 Alright folks, I'm giving people just another few seconds to possibly stream in before getting started. I think it's a good time to start. So welcome to the sixth lecture in the 2021-22 iteration of Dalhousie's Health Law and Policy Seminar Series. I'm Sheila Wildman. I'm a faculty member of the Health Law Institute. Our associate director, Adelina Iftenay, has done a terrific job of pulling together this year's challenging, timely roster of imaginative, tough-minded, critical speakers. And today's session is a real highlight for me and us all. Our speaker today is Professor Marina Moro, who is chair of the School of Health Policy and Management at York University. Professor Moro works and writes in the area of critical health policy with a focus on mental health reforms, neoliberalism and intersectional and social justice approaches in mental health. She is lead editor of the important 2017 volume, Critical Inquiries for Social Justice in Mental Health. Methodologically, Marina is a leader in the area of community engaged research, having established groundbreaking collaborative research partnerships with community-based organizations, healthcare practitioners, advocates and policy makers, one example of which we'll have a chance to hear a little more about today. A couple of technical things before I turn it over to Professor Moro. The session is being video recorded and will be available on the Law School's YouTube channel. Close captioning is available and you can find a link to this in the chat if you want to turn it on. And last, please use the Q&A box. You see a link to it or a click button for it at the bottom of your screen. Use that if you have questions that you want to type in and you can do that at any time during the lecture. They won't be popping up and disturbing the lecturer and I'll be able to draw on those at the end of the session. And in fact, you can even upvote questions that you see in that text box that you want to be prioritized as you listen to the lecture if you like. Professor Moro will talk for 30 to 40 minutes followed by time for your questions and discussion and we have to wind up by 120. All right, so that's it for me. Over to you, Professor Moro. Well, thank you. Thank you so much, Sheila. And I also want to thank the organizers, Adelina and Ashley and Pamela, our captioner. I'm very excited to have been invited to participate in this speaker series at the Dalhousie Health Law Institute. Most of you will probably not be aware, but the Institute has always held a little place in my heart because many years ago in its early inception as a PhD student, I worked with the Institute on a large research project related to elder abuse. And at that time, it was really a wonderfully wonderful sort of mentoring experience for me at that point in my career. So I'm really sorry that we can't be there all together in person so I could meet you, but I'm really looking forward to this virtual engagement. So I'm going to just share my screen. You can see my slides. There we go. So I'm going to be presenting today on a Shirk funded project related to mental health and social justice. This project is a four year venture and I'm going to be presenting preliminary results just from phase one of the research. You can keep up with the project with the URL that's on the front of the slide. We're just in the process of developing our website so it won't be active probably until the end of March, but stay tuned. So I just wanted to start by saying that I'm coming to you from the area known as Toronto, otherwise known as Toronto, which is on the traditional territory of many indigenous nations, including the Mississaugas of the Credit, the Anishinabek, the Chippewa, and the Haudenosaunee and the Wendat peoples. I want to honor and respect the many diverse First Nations Inuit and Métis peoples that inhabit this land. So before I start, I also want to just sort of acknowledge the research team. This is a very large project international with a lot of different players. It's a multi-site project taking place in Canada, Kenya, and Australia. And in each location we have an academic partner partnering with a community-based organization that represents disability rights activism in each location. And of course we also have many very involved and engaged research assistants, some of which you can see on this slide. The project is also overseen in part by a large knowledge user group, which is an international collection of people who represent people with lived experiences of mental distress and disability human rights organizations. And the role of the knowledge user group has really been to help oversee various activities of the project and really to assist us with knowledge exchange. And we're hoping that over time it will become kind of a network and a place for people to share ideas that have similar interests in this area. So as you can see, we have membership from places like the International Disability Alliance, the World Health Organization, Peer Zone, and a number of others. So in my presentation today, I'm going to start with just a little bit of background, sort of how did the team come together, what are some of the issues we wanted to address in the research. I want to talk a bit about how we work, so centering intersectional values, how we work as a team and what our process is. And then I'm going to talk about the methodology and present to you some of our preliminary results with an opportunity to discuss the implications and really looking forward to having some engagement with all of you around that piece. So in terms of the rationale, the impetus for this project really came out of the recognition, and this has come from many years of my own community-based research, that despite the promises of de-institutionalization and recovery models, where we thought we were moving towards a more humane form of mental health care in line with human rights, in fact coercive practices and human rights violations in mental health care continue. Here, I'm speaking about things like involuntary detainment and treatment, the use of restraints and seclusion, but I'm also talking about other kinds of coercive practices which relate to discrimination. We know that stigma, discrimination and human rights violations are experienced by many people accessing mental health care, and yet system response to this evidence has been poor. Indeed, many countries' domestic mental health laws have been found to contravene international human rights covenants like the UN Convention on the Rights of People with Disabilities, and this is true in the Canadian, Australian and Kenan context. Stigmatizing attitudes, discriminatory practices, and involuntary detainment and treatment mechanisms, we know that those all undermine people's self-determination and their human rights. Another thing that we know, of course, is that racialized and indigenous populations are disproportionately impacted by mental health human rights violations. These practices, as I said, exist despite the fact that we've moved towards recovery-oriented paradigms in mental health. And internationally, when we look internationally, we can see that non-governmental organizations and persons with disability organizations that are user-led, that is led by people themselves that have experience of the mental health care system, have really played a key advocacy role, and we do have some excellent models for recovery-oriented, non-coercive, community-based mental health care. So it's not like we don't have the models out there, but we're not always implementing them or following them. So really then, the overarching aim of this research is to investigate service user experiences of coercive practices and the role of recovery-oriented service user-involved organizations in advancing equity and aligning mental health services, both with the UN's Convention on the Rights of Persons with Disabilities, their human rights framework, and with the WHO, the World Health Organization's Mental Health Quality Rights Initiative, which is a toolkit that can be used in mental health to ensure organizations are complying with human rights. So this slide just gives a couple of examples of the ways in which coercive practices are disproportionately experienced by certain populations. So the first is just sort of to say that men who are racialized migrant and indigenous are more likely to be involuntarily detained and subject to coercive practices. And the practice of electroconvulsive therapy, ECT, which has been proven in many instances to be damaging to the brain, is used more frequently on older women. So we can