Northern Connections:
Providing Mental Health Services via Telehealth to
First Nations Communities
eHealth 2013: Dr. Mo Watanabe Memorial Lecture
Mark Koltek MD FRCPC
Child and Adolescent Psychiatrist
Objectives
• Telehealth in Manitoba
• Rural and Northern Telehealth Services
• Challenges and Opportunities
• Cultural Safety and Awareness
The Golden Boy
Telehealth
An Overall look at MBTelehealth Growth
MBTelehealth Utilization
First Nations and Inuit Health (FNIHB)
Utilization
Mental Health
Overall Clinical Utilization
Mental Health
Clinical Utilization by Specialty
Total Mental Health vs.
Pediatric Mental Health
Clinical Utilization
Manitoba Adolescent Treatment Centre (MATC)
MATC Clinical Activity to FNIHB sites
Telehealth at MATC
• Psychiatric consult model – 2001
• Rural - Northern Telehealth Service -2010
• Staff funding is secure into the future
• Utilized existing resources
Goals of the Program
• Reduce suicide behaviors and outcome
• Improve access
• Collaborate
• Create awareness
Link to Reclaiming Hope at http://www.gov.mb.ca/healthyliving/mh/hope.html
Dene
Cree
Ojibway
 Dahlu T’ua Lac Brochet
 Mathias Colomb
Pukatawagan
 Pimicikimak Cross Lake
 Manto Sakikan
God’s Lake Narrows
 Kinosawi Sipi
Norway House
 Mememwi-Ziibiing
Berens River
Program Data by Community
# of clients seen in 2012
Community
Cross Lake
43
Pukatawagan
11
15
God’s Lake Narrows
Berens River
1
Lac Brochet
4
Sunset in Cross Lake, MB
Our team
Referral Sources
•Medical professionals
•School personnel
•Child protection workers
•Community service providers
( e.g. BFI, BHC, NAADAP, FNIHB)
Process
• Intake
• Assessment
• Intervention
• Referral
• Follow-up
Reasons for Access
•Suicidal thoughts and behavior
•Anxiety
•Post-traumatic symptoms
•Grief and loss
•Mood-related concerns
•Medication review
Reasons for Access
• Psychotic symptoms
• Parent-Child relationship difficulties
• Substance-related difficulties
• School-based issues
• Neurodevelopmental challenges
• ADHD
• Peer difficulties, bullying
• Situational stressors
Case Report - JOEY
• 16 years old
• Suicidal
• Self-Injurious
• Hopeless
• “Two-Spirited”
Guiding Principles
• Community-focused
• Capacity Building
• Sustainable
• Accessible
• Collaborative
• Mental Health
• “At-risk” Youth
Promotion
• Culturally Safe
Community-Focused
• Protocols followed
• Recognize assets and strengths
• Identify needs
• Build relationships
Sustainable
• Services ongoing
• Not a “research-based” project
• No limits
Nikawiy Health Centre, Pukatawagan
Collaborative
• Multi-systemic collaboration
• Consultation
• Treatment plans
“Welcome to Pukatawagan”
City hospital services
• Facilitate admission and discharge
• Acute care
• Reduce re-admissions
Focus on Youth At-Risk
• Suicide
• Substance Use
• Child Protection
• Neuro-development
• Justice System
God’s Lake Narrows School
Capacity Building
• Enhance, not replace
• Consultation
• Education
Accessible
• Local Service
• Minimal Barriers
• Open Criteria
• Flexible
Our team on the road to Lac Brochet
Mental Health Promotion
Culturally Safe
• Avoid Assumptions
• Explore Cultural Variables
• Dimensions
Case Report – DEE DEE
• 12 year old girl
• No school
• Bannished
• Solvent abuse
• At risk of S. Abuse
Telehealth-based Challenges
and Opportunities
• Engagement
• Equipment
• Distance
• Confidentiality
• Limited treatment
models
Engagement
• Therapeutic Relationship
• “Presence”
• Affect Recognition
• “Intuition”
Engagement Strategies
• Energy and Extroversion
• Establish Trust
• Electronic “distance”
• In-person opportunities
Equipment Strategies
• Explain equipment
• Manage interruptions
• Advocate
• Designated telehealth coordinator
Distance
• Coordination
• Consent
• Connection
• Milieu
Aerial view of God’s Lake Narrows, MB
Confidentiality
• Infrastructure
• Stygma
• Small communities
Limited Treatment Models
• Play therapy
• Sensory Self Regulation
• Behavior Modification
• Long-Term psychotherapy
Strategies to Address Limited
Models
• Modify
• Assist
• Communicate
Culture
• Bestowed and Inherited
• Values and Knowledge
• Social behaviors and practices
• Foundation of Mental Health Resiliency
Cultural Identity
• Racial and ethnic identity
• Professional or vocational identity
• Religious affiliation, practice, and worship
• Sexual identity
• Artistic and leisure activities
Cultural Safety
• New Zealand – 1990’s
• Awareness of Power
• Protects Perspectives
(Papps E. & Ramsden I.: Int J Qual Health Care. 1996;46:383-405)
Mental Health
Commission of Canada
• First Nations, Inuit, and Metis contributions
• Seven goals
• Third Goal: Respond to diversity
(Mental Health Commission of Canada, 2009; Toward Recovery and
Well-being: A Framework for a Mental Health Strategy for Canada)
Training and Cultural
Competence
• Implicit de-emphasis on history
• Institutional racism
• Cultural formulation interviews
(Kirmayer et all, 2012, CJP:57(3) Guidelines for Training in Cultural
Psychiatry)
Cultural Competence
• Self-awareness
• Knowledge
• Skills
(Kirmayer et al, 2012, CJP:57(3) Guidelines for Training in Cultural
Psychiatry)
Case Report - MATTHEW
• 6 year old boy
• Foster home
• Mother incarcerated
• Reputation
• Aggression
Intergenerational Trauma
• Massive group trauma
• Effects suffering in subsequent
generations
• Undermines identity
• Bill 14, 1920
(Bombay, Matheson, and Anisman – J Aboriginal Health 2009)
Intergenerational Trauma
• Trauma linkage
• Benefits
• Limitations
(Kirmayer, Tait and Simpson in” Healing Traditions” Kirmayer and Valaskakis,
2009)
Historical Trauma
• Cumulative
• H.T.E.
• Inter-generational
• Post genocide
DR. MARIA YELLOW HORSE BRAVEHEART - 2000
Relevance
• Re-conceptualization
• Sophisticated formulation
• Social justice
• Educational Progress
Questions?
Thanks Aulneau Centre, Ms Frankie Scribe, Ms Lori
Middendorp, Ms Ainsleigh Marcinychyn, Ms Lise Turenne,
Ms Katelin McDermott, and Mr. Stan Kipling for their
contributions to the presentation and our work
Photo credits:
Sunset in Cross Lake by Gerald McDonald c/o CTV News
Aerial view of God’s Lake Narrows c/o God’s Lake
Narrows
First Nation School
Photos of Pukatawagan by K. Hillman
Cross Lake and MB Youth (Front and slide # XX) aadncaandc.gc.ca