary patient might be considered legally competent to refuse treatment. However, the review boards first established in the 1967 MHA were empowered to override such a refusal. A high-profile 1983 case brought this issue to public attention when an involuntary patient—supported in this case by her family—retained a lawyer to contest the board’s right to override her refusal of electroconvulsive therapy. The issue was resolved in an outof-court settlement that respected the patient’s refusal, but publicity associated with the case led to the belated proclamation (coming into effect) of sections of the 1978 MHA amendments that provided patients the opportunity to appeal review board decisions to the courts (Savage & McCague, 1987, pp. 95–99). Review boards still were permitted by statute to override competent patients’ re-

fusal of treatment. This changed only with a package of legislative amendments that were passed in 1987 in order to bring the MHA into compliance with the Charter of Rights and Freedoms. The Charter came into force in 1982, but the implementation of its equality rights provisions was delayed for three years to give governments time to amend the relevant statutes. These amendments also specified a prioritized list of substitute decision makers from whom consent to treat must be sought in the case of incompetent patients, and required that substitutes’ consent be based on the wishes a patient had expressed while competent, if these could be determined. A 1991 court decision held that the Board could not overrule substitutes’ consent based on such wishes, leading to repeal of the relevant sections of the MHA. Subsequent legislation separated involuntary admission to hospital (covered by the MHA) from issues of consent to treatment, regardless of the setting. However, appeals related to hospitalization and treatment were and are heard by the same body—a province-wide panel created by the 1992 legislation to replace the previous regional boards. In a parallel set of developments, the Psychiatric Patient Advocate Office was established and funded in 1982, at least partly in response to three highly publicized deaths at a Toronto PPH (Ontario Ministry of Health, 1987; Simmons, 1990, pp. 232–233). Subsequent amendments to the MHA and changes to accompanying regulations required that patients in PPHs, as well as psychiatric patients in general hospitals, be provided access to “rights advisers” in a variety of situations involving involuntary admission or treatment. Recent (2000) amendments to the MHA that provide for involuntary treatment outside hospital (community treatment orders [CTOs]) under certain clearly specified conditions also specify that patients must have access to rights advisers once they are presented with the possibility that a CTO will be imposed. Thus, rights advice and advocacy—and, it could

K. Hartford, T.Schrecker, M. Wiktorowicz, J.S. Hoch, and C. Sharp

be argued, a rights culture—have become entrenched as a component of mental health services provision in Ontario.

A TURNING POINT: THE GRAHAM REPORT AND BEYOND In the latter part of the 1980s, efforts at comprehensive reform of Ontario’s mental health system appeared finally to have achieved the necessary momentum. Catalysts for change included two external reports that highlighted the lack of community-based services (City of Toronto & Supportive Housing Coalition, 1982; Marshall, 1982); a critical 1987 report by the provincial auditor (Ontario Office of the Provincial Auditor, 1987); and, perhaps most importantly, the end of more than 40 years of Conservative rule. In 1987 the new Liberal Minister of Health appointed a working committee whose report (the Graham report) noted that while funding for community mental health services, and mental health services in general, had increased in dollar terms, it had actually declined relative to other areas of government spending. The report further echoed many earlier reviews in identifying: (a) a lack of clear policy regarding who was to be served and how services were to be provided, (b) the lack of a systems approach, (c) a lack of a multiyear plan, (d) little coordination, (e) disparities in the availability of services, especially between urban and rural regions of the province, and (f) lack of continuity of care. Among other conclusions, the Graham report recommended that each PPH develop a plan for its programs until 1995, and that each of the province’s nonelected advisory District Health Councils develop multi-year plans for the provision of mental health services in their specific geographical areas (Provincial Community Mental Health Committee, 1988). For planning purposes, the Graham report introduced a category of “seriously mentally ill” people, defined with reference to diagnosis, disability, and duration