begin to see here kind of how intersections impact in this area. So the research itself has six objectives, four of which I'm going to touch on today, but just so you have a sense of the overall kind of scope of the project. And you'll see the ones that are in red are the ones that we're going to touch on today. So the first part of our project has been to synthesize the current evidence base on the use of involuntary detainment and treatment and other coercive practices. And we're doing this through something called a critical realist synthesis review, which I'll describe to you. And we're really trying to identify barriers and facilitators of equity in that review. Secondly, we're identifying the contextual influences on mental health policies, where we're focusing on underlying values and assumptions which promote or undermine the uptake of equity and human rights as a policy priority. And we're doing this through a critical discourse analysis of policy. In phase two of the project, we're not we're just getting there now, and you won't unfortunately don't have the results yet for this piece, but we're going to be documenting a diverse range of service users experiences within voluntary detainment and other coercive practices. And we'll be doing that at all of the different research sites, mostly in mostly in the urban context, but possibly some rural areas in Kenya as well. Fourth, we are identifying recovery oriented service user led and involved organizations that provide community based mental health care services, support resources and advocacy that exemplify equity and respect for human rights. So we didn't want this project just to stay at the level of critique. We wanted it to also be able to foreground and, I guess, bring forward into the evidence base some of these really amazing practices that are going on and that are really respecting the principles of equity and human rights. And we're going to do this through case studies and rapid ethnography and you'll see in the discussion of the results today that we've started this process. And then of course, resulting from all of the research and data that we've collected and a synthesis of that, our aim is to develop a framework for equity and human rights that enhanced community based mental health care. And then number six, what's something that we've been doing all along the way is to develop and engage in an integrated knowledge translation strategy. And this strategy is meant to build capacity, research capacity among students and community based researchers and interactively share the results of the research with a range of relevant audiences to ensure that it's not something that just sits in a report on a shelf. So before we talk about the methodology and the preliminary results of the study, I really wanted to give you a little bit of a window into our collaborative and intersectional approach to the research. So intersectionality as a theoretical framework for a paradigm is something that we're very much adopting in our work. And intersectionality, if you're not familiar with it, understands oppressions or inequities as overlapping and interconnected. And what it urges researchers to do is to look at what those intersections can tell us about power and how power operates in the systems that we're examining. But it also requires researchers not just to be outwardly focused, but to also be inwardly focused and reflexive in our practice. So as a team, we take the use of intersectionality to mean that we need to interact, that we need to actually enact intersectional values in our practice and process. So we've been doing that in a number of different ways. So we've done together with our knowledge user group, which we affectionately refer to as the CUD, our knowledge user group, the research team and the research assistants have connected with each other virtually, and then a values-based kind of exercise where we established values together that we felt would both guide our own interactions in the project, but also would guide how we evaluated some of the evidence that we're looking at. And some of those things include things like the valuing of lived experience. So both in terms of representation, and so throughout our team, we have people who identify with lived experience of mental distress and experiences within the mental health care system, including course of practices. So we have representation, but we also have a real commitment to what we describe as the epistemological significance of lived experience. So here is what I mean is that lived experience or centering voices that are on the margins can really better help us better understand oppression and understand some of the inequities and how they're operating in the mental health care system. Another sort of value commitment we had was something that we sort of loosely describe as capacity building, but it's really about recognizing that people bring different strengths, they bring different context, different backgrounds to the context of the project, and we want to build on that together. We all bring a strong commitment to human rights and social justice and an understanding of mental health as embedded in a context, a broader social context. And so those are just some of the values that guide the project and guide our working together. Of course, this work is not without its challenges. It's an international project with three sites that have some commonalities, but also some very distinct differences. Each of the sites are similar in that we have ongoing legacies of colonization, and those are central to our analysis. But of course, that colonization has played out differently in the different communities that we're engaging with. How we talk about disenfranchised groups also really differs across the sites, and so we've had a lot of lively discussion about language, and so you'll see a couple of acronyms up there, some of which you might be familiar with. The acronym called is used in the Australian context. It means culturally and linguistically diverse peoples, and it really references, it's used, it's important because it's used to gather statistics in the Australian context, but it references mostly people for whom English is not a first language and new immigrants. And so it doesn't really capture racialization, for example. Of course, in Canada, the term black indigenous and people of color has become more popular. But of course, what we've discovered in working across these sites is that black is used in a very different way across the sites. So just as an example, in Australia, many indigenous groups claim the label of black. So these are just some of the challenges that we're working with. Of course, you might be asking why these three countries, why did you choose these? Well, what's interesting in terms of what unites these countries is that they're all common law countries with the same legislative framework. So we all are subject to the Mental Health Act, but we have different mental health care systems. So of course, Canada has a publicly funded system. Australia and Kenya have a mix of public and private. And then important to note that Kenya does not really have a community based mental health infrastructure. So their care is still very much institutional and hospital based. Just finally, a couple of other little challenges I wanted to mention, the pandemic, all of us are still amidst this incredibly challenging time. And of course, for research where you want to be connecting on the ground and engaging with people, that's been a real constraint for us. It's why we push the field research forward a bit, hoping that we can still do some of that work in person. Certainly we've had a lot of conversations as a team, as the pandemic was unfolding, how it was affecting us. Our Kenyan partners were very slow to get access to the vaccine as an example. They've struggled a lot with internet access. They often have blackouts of the internet. So recognizing that not all of the team members are working with the same amount of resources in this context. And I did also want to just say a few words about mental health challenges. As a team, given that we have representation across our team of folks with lived experience, we work as a team to accommodate those challenges. We understand that it's likely to happen. And in fact, some of us have gone through periods of unwellness. And so as a team, we strive to create an open space for people to take time away as needed and then to re-enter when they're well. And we have a little bit of a plan in place to ensure that the work goes forward regardless. So those are just