Case 2: Engaging Canadians in the development of a mental health strategy for Canada

The Mental Health Commission of Canada
Tristan Eclarin and Mary Pat Mackinnon, Ascentum

Introduction

The Mental Health Commission of Canada (MHCC) was established in 2007 to act as a catalyst for the development of Canada's first national mental health strategy.¹ In January 2009, the MHCC published a draft framework document, entitled Towards Recovery and Well-Being — A Framework for a Mental Health Strategy for Canada, for external review by the public and stakeholders.² This document set out eight high-level goals for a comprehensive approach to mental health and mental illness in Canada (see Table 1). In locations that spanned the breadth of Canada, the MHCC conducted 12 Regional Dialogues and three "focused consultations" on the proposed framework between February and April 2009.

Why citizen engagement?

The MHCC had two complementary objectives in conducting these engagement activities. First, it sought to draw on the rich experience and knowledge of the mental health community in revising the draft document, paying particular attention to diverse lived realities and previously ignored viewpoints. Second, the MHCC wanted to build support for the emerging orientation of a pan-Canadian mental health strategy.

Table 1: Draft framework goals for towards recovery and well-being — Pre-engagement

Methods

Prior to the public and stakeholder engagement process, the MHCC conducted an extensive internal review of the draft Framework by engaging the MHCC "family," which includes the Consumers' Council, Board of Directors, Advisory Committees, and federal, provincial and territorial (FPT) officials.³ This process helped gather detailed feedback on the draft Framework from these groups and build working relationships with stakeholders — an important part of the broader consensus-building process. Once completed, the input from the internal review process was integrated into a revised version of the draft Framework, which was published in January 2009 for public discussion. Immediately following the public release of this document, the public consultation process was launched. Ascentum, an Ottawa-based public and stakeholder engagement firm with experience in the mental health field, was hired by the MHCC to design, deliver and report on the consultation process.

The MHCC engaged a diverse range of individuals and organizations that represent the complex mental health community in Canada. This diversity includes people with the lived experience of mental health problems and illnesses, families and caregivers, advocates, service providers, researchers, policy experts, FPT governments, and Aboriginal organizations. The MHCC used a two-pronged engagement process that combined in-person and online methods. This distinctive design helped ensure robust representation in the engagement process by providing complementary opportunities for participation. The in-person Regional Dialogues enabled deeper deliberation and facilitated input from specific constituencies, while the online consultations not only fostered increased involvement from youth and people living with mental health problems, but also helped to alleviate the effects of stigma. This resulted in a greater willingness among members of the mental health community to participate in the engagement process.

The regional dialogues

Participation in the 12 Regional Dialogues was by invitation, with national, provincial, territorial and local stakeholders providing advice to the MHCC to ensure that the invitee list was well balanced. The Regional Dialogues were structured to maximize the opportunities for participants to make concrete recommendations to improve the Framework, to raise pertinent issues for their regions or sectors, and to provide the MHCC with comparable data across regions. In total, 450 individuals participated in the Regional Dialogues. The MHCC also hosted three "focused consultations" in Ottawa to explore the perspectives of three specific groups: representatives of First Nations, Inuit and Métis organizations; federal departments with responsibility for policies that have an impact on mental health and mental illness; and representatives of national organizations, including health professional associations.

All in-person dialogues were full-day events. Each dialogue began with "pre-test" keypad voting to assess participants' initial "gut reactions" to each of the eight goals outlined in the draft Framework. This was followed by a focused presentation on the role and mandate of the MHCC, including a succinct overview of the Framework by the MHCC's Director of Mental Health Strategy. Participants were assigned to small groups for facilitated dialogues. Each group was tasked with reviewing three or four of the eight goals, with a focus on identifying what they liked about the formulation and description of the goals, what they felt were areas of concern, and what they would like to see changed, deleted or added. Each group shared its conclusions in plenary, which allowed for a broader discussion among participants on all the goals. The dialogues concluded with a round of "post-test" keypad voting to assess any shifts in participant attitudes on the Framework's goals, followed by plenary discussion on the voting results. The agenda for these events is presented in Table 2.

Table 2: Sample regional dialogue agenda

Online participation

The MHCC also conducted a bilingual online consultation, which was open for just over two months, from February 11 to April 19, 2009. This was designed to complement and expand the reach of the Regional Dialogues, and the general public and stakeholder groups were encouraged to attend. Participants were recruited through a variety of methods, including a broad e-mail campaign, promotion during the Regional Dialogues, media coverage, word of mouth and networking within the mental health community. In total, 1700 members of the general public and 300 stakeholder groups shared their views with the MHCC through the online consultation process.

There were two options for online participation. In the first option, participants could complete an online workbook, which used a mix of close-ended and open-ended questions to elicit feedback on each of the Framework's eight goals. The distinctive feature of the workbook was its focus on informed participation — it supplied participants with critical information that allowed them to learn about the issues and options under consideration before asking for their thoughts and perspectives. The workbook questions mirrored those asked in the Regional Dialogues, allowing for comparison of results.