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(the 3 Ds), which is now routinely used by Ontario health planners (Ontario Ministry of Health, 1993, p. 15; Ontario Ministry of Health, 1999a, p. 63). The Graham report provided no documentation of how it arrived at the definition. Indeed, in contrast to today’s emphasis on evidence-based medicine and health policy, the report’s bibliography included just seven references to the journal literature. The Graham report also “used two new words: consumer and partnership” (Everett, 2000, p. 63), which originated with earlier work done for the Canadian Mental Health Association. This terminology almost certainly reflects the rise of an articulate movement consisting primarily of previously hospitalized patients (Shimrat, 1997; Everett, 2000). A committee established by the Ministry of Health to develop an implementation strategy for the Graham report (Ontario Ministry of Health, 1991) was guided by the themes of transforming an institutionally based system into a community focused system and devolving administrative, fiscal, and clinical responsibility for mental health care to regional authorities. Following another change of government, the Ministry of Health outlined a 10-year strategy for mental health reform under the rubric of Putting People First (Ontario Ministry of Health, 1993). The strategy identified PPHs, general hospitals, community mental health programs and services provided by family practitioners and psychiatrists on a fee-for-service basis as “the four solitudes of mental health” (Ontario Ministry of Health, 1993, p. 5) and articulated key principles guiding mental health reform: (a) enabling people with mental illness to remain in the community, (b) using the hospital only when clinically necessary, (c) providing more community and informal supports, and (d) integrating mental health with other services. The report followed Graham in attaching the highest priority to the needs of “people who are severely mentally ill.” Perhaps most significantly, Putting Peo-

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ple First specified concrete objectives with respect to shifts in funding and in the locus of care. By 2003, the number of psychiatric hospital beds (both PPHs and general hospitals) was to drop to 30 per 100,000 population, from 58 per 100,000 in 1992 (Ontario Ministry of Health, 1993, p. 29), even though the viability of such a low beds/population ratio had not been demonstrated elsewhere (Sussman, 1997). Further, by 2003, Ontario was to spend 40% of its mental health budget on institutional care and 60% on community services, as compared with an approximate 80/20 split in 1992/1993 (Ontario Ministry of Health, 1993, p. 28). However, defining the split between hospital-based and community services and tracking the relevant expenditures is a continuing problem. Both targets survived, with minor modifications, the change in government that occurred in 1995 when the Progressive Conservatives returned to power. A key element of the Conservatives’ approach to expenditure restraint was the appointment of a Health Services Restructuring Commission (HSRC), with a sweeping mandate to reorganize hospital services in Ontario. HSRC was backed by legislation allowing the provincial government to close general hospitals, which are nominally independent corporations although they operate with a core annual budget from the provincial Ministry of Health. HSRC proposed sizable overall reductions in the number of psychiatric beds and a major contraction of the PPHs, including hospital closures and bed transfers to general hospitals (Health Services Restructuring Commission, 1999). HSRC also called for the appointment of regional Mental Health Implementation Task Forces, which would be asked to make recommendations to the Ministry concerning priority areas for reinvestment in the community. While the HSRC was pursuing its mandate, in 1998 the government initiated “a comprehensive 5-week consultative review of mental health reform in Ontario”

overseen by a Member of Provincial Parliament. The resulting report (Newman, 1998) called for a review of MHA provisions regarding involuntary admission and treatment, apparently responding to concerns raised by a few highly publicized incidents of violence involving previously hospitalized patients (Boyle, 1998a, 1998b; Ibbitson, 1999; for critical commentary see Szigeti, 2001). The report was followed by the MHA amendments that removed the “imminent” harm test for commitment and provided for compulsory outpatient treatment in a strictly limited set of circumstances. The report also called for reform of mental health service delivery in language strikingly similar to that of the Graham report and Putting People First. Like the Graham report, this initiative was followed by development of an implementation plan and operational framework, under the title Making It Happen (Ontario Ministry of Health, 1999a, 1999b). Anticipating the closure of several PPHs as recommended by HSRC, the Making It Happen reports raised the 2003 target to 35 beds per 100,000 people (Ontario Ministry of Health, 1999a, p. 7). They also emphasized a comprehensive continuum of client-centered services based on level of need; streamlined access to services; shared service models of care; strategic reinvestment of funds made available by the closure of PPHs; and decentralization (Ontario Ministry of Health, 1999a, pp. 14–27). In response to the HSRC recommendations, the Ministry established the Mental Health Implementation Task Forces recommended by HSRC. At this writing (September 2003) their reports have not been released. Crucially, it is not yet clear what management and oversight mechanisms will be put in place to ensure that resources follow patients into the community, especially when multiple Ministries (for example, Health and Long-term Care, Community, Family and Children’s Services, and Municipal Affairs and Housing) are involved.