some things to kind of get us centered, get you, give you a window, I guess, into how we're working together with this large team. And in some ways, I would say that that Zoom technology has been very helpful for that because we have been able to connect more regularly than we would be another time to suppose. But of course, the disadvantages that we haven't been able to physically be together at any of the sites as of yet. In addition to intersectionality, there's a couple of other key concepts that are really important in our work. So I just want to share these with you. So the first is, well, I guess maybe just before I say that, I want to say that these concepts, the reason they're so integral, they're in some ways, quote unquote, the air we breathe in. So they become so naturalized, we almost don't even recognize them. So these two concepts are neoliberalism and biomedicalism. So neoliberalism, much has been written about it. It's really a set of practices that are centered on the increased role for the free market. And it can also be understood as a form of governmentality in Pucos terms, which means that we can see neoliberalism operating in discursive practices. So that's in the operation of language. And in the case of our work in policy discourses that influence our understanding of the social world. And people have talked about neoliberalism as creating new identities, the shift from sort of collective forms of identity to more individualized ideas about what constitutes subject formation. So when you think about this in the context of policy, it promotes individualistic understandings of complex social problems. And it really urges people to take responsibility for their own mental health. So this notion of responsibility. And then we also have seen the increased use of market mechanisms in health and mental health care delivery, sometimes referred to as managerialism and welfare state retrenchment, that is cutbacks in favor of self-reliance and volunteerism. Nicholas Rose has talked about biological psychiatry as a style of thought. And that is, it's so normalized as the dominant discourse that it becomes a routine way of thinking about mental health and mental illness, even though we know on the ground and then certainly in many conversations, people talk about the social determinants of mental health. Biomedicalism still tends to really dominate our treatment systems. And in our work, we understand biomedicalism and neoliberalism to mutually reinforce each other and they mutually reinforce each other with respect to individualistic understandings of social problems. And they also have the effect of blunting the scholarship and activism that point to complex interactions between the biological and the social. So although our research is very much focused on the social side of this discussion, none of us want to throw out the biological side. We understand it to play an important role, but we see the system as really imbalanced with respect to the focus, which is why our work is focused more on the social side. So today I'm going to talk about the methodology and then the preliminary results for phase one, which is the critical realist review, the environmental scan and the intersectional based policy analysis. And you'll see there are several other phases of the project that are coming up and ongoing. So with respect to the methodology, we chose a critical realist review, which is a literature based methodological approach to critical analysis, which allows researchers to understand social interventions by examining the underlying social, cultural and political context of an issue. So when you do this kind of literature review, you're asking what works for whom and what circumstances and in what respects. Now critical realist reviews differ from realist reviews in that they're a review of the literature. They're not really an empirical review of interventions. The realist reviewers, for example, avoid making normative claims while critical realist reviewers are concerned with the broader macro social structural context in which interventions are embedded. So when you conduct a realist review, a critical realist review, edgely suggest, and I'll just read this quote, that students and researchers be encouraged to use theories and explore ideas which embody notions of social justice or critique of underlying assumptions about social and health organizations. So that gives you a little bit of a window into what that kind of literature review looks like. Alongside of this, we've also engaged in an environmental scan and we use the way we did this in part was we took the expertise of our research team and our knowledge user group and we did these online workshops using a really interesting online platform called Miro, Miro boards. I don't know if anybody's familiar with them, but they're kind of like having, you know, a conference room with a white board that people can, you know, write on and contribute ideas to. So we use that for people to be able to, you know, we had generated as a team values that would guide the project and values that we thought should guide system responses. And we use as our starting point and got people to kind of then brainstorm about organizations or practices that they felt fit those values. And then we also engaged with a gray literature scan. So that is to say, looking at websites, looking at reports from organizations to find and surface organizations and practices in line with equity and human rights and mental health. And then finally, we used an intersectional based policy analysis. So, of course, intersectionality is known to people from the work of Kimberly Crenshaw, who coined that term back in the late 80s, as a critical race theorist in the US. And we know, of course, that though, those sort of the ideas behind intersectionality really come from the second wave of the feminist movement from black indigenous Latina, post colonial and queer scholars, all of whom were producing work that was trying to understand how complex factors and processes shape human lives. And so drawing on that, we're using a tool called intersectional based policy analysis, which brings that theoretical and activist framework to analyzing policy. So it surfaces underlying values and assumptions. So with the critical realist review. So one of the portions of that method is that you start with candidate theories, and they these are tied again to the values that we generated with the knowledge user group. And we tested these five candidate theories to see whether or not there were evidence of them in the literature and how they were spoken about. So just to tell you briefly about each of them. So one theory is this notion that, and we use many terms because these different terms appear in the literature. So user led peer led consumer led or site survivor led initiatives are going to be more likely to promote equity in human rights. That's a theory that we were working with. That an understanding and operates and being able to operationalize social and structural determinants of health, mental health will promote equity and human rights. That the values underlying a system of delivery play a key role in promoting or undermining equitable practices. So part of what our research has been a certain policy analysis has been to surface what are those underlying values and assumptions that are guiding system response today. Emphasizing the importance of community led initiatives and that explore individual and system change and explicitly attend to power in their operations. So again, we theorize that that will result in more equitable responses. And then initiatives that address the historical and ongoing impact of colonization are more likely to promote equity in human rights. So to do this critical realist review, we did it in partnership with one of our Canadian organizations, Evions, which is the Center for Study on Disability Rights. It's a cross disability organization, human rights organization. And in the context of that search, we searched 25 databases, we identified 51 articles. And as I mentioned, we also did these three workshops with our international knowledge user group to kind of supplement the material. We found that in the literature, we could only get so far without going to the gray literature and to the expertise of our knowledge users. For intersectional based policy analysis, what we did is we applied and if you're interested, you can look up the intersectional based policy analysis framework and guideline. It's easily accessible online. It uses the principles of intersectionality and applies it to policy analysis