The second option allowed participants to provide "free form" qualitative comments on the Framework. They were invited to share their personal stories and ideas relating to any of the eight goals and to comment on whether the goals described the direction and scope of change required to transform Canada's mental health system. Participants could choose to have their submission published on the consultation website for others to read or to submit it privately for the MHCC's final analysis. Stakeholders were provided with a similar opportunity to provide comments and suggestions. Following analysis of dialogue and online results, the findings were presented to the MHCC "family" in May 2009 and a consultation report was made publicly available on the MHCC website.

Outcomes and impact

Throughout the engagement process, the MHCC gathered an extensive amount of data: nearly 160,000 words of detailed notes were produced from the in-person Regional Dialogues, and over 465,000 words of comments were collected from the online consultations. There was a high degree of congruence that emerged across different individuals, groups, and organizations that participated in the consultation process. Given the volume and diversity of participants, this attests to an emerging consensus around both the desire to address mental health issues in Canada and the foundational pillars on which a strategy should be built.

The MHCC carefully reviewed the public and stakeholder contributions, including those from provincial and territorial officials, and this resulted in a number of significant changes to the draft Framework. First, the document was reframed to better integrate mental health promotion and prevention, as many participants felt that this required more attention. Second, a number of key concepts were more clearly explained and refined within the document. For example, many participants were concerned with the Framework's repeated reference to an integrated "mental health system" in Canada. They suggested that this framing was misleading given that instead of an integrated system, Canada actually has a patchwork of multiple provincial/territorial systems with significant variation in policies, programs and services. The use of terms such as "cultural safety," "recovery," and "family," in the draft Framework were also reassessed and clarified as a result of the concerns of participants. The Framework goals following the engagement process are presented in Table 3.

Table 3: Draft Framework Goals for Towards Recovery and Well-Being — Post-Engagement

The end result was that all eight of the Framework's goals were revised to varying degrees. In addition, the goal of "A Broadly-Based Social Movement Keeps Mental Health Issues Out of the Shadows — Forever" was turned into a "call to action," as participants saw it as a means to an end rather than a stand-alone goal.

The revised Framework document is now seen as a milestone for advancing mental health in Canada.⁴ It has been embraced by provincial and territorial governments, civil society organizations and people with the lived experience of mental health issues. The engagement process was central to the successful completion of the first phase of the development of a mental health strategy that was achieved with the release of the revised Framework. This set the stage for the second phase of the process — determining how to achieve the vision and goals identified in the Framework. The MHCC's engagement process also fostered productive, trusting relations that bode well for future collaboration on this issue over the long-term.

Lessons learned

The MHCC's engagement process demonstrates that investing in respectful, meaningful public and stakeholder engagement can pay dividends on a number of fronts. First, it can lead to more inclusive, comprehensive and nuanced policy. Second, this initiative demonstrated that an effective engagement process can build greater trust and healthier relationships between (and among) diverse actors, which is needed to implement and sustain policy initiatives in areas such as mental health.

The experience also illustrates the importance of employing a range of methods in consulting with a complex stakeholder community. This engagement initiative shows that blending complementary online and in-person engagement processes using a common framing of key questions and objectives can help to achieve both breadth and depth of reach. It enabled participation from a fairly representative cross-section of Canadians, based on a number of key demographics such as region, gender, annual household income, rural/ urban distribution, ethno-cultural background and Aboriginal heritage. It also allowed the MHCC to achieve higher levels of participation from those with lived experience of mental health problems and illnesses, as well as from the broad range of mental health stakeholders, such as health and social service workers, advocates, researchers/ academics, and government officials.

Two limitations of the process which the MHCC worked to address were: 1) online recruitment methods; and 2) Regional Dialogue time constraints. Due to budget considerations, the MHCC decided to not use random recruitment for its online participation, opting instead for self-selection through its website and extensive outreach to a diversity of organizations to encourage online participation. While a combination of random recruitment, outreach and self-selection is ideal, the process chosen by the MHCC nonetheless achieved high levels of participation from diverse groups across the country.

The second limitation stems from having Regional Dialogue participants working in small groups in focused discussion on a subset of the Framework goals rather than all of the goals. This was a conscious tradeoff given the reality of eight goals and time constraints. Following the small group work, a plenary session provided opportunity for all participants to engage on all goals. Having an extra half day to allow more time for participants to work through all the goals might be desirable, although the risk of a more substantial time commitment posing a barrier to the recruitment of participants would need to be carefully assessed.

Of a different order — and a subject for a separate case study — is the limitation or challenge that relates to the MHCC's unique position within the Canadian mental health domain. As a catalyst, it is neither a policy maker nor does it deliver services; instead, it must work through influence and persuasion. The longer term policy impact of participants' contributions to MHCC's work is intimately linked to the Commission's impact on the mental health system in Canada. This question would merit careful reflection in the next phase of the Commission's work.

Date modified:

2013-11-19