K. Hartford, T.Schrecker, M. Wiktorowicz, J.S. Hoch, and C. Sharp

CONCLUSION: QUESTIONS UNANSWERED (AND SOMETIMES UNASKED) These two epigraphs show that deinstitutionalization is nothing new: A few voices have been raised in sceptical criticism of policies which encourage discharge of institutionalized patients without the provision of adequate and carefully planned residential and support services. (Allodi, 1973, p. 279) Restructuring and reinvesting in the mental health sector . . . is particularly sensitive given the concerns of the Commission and others in the province who remember the ‘disastrous’ attempts to revamp the system in the early 1970s when the PPHs [Provincial Psychiatric Hospitals] were ‘downsized’ without adequate preparation being made to provide the patients who were displaced with necessary communitybased services (and especially accommodation). (Health Services Restructuring Commission, 2000, p. 69) By the late 1980s, research and rhetoric from the United States were suggesting a direct link between deinstitutionalization and the rise of homelessness (Lamb & Shaner, 1993; Lamb, 1998). Although Canadian evidence on this point was and is equivocal (Morrell-Bellai, Goering, & Boydell, 2000), the rhetoric alone should have directed research and policy attention toward the crucial questions of: (a) what happened to people who were previously cared for in a hospital setting, and (b) what happened to people who would once have been cared for in a hospital setting, but for whom that was no longer a preferred (or even available) option? Did they recover, adapt with at least minimal success, or fall through the cracks and into the institutional complex of police, courts, and jails (Lamb & Weinberger, 1998; Valpy, 1998)? Policy choices do not appear

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to have been informed by research on these or related questions. In addition, the rights culture was associated with changes in legislation that (until 2000) progressively narrowed the conditions under which involuntary hospitalization and treatment were legally permissible; but the culture’s proponents do not appear to have achieved similar progress toward what might be described as a right to services. Although the Implementation Task Force reports have not yet been released, preliminary accounts of the findings of one Task Force suggest that fundamental reorganization of mental health services, at last, may be in the cards (cited in Centre for Addiction and Mental Health, 2002). The question that will remain is why it took so long. One explanation is the invisibility of people with serious mental illness: Having been invisible behind the walls of institutions, so the argument might run, they then became invisible—or worse, perceived as threats—because of their limited options in the community. People with serious mental illness are affected not only by stigmatization, but also by the fact that ‘they have no poster children.’ Yet if nothing else, the chronology of proposals for mental health system reform in Ontario demonstrates that the problems of people with serious mental illness have not been invisible for policy purposes. The striking feature of the Ontario situation is the frequency with which reform was unsuccessfully urged by the government’s own advisors and review panels, so that only 15 years after the Graham report does its vision of a genuine system for mental health care in the community have a serious chance of becoming reality.

REFERENCES Allodi, F.A. (1973). The vanishing chronic. Canadian Journal of Public Health, 64, 279–289. Boyle, T. (1998a, February 5). Overhaul mentalhealth laws, Ontario urged. Toronto Star. Boyle, T. (1998b, March 16). ‘Urgent’ changes proposed in laws for mentally ill. Toronto Star.