through a series of questions. So the questions are things like, how is the problem being represented? How is the problem in its representation? How is it impacting different populations in specific kinds of ways? What are some of the values and beliefs that you bring to the policy analysis, Serena? So it gets you into kind of reflexive questions as a way of analyzing policy. And it draws on an Australian academic Karabaki's work who uses kind of a post-structuralist lens and a method called what's the problem represented to be. It draws on that methodology but brings more of a social justice orientation or focus. So we applied that form of analysis to key policy documents, domestic policy documents in Canada, Australia and Kenya. And in Canada, we had two sites, BC and Ontario. And in BC, we were able to look at both the general sort of provincial mental health strategy governing mental health provision, service provision, as well as policies and strategies emerging directly from their First Nations Health Authority. So you know that in BC, it's the only province in Canada that has a First Nations Health Authority. So we were able to actually look at documents that are coming out of First Nations communities themselves. In Ontario, we were looking just again at sort of domestic health policy, the roadmap to wellness was one of the documents for example that we looked at there. In Kenya, they have only a national mental health strategy. So it's not done regionally. Their strategies are not regionalized. They're not decentralized in the same way as Canada and Australia. So we looked at specifically their Kenyan mental health policy and some of the accompanying documents including a task force report. And in Australia, in Melbourne, what was really interesting when we started the work, this was just beginning, they had established a Royal Commission in the state of Victoria to examine mental health. And so we were able to actually look at the results of that commission and analyze that alongside of some of the other documents, sort of domestic Melbourne mental health strategies. So we chose all of these documents based on how recent they were and how influential we felt they were in guiding policy and practice. And we used, as I said, the principles of intersectionality in our analysis. So things like understanding categories of oppression as intersecting, understanding the benefits of diverse knowledge. So certainly in the context of BC, we were able to do that in more specific ways because we had documents from First Nations communities themselves. So we use those to guide our analysis. The environmental scan I've already kind of described to you, but it really came from a number of different sources, the Miro exercises, so the Miro board exercises online, as well as the critical realist review, and then just conversations with the research team and review of the gray literature. And then what came from that is we were able then to shortlist organizations that we compiled for deeper analysis, based on we kind of used a three star kind of rating. And that criteria was really the candidate theories that you saw earlier outlined in the critical realist review. Those guided whether or not we rated an organization or a practice as three stars, two stars or one star. After we kind of compiled the three star resources, we did a much more deeper dive into each of those organizations through the internet, through publicly available material and check reflexive notes and provided commentary about the details of the organization and how they actually meet those candidate theories. And we've done that in a very systematic way because you'll see in a lot of part of the research, we want to actually do case studies. And so we will draw our case studies of organizations that are enacting human rights and social justice practices. We'll draw that from this environmental scan and then we'll actually do rapid ethnography and case studies with some of those organizations. So a total of 34 resources were identified as aligning with those candidate theories. And this environmental scan will stand on its own, I think, as a really good resource. And it's kind of interesting. It aligns nicely with a recent document that came out from the World Health Organization called Guidance on Community Mental Health Resources. And our partner at the World Health Organization, that document was being developed at the same time as our research. So we actually had an opportunity to have input into it. And it's now been publicly released so people can take a look at it. So I'm going to start and tell you a little bit about some of the key themes that emerged from each of these preliminary findings. So from the realist, critical realist review, and anybody who's done these literature reviews, you know how daunting it can be. There's so many online resources these days and so many different databases. And so we worked pretty closely with librarians and folks who could help to guide us on this piece. And these are just some of the themes that have emerged. So it was interesting to us that very few peer reviewed academic articles spoke directly to equity and human rights. Yes, there was a lot of material on legislation and law and legal kinds of arguments, but not a whole lot of stuff that really was looking at in the comprehensive kind of way that we're thinking about equity and human rights. But in line with one of our candidate theories, peer consumer psychiatric survivor led initiatives were discussed as more likely to promote equity and human rights. And mental health care was described interestingly as transitioning from a system driven kind of system to a user driven perspective. So a recognition that we've moved from a time period where we didn't think very much about people's own experiences of the system or engage people with those experiences or engage peer support workers, for example, that now we're very much doing that work. And there was lots and lots of literature on peer support and peer workers and kind of the barriers, the challenges, the struggles there. Another theme that emerged from the Realist Review was that collaborative knowledge production that emphasizes shared power is something that is seen as enhancing equity. So shared power here between people with lived experience, whether that's people themselves or family members and carers and people working in the system that that collaborative kind of knowledge production is really important. There was also lots of literature talking about holistic and person centered approaches to mental health. So many of you will be familiar with this, lots of conversations about how there's not such a thing as a one size fits all kind of approach to mental health that that people needs, people's individual circumstances, as well as the broader social context really need to be taken into account. And then interestingly, quite a lot of literature on spirituality as an integral element in mental health approaches emerged in our review. With respect to the policy analysis, we have some very interesting kind of themes that have emerged, and I want to give you kind of some examples of each of these. So the first is that colonialism and psychiatry are deeply interconnected. So for example, in the Kenyan context, one of our investigators, Muhammad Ibrahim, he's been tracing historically the ways in which psychiatry and psychiatrists were very much key players in the colonial project, very much like in the Canadian context where the field of medicine hospitals and also I would argue psychiatry played a role in that early formation of colonialism. And in the Kenyan context, as in the Canadian and Australian context, what this has meant is the suppression of local knowledge and traditions and how this has and what we were able to see in the current national Kenyan mental health documents is that that same kind of perspective continues today so that there's very much been an adoption of Western biomedical understandings of mental health over and above traditional knowledges, for example. And what makes that even more interesting in the Kenyan context is that most people in the Kenyan context still get their mental health care supports either through spiritual leaders or through traditional healing practices. So you have a policy document that barely mentions these things and really is based on the sort of biomedical Western framework, while at the same time, you know your population is actually mostly accessing services and supports that you're not really even acknowledging at the policy level. In the BC context, I mentioned this before that we have mental health strategies that are actually emerging directly from Indigenous communities through the First Nations Health Authority that are kind of interestingly kind of placed alongside of the more Western traditional mental health documents. So lots of really interesting pieces there that we're pulling together and trying to understand with respect to colonization. Another key theme, of course, that's emerged that won't be surprising is the dominance of biomedicalism. A couple, I've given some examples already, but a couple of interesting examples. So you'll see in these strategies, it's always fascinating to me there'll be conversations about social determinants of mental health. So lots of acknowledgement that housing is important, that income security is important, that social support is important. Sometimes there's acknowledgement that people have experiences of racism or sexism or heterosexism in there and that, excuse me, that impacts mental health. But inevitably in these policy documents, there's a default back to the biomedical. So social things are seen as kind of there and playing a role, but not intricately connected to mental health. And so what I mean by that is that there's not really an understanding that people are socially embedded, right, that they're embedded in social, political, economic contexts that can't really be pulled apart from their mental health. And so none of the policy documents that we reviewed really, you know, were able to really frame mental health in that particular kind of social and structural way that we were looking for. Neoliberalism, a good example would be in Ontario, where a lot of focus, and this is true in a lot of Canadian mental health policies today and strategies, you'll see a lot of focus on coordination of the system, integration of the system, lots of conversations about lack of resources. So a lot of focus on the sort of technocratic aspects of the system, without much reference to quality of care. And in many of the Canadian documents, any kind of discussion about human rights was completely absent, as though those violations don't exist, as though we don't aren't governed by mental health acts. And so in the Ontario context, another kind of striking thing in the strategy here in Ontario was a real focus on trying to get people back to work. So, you know, how can we quickly get people well and get them back into the workforce? And of course, that doesn't recognize that for many people that may not be a reality. However, there's some really promising things happening at the local level in Toronto. We captured through municipal policy, following the resurgence of the Black Lives Matter movement. The city is actually piloting non-police crisis response to mental health. And so we've got some municipally funded pilot projects that are taking place in the city of Toronto. So we're able to bring that into our analysis as well. With respect to human rights, it's really interesting. So I mentioned in the Canadian context, pretty much absent. However, it's very much foregrounded in the Kenyan context where there's a lot of reference to the UN Convention on the Rights for People with Disabilities. And in the Australian context, particularly in the Royal Commission, lots of conversation about the broader human rights context. But again, what's striking in each of those contexts is that the mechanisms for attaining human rights are not really articulated. And in both cases, they continue to uphold domestic mental health laws, which are in contravention of the UN declaration. So suffice to say that intersectional values and frameworks were not typically used to understand mental health and the structural determinants of mental health in our policy analysis. So what do we kind of take away from this? These are just three kind of areas that would be interesting to have kind of a further conversation with each of you around this piece. So some of the takeaways are disrupting biomedical reductionism, protecting human rights and mental health, and enhancing equity. And so what will we require in order to ensure that these things happen? Well, we have to adopt values and principles that uphold human rights and equity. And that has to be done by governments, by policymakers and service providers. We also have to support the leadership of people with lived experience at policy development tables and in service delivery. There's certainly lots of engagement of people with lived experience now in the policy arena and the Canadian context and internationally. But sometimes this is still very tokenistic and or not really led by service users. We will need to adopt intersectional and decolonizing approaches in mental health, given the intersecting and overlapping forms of oppression that flow from inequities of power throughout society. So we really think it's important to use intersectional and decolonizing lenses and apply those to policy and practice. And the intersectional based policy analysis framework is one that's out there and is actually being used by policymakers now, especially in the international context, showing that it is possible to do this. Embrace reflexivity as a key component of research policy and practice. So it's something that we are not going to say we're doing it perfectly on our team, but we're striving to do it. We're trying to do it and we hope to be able to write about it in terms of how it might impact how we were able to work together and impact the research that we're doing. And then ultimately, I suppose we're calling for transformative change. So just as my last slide here, I just wanted to let you know a little bit about our next steps so that you can see that the project is ongoing. So we're just starting into phase two, the field research, and excited to announce that we're just in the process of finalizing, hiring peer researchers to work with us from all of the sites to work collaboratively with us to develop the field research instruments to help us think through who should we talk to, who should we bring together in focus groups? How do we capture some of the inequities that we know exist out there? So we're going to be doing key informant interviews with people in the system who work in the system, as well as focus groups with people with lived experience. The case studies I mentioned, those will not happen now, probably now for another year, and that's where we're actually going to use the environmental scan to select some organizations that we can actually study in more depth, do some case studies on them. And part of the goal, and this comes from my own experience of looking at the literature in community-based mental health care, there's lots of evaluations of programs such as a sort of community treatment programs, very little in the literature that looks at what's, you know, some of these promising practices, very little evaluation, very little documentation. And so the case studies are a way for us to begin to bring some of this knowledge that we know is out there into the academic literature, so that it can in fact be taken into account more seriously in policymaking. And then of course, ongoing in our project is really knowledge integration and mobilization. And so we're having some really interesting and fun discussions with the Knowledge User Group right now about developing a series of webinars. So one idea that we have that's still to be fleshed out is that how do we bring some of what we're learning in this project to people who are accessing mental health care? How do we, you know, step out of sort of the more academic language that we're using and distill some of our work into a context so that people can take it up and use it in their own work environment? So thinking about practitioners here as well as people with 50 experiences. So those are our next steps. We've got another two years and we're excited. Oh, I guess I should just say one other quick thing in that is the website is under development. And as I mentioned, one way to follow us would be to look at the website. We're going to have an electronic newsletter, very short newsletter that you can sign up for that will give you kind of probably quarterly updates on the project. So that website should become live towards the end of March. So thank you. I'm looking forward to any kind of questions or discussion you can have. Thank you so much, Reina. That was just a fabulous presentation and gives us so much to think about. And I'm sure there are many questions on many folks minds. I have my own, but I'm going to start with a question that came up in the text box. And I suppose, you