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Centre for Addiction and Mental Health. (2002). Succeeding in mental health reform: Critical elements. Response to Toronto-Peel Mental Health Implementation Task Force. Toronto, Ontario, Canada: Author. Chandrasena, R., & Smith, S. (1986). Regional review boards of Ontario: A medico-legal analysis. Canadian Journal of Psychiatry, 31, 643–648. City of Toronto & Supportive Housing Coalition. (1982). The housing gap: Deficiencies in appropriate housing for ex-psychiatric patients. Toronto, Ontario, Canada: Department of Public Health. Dymond, M.B. (1959). Proposed revision of mental health programmes in Ontario. Toronto, Ontario, Canada: Ontario Department of Health. Everett, B. (2000). A fragile revolution: Consumers and psychiatric survivors confront the power of the mental health system. Waterloo, Ontario, Canada: Wilfrid Laurier University Press. Health Services Restructuring Commission (1999). Advice to the Minister of Health on building a community mental health system in Ontario. Toronto, Ontario, Canada: Ontario Ministry of Health. Health Services Restructuring Commission (2000). Looking back, looking forward: The Ontario Health Services Restructuring Commission (1996–2000)—A legacy report. Toronto, Ontario, Canada: Ontario Ministry of Health and Long-Term Care. Heseltine, G.F. (1983). Towards a blueprint for change: Mental health policy and program perspective. Toronto, Ontario, Canada: Ontario Ministry of Health. Ibbitson, J. (1999, September 14). More will die unless Harris toughens Mental Health Act now. The Globe and Mail, p. A2. Lamb, H.R. (1998). Deinstitutionalization at the beginning of the new millennium. Harvard Review of Psychiatry, 6, 1–10. Lamb, H.R., & Shaner, R. (1993). When there are almost no state hospital beds left. Hospital and Community Psychiatry, 44, 973–976. Lamb, H.R., & Weinberger, L.E. (1998). Persons with severe mental illness in jails and prisons: A review. Psychiatric Services, 49, 483– 492. Marshall, J. (1982). Madness. Toronto, Ontario, Canada: Ontario Public Service Employees Union. McCormick, W.O. (1981). Involuntary commitment in Ontario: Some barriers to the provision of proper care. CMA Journal, 124, 715– 717. Miller, A. (1979). The Ontario Mental Health Act, 1978: A comment on its application. Canadian Journal of Psychiatry, 24, 515–516. Morrell-Bellai, T., Goering, P.N., & Boydell, K.M. (2000). Becoming and remaining home-

less: A qualitative investigation. Issues in Mental Health Nursing, 21, 581–604. Newman, D. (1998). 2000 and beyond: Strengthening Ontario’s mental health system: Report on the consultative review of mental health reform in the province of Ontario. Toronto: Ontario Ministry of Health. Ontario Council on Health. (1969). Report of the Ontario Council of Health on physical resources, Annex B. Toronto, Ontario, Canada: Ontario Department of Health. Ontario Council on Health. (1979). Agenda for action: Report of the Committee on Mental Health Services in Ontario. Toronto, Ontario, Canada: Ontario Ministry of Health. Ontario Department of Health. (1970). Task force on mental health costs: Interim report. Toronto, Ontario, Canada: Author. Ontario Ministry of Health. (1987). Advocacy in psychiatric hospitals: Evaluation of the Psychiatric Patient Advocacy Office. Toronto, Ontario, Canada: Author. Ontario Ministry of Health. (1991). The road to reform: Final report of the Implementation Strategy Sub-Committee. Toronto, Ontario, Canada: Author. Ontario Ministry of Health. (1993). Putting people first: The reform of mental health services in Ontario. Toronto, Ontario, Canada: Author. Ontario Ministry of Health. (1999a). Making it happen: Implementation plan for the reformed mental health system. Toronto, Ontario, Canada: Integrated Policy and Planning Division, Ontario Ministry of Health. Ontario Ministry of Health. (1999b). Making it happen: Operational framework for the reformed mental health system. Toronto, Ontario, Canada: Integrated Policy and Planning Division, Ontario Ministry of Health. Ontario Office of the Provincial Auditor. (1987). Annual report of the Provincial Auditor of Ontario for the year ended March 31, 1987. Toronto, Ontario, Canada: Queen’s Printer. O’Reilly, R.L. (1998). Mental health legislation and the right to appropriate treatment. Canadian Journal of Psychiatry, 43, 811–815. Provincial Community Mental Health Committee. (1988). Building community support for people: A plan for mental health services in Ontario [the Graham report]. Toronto, Ontario, Canada: Ontario Ministry of Health. Savage, H., & McCague, C. (1987). Mental health law in Canada. Toronto, Ontario, Canada: Butterworths. Sharpe, G. (1979) The Ontario Mental Health Act, 1978: A legal perspective. Canadian Journal of Psychiatry, 24, 517–519. Shimrat, I. (Ed.). (1997). Call me crazy: Stories from the mad movement. Vancouver, British Columbia: Press Gang Publishers. Simmons, H.G. (1990). Unbalanced: Mental

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health policy in Ontario, 1930–1989. Toronto, Ontario, Canada: Wall & Thompson. Sussman, S. (1997, January). The alienist and community care. Mentalities/Mentalite´s, 11, 75–81.

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Szigeti, A. (2001, February). Ontario’s community treatment orders: How did we get there and where do we go now? An advocate’s perspective. Health Law in Canada, 21, 66– 83.

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