know, just to kind of frame it in a more general, well, in a more, more general light. I take this question to kind of instantiate the contested nature of knowledge and of experience based claims in the realm of mental health and mental health recovery. So the question relates to ECT specifically. And I think it came up at a point where you had given this as part of the example of resistance to biomedical approaches to mental health. And the question asked, I'm wondering if there's been further consideration of recent, very strong evidence supporting both safety and effectiveness of ECT. The person adds as an active practitioner, I'm discouraged by the ongoing stigmatization of ECT. Evidence from 2000 is outdated for this 70 plus year old practice, they say use in an older population with depression with or without psychotic features with vegetative symptoms has been demonstrated as very safe and highly effective. The most effective actually the approach is much more humane compared to past popular media depictions, patients if untreated offer an art risk of severe malnutrition frailty and death with women living longer higher rates of depression versus men at older age. The use represents current evidence based practice. Unfortunately, in the USA, we often see lower privilege and lower SES, social economic groups having limited access to this treatment. I wonder if this could be the lens to look at ECT through an equity values approach. So that's my long just articulating. I wanted to just say the question and open it up to you for response. Great. Thanks. Thanks for that question. And, you know, certainly this is not an area that I've done a lot of research into. And I like Sheila how you kind of framed it as, you know, potentially a little bit of, you know, when we think about how knowledge production and how certain kinds of evidence enters its way into, you know, academic journals into society and how that then starts to guide our policy analysis. So partly, or sorry, our policy frameworks. So I think what's interesting is that, you know, you've got, you do definitely have literature that suggests that ECT is effective from the perspective of the scientists who've studied it, but you also have lots of literature, some of which is not, you know, really apparent in the academic literature, but is more in what I would call the gray literature, sort of accounts from people who've had ECT and how that has impaired their memory and affected their brains in a variety of ways. And so you have these kind of almost two conflicting modes of evidence, I guess, around ECT, which I think makes it a really complex terrain and a very difficult practice to fully stand behind when you've got kind of conflicting forms of evidence. At the same time, you know, I would agree with you, it's kind of, it's certainly one, I guess, you know, practice or treatment that's been very much demonized and, you know, misrepresented, you know, particularly in the media or popular culture, etc. And we know how it's practiced today, you know, it's very, it's very different than it was practiced, you know, historically. So, you know, those are some of the things I guess I would offer up. I'm not sure if there's an equitable way to do ECT. I think it's very distressing that it that we do see it disproportionately used on certain populations and that those who have spoken out against ECT and raised concerns about it have often been their, you know, dialogue is often being closed down. And so, but I think, you know, in the spirit of communication, I think it's really important to have these conversations, and that's maybe where the equity piece could start is being able to bring people together that might have divergent views around ECT in a safe way to tables to have conversations about ways to actually talk about it that might result in some of the equity pieces you're suggesting. So, thank you for that. Thank you. Thanks for that response. The next question reflects in part on federalism on the federalist, you know, reality in Canada. This would also be true in Australia. And so, the writer says mental health legislation is diverse even across Canada. For example, BC is one of the most progressive even compared to Ontario. It may be helpful to have a nuanced approach per jurisdiction using universal principles of human rights and social justice. And so, I might just put that to you as a question about how you have navigated the reality of federalism within jurisdictions. I think this person that originally commented when you said these are all nations that have inherited, you know, a mental health act model. I take a British mental health act model, but of course, some of them are federal jurisdictions. And so, in fact, there are diverse expressions of that across nations. So, how have you integrated that fact into your work? Yeah, thank you very much for that question. It's very, I mean, it's integral to our work. And so, in the Canadian context, and you're right to point out that BC has one of the most, I think the most progressive mental health acts. So, mental health acts in Canada are provincial, right? So, each province has its own mental health act. There are some common features. So, under each, you know, across all provinces and territories, you know, there is the mental health allows people to be detained involuntarily, usually for similar kinds of reasons. So, what if they're considered to be of harm to themselves or to others? Or if they're seen as rapidly deteriorating or, you know, their mental health is rapidly deteriorating. But what is different across provinces is partly the process, the degree to which rights are respected, you know, so there's a number of different features that are really important. And so, when you compare, say, BC and Ontario, so in BC they have something called deemed consent. So, if you're taken in under the Mental Health Act, you immediately seem to be consenting to treatment. So, there's not a separate process to consent to treatment. You just go straight, you know, just one, there's sort of one process from involuntarily being detained to being involuntarily treated. Whereas in the Ontario context, those are two separate processes. So, you can be involuntarily detained and held for a period of time, but you have to be then assessed as to whether or not you can consent to treatment. So, it's two separate processes. In the Kenyan context, it's more of a national, so it's not regional, it's a national mental health act that's used. And in the Australian context, like Canada, it's based on states. So, Victoria, where Melbourne, the state of Victoria, Melbourne has its own mental health act, which, and again, they have some similar features. But I think what differs the most is the oversight, people's access to rights, et cetera. So, yeah, really important. And so, we are absolutely taking that into account in each of our sites and looking at those differences. And for example, in BC, there's been a lot of writing about the Mental Health Act, a lot of critical writing reports coming out from their ombuds person, for example. So, a lot of that material is referenced in the work that we're doing. Thank you. There are a couple more questions. I just want to say to people, if you have a question, it's helpful to me if you type it into the Q&A, although I do have my chat right now as well, if something comes up there. So, the next question is, are there distinct aspects of neoliberalism, biomedical dominance, and colonialism across Canada, Kenya, and Australia that have different effects on the mental health of marginalized groups? So, I guess we're looking for distinct, yeah, expressions of these core concepts that might manifest differently as your research is proceeding. Great. Yeah, great question. And I tried to give a little bit of an example of that in the policy analysis. And yes, absolutely, these things are playing out in distinct ways. And one thing that's that, I mean, it's hard to answer this because there's so much, you know, in each of those neoliberalism, biomedical dominance. So, as I was talking, I gave the example in the Kenyan context where most people are still accessing traditional healers or spiritual leaders for their mental health care. And yet you've got this, you know, kind of imposition of a Western biomedical framework. Again, not that people want to completely dismiss that framework or not use it, but it's kind of interesting. It says, though the other part of what's actually going on in the ground is not actually happening at a policy level. If you just read their mental health strategy, you'd think, oh, they just use a Western medical model the same way we do in Canada. But if you actually look what's happening, that's in fact not true, although certainly some people are accessing hospitals and are subject to biomedical practices. You know, with respect to neoliberalism, this is a really interesting question. And I would say that we have not investigated it yet at the level that we need to in the context of Kenya and Australia. We've been focused a lot more on analyzing that in the policy context in Canada, partly personally, because I'm more familiar with the Canadian context. But we are going to see real differential, real different ways in which this impacts. Another really interesting aspect of the project, which I think touches on what you're asking, is that we've really had to explore what does intersectionality mean in each of these contexts, right? So, you know, part of the reason I brought up the language issue and how people refer to different populations is because when we started thinking about, like in the Canadian context to me, it's obvious, okay, if you're talking about intersectionality, you've got to talk about colonialism, you've got to talk about black populations, you've got to talk about you know, new immigrants, people of color, you know, LGBTQ populations, you know, it's really clear, right? When you try to translate to the Kenyan context, it's very different because you're really talking there more about historical conflicts between different ethnic groups and tribes. And you know, so our Kenyan team is really helping us to better understand kind of how do we think about that and which populations do we want to bring, for example, into our focus groups who might be having more difficulty accessing services there. It's going to be really, really different than in the Canadian or indeed the Australian context. One thing that's true across all sites is that there's very little data collected even at the level of, so in the Canadian context, you know, when you look at admissions under the Mental Health Act, you can get sometimes if you push hard, you can get break down by sex, but getting information about ethnicity, indigeneity or first nation status, any other, you know, social locations, the data just isn't broken down that way. So it's not, it wasn't built into our project from the beginning, but we're now talking about partnering with some of the community organizations to develop kind of a critique of, but also a data strategy. So what could in the Canadian context, for example, what could provinces be doing to gather better data so we can better understand the disproportionate impact of these practices? Because we know at the service level, we know that this is happening. And so for example, in the Canadian context, in Toronto, the big, you know, the big center for addiction and mental health research hospital, they recently released a report showing that Black patients are 44% more likely than white patients to be secluded and restrained, like just as an example of some data that's emerging locally. So hopefully that helped to answer that question. There's so much in there and I really appreciate that question because it's definitely ongoing. Which is part of the reason why this research project is so important and so essential in its inter-jurisdictional, you know, approach as well as being centered in these core questions. So thanks for that. Another question, and this was in the text, but now I see it is in our Q&A. I am curious about how mad studies may fit with this research and the alignment that mad studies body of knowledge has with this research. Great. Excellent question. So for those of you who might not be familiar with mad studies, I mean mad studies really, you know, certainly it builds on many, many decades of mad activism. So people who've reclaimed the negative, what's often seen as a negative term, mad have reclaimed that in a positive way and have in many ways kind of said, we don't even want to identify ourselves with concepts like mental health because they've been so, so much dominated by, you know, particular kind of professional knowledges. So mad activism and mad scholarship is really based on gaining knowledge specifically from people with lived experience and also recognizing, I think, I know you're not asking for a definition of it, but I thought I would give it any, and then I'll answer your question, but also recognizing that people's experiences of what are often referred to through diagnostic labels like schizophrenia or psychosis are not always experienced negatively by people. So that there's a space within mad scholarship and mad activism to embrace some of the different ways of being or consciousness, if you like. So having said that, so mad studies I think does play a big role in our project. It's perhaps a silent partner, and I think the reason for that is in part because our work is intended to influence the, you know, the policy domain influence practice and terms like mad are not typically yet adopted in those spaces. And they don't have the same meaning in the Kenyan and Australian context as they do in the Canadian context. However, I would say many of the people involved on the team and many of the activists involved on the team would identify with mad scholarship and mad activism. So I think it does play a role and certainly one of the ways we're trying to enact it is true, and I know we use the term peer because it's a popular term, people understand it, but in our team we have people who identify having experiences with the system many different levels. So it's not just we have peer researchers and then we have other researchers and many of our high profile researchers have lived experience and some of our RAs do, some of them don't. So we tend not to use the labels as a way of, we allow people I guess to adopt the labels when it's necessary or when they want to to foreground their experience, but I think one of the ways we're speaking to mad scholarship is to have that integration throughout the team so that those knowledges are captured at every level. I have a question for you that follows up on what you're describing because I'm really interested in the reflexive method that you have described and been so intentional around. And it seems to me, I mean it's just stating the obvious I suppose, but there are so many experiences and forms of oppression and in some cases privilege instantiated in this concept of lived experience, including lived experience of mental health conditions. It just, it embraces so so much, right, in terms of relative power to define what that means. And so what I hear from you in your project is just a delightful example of bringing people together and making an effort to be conscious of those power differentials and open up opportunity for folks who are located and identified as researchers and located in very different circumstances to participate together. And as you said right from the ground up identifying the values and then doing the research in light of those values. But the question that I want to ask you goes takes you back to the challenges around that because I think that's such rich terrain to explore further as as researchers and you've already offered some examples of things that you have done in this project to try and open up access to participation in the researcher as an equal sorry in the research as an equal. But I just wanted to hear more from you on challenges and ways of overcoming those so just to again set the stage for people you're talking about multiple jurisdictions and multiple social positions and multiple experiences of mental health crisis or episodic or throughout one's life. And yeah I just I'm grappling with all of the challenges involved maybe there are also linguistic differences I'm not sure whether you know English as the base is potentially an issue maybe it's not given you know the jurisdictions that you chosen and specifically I mentioned mural boards as something that you used early on and I'm really interested in how exactly like you know you can't get into all the deal but how the conversations were convened using these drawing type tools potentially to open up access and all of that is asked with cognizance of the fact that we've seen this tectonic like amazing shift in research funding to encourage community academic you know institute university institutional collaboration and we've seen this amazing open opening up of the idea of co-creation of knowledge which is all so exciting and you know the WHO documentation that you referenced is an example of this and your work is so important and yet there it seems to me there's always this worry on our parts as university-based researchers that we're going to reproduce or create new forms of hierarchy where you know in a sense we're asking people to join on our terms you know what I mean is so how we counter that is so important all right I'll open it up to you yeah no they're fantastic questions and there's there's certainly no easy answers with this stuff I mean because it starts right at the beginning you know in terms of you know the social sciences and humanities research council I mean had been a leader in this when they had you know they had their what were called community university research alliance grants which allowed the money for the first time to go to the community partner as opposed to the academic partner now this grant is not of that nature so it starts right there I mean who's holding the money right in the first string so it's it's it's you know the university and there's so many restrictions on what you can do with that money like so we've had to so that's just one example and I don't want to stay with the finances necessarily but but it's one example you have to do a lot of workarounds because in fact according to shirk rules they don't want to fund investigators in other countries right they want because fair enough it's our federal government money they want to be they want the money to be going to building capacity for students for example in the Canadian context so so some of that has been really really tricky right because because money does mean a lot right it's resources right and it and it and it it is a symbol of power right so we've we've you know we've we've worked I think well in that context we figured out ways to transfer funds to other locales to be used in ways that make sense in those locales so that's just one example of you know one of these sort of more tricky areas I think where it also comes down is you know it's all this so we do share a language base so that that is helpful even though it's a colonial language in the context of of Kenya and also Canada and Australia arguably you know but we have a shared language in terms of you know the written but that's not to say in the Kenyan context that it won't become a barrier when we go into the field research because I'm anticipating especially if we're going to include people outside of large cities that that language then will will come up and probably will come up in all sorts of ways I'm not even aware of yet so so I think that will be a challenge one of the things that we do have on our Canadian team that's helped has been a colleague at UBC who is from Kenya and works still in Kenya so he's been able to be a bit of a bridge to our Kenyan partners there the community partners there so he's able to go back and forth between the two countries and has you know deep knowledge of both so that that helps a lot and I would almost recommend that as a almost like a methodology if you've got people that can bridge different cultural locations etc I think it's really helpful in terms of being able to understand some of the nuances of this stuff at a day-to-day level I mean some of it is just identifying you're never going to you know you're never going to be able to equalize the power right so I think a lot of it is about identifying and acknowledging the power power differences and trying to make those things visible in our day-to-day work and so we've done you know our our research assistants we often you know as anybody knows on a research project it's usually like you know the lead researcher and the research assistants that end up you know connecting most often right and and having conversations most often and so I think about that a lot in terms of our team and we have done some quite intentional reflexive exercises together as a way of identifying kind of where we are each positioned in the in the research but our ability to carry that through consistently I would say is is always a struggle it's an ongoing struggle I'm trying to think of examples that I can give you I mean I think some of it I think another thing that's helpful you know especially if you're thinking of doing this kind of work is to have relationships that are already built so although Canada Australia and Kenya have some interesting overlaps and you know they would ended up being great sites to choose they were partly chosen because I had been to Australia I had met with our community partners before I started the the grant development I got people on board in advance had you know had those conversations I was able to meet our Kenyan partner at a UN event in in New York you know the year before where we you know we were able to actually sit at a table and talk to each other and see if there was some mutual you know gains to be made from from them partnering with us on this project so you know so that was really you know that was pre-pandemic it was really nice to be able to do some of that upfront work and I think that's really important so that you're not you know just bringing people on that you that you know by name but don't have any kind of real connection to that said you know we are you know we are built that things are building out and some of our knowledge users are people I've never met before that I only know through other team members or have come on just because they're interested in the project so but but there's a lot of I think people underestimate like the relationship building piece and that that of course is really important and it's hard to do within the constraints of research projects where you know many of us are wearing multiple hats and doing lots of different things the research is over here you're teaching and doing your service stuff community-based organizations you know often doing this stuff off the side of their desk have no recognition for it whatsoever students are in it because they want to gain experience work experience they might be attaching their own you know masters or phd work to it so everybody's got a little bit of a different you know reason they're engaging with it and and everybody is really busy and we still have to meet deadlines and so that can lead to you know where you shortcut some of this stuff right and I think it's the one the one gift the pandemic I guess has given us on this project was the gift of time originally because everybody when this project started we were in the first lockdown it's never been so easy in my academic career to convene international you know partners to get together because nobody was doing anything other than sitting at home right so we were able to have these meetings and many of them to kind of build those relationships so that gift of time at the beginning which allowed us to really and because we couldn't go into the field research you know we could have a lot of conversations about values and and getting we did a lot of setup work I would say meeting up to the actual research and and shirk and as many other funding bodies gave everybody an additional year automatically because they knew people would be slowed down so that just was like okay we can actually do some of this team building and discussions about equity and power in a way that you often don't have the luxury of doing so that's the silver lining I would say of the pandemic. Marina um and I thank you so much for that answer and I asked you such a loaded question that I I'm really regretting the fact we can't have a workshop on just that just that question from multiple perspectives with many participants but we will do that some other day speaking of the gift of time we are we're out of time I'm so sad about that because I would like this to go on but I just want to take the opportunity to thank you for this just a thought-provoking very rich presentation that you've given us today. I also want to take the opportunity to do something I've failed to do at the start in my you know nervousness and my haste to do the introduction I did not acknowledge that we are convening this and have convened this presentation on the ancestral and unceded territory of the Mi'kmaq and that is something that you know I say with a tremendous gratitude but also a sense of tremendous responsibility you know heavy hearts in light of the the evidence that Professor Morrow has discussed about disproportionate course of applications on indigenous and racialized folk but also with you know a sense of hope because of this kind of powerful in a good way research that that's going forward so thank you again Professor Morrow for joining us today and sharing this timely important research with us and thanks to everyone who has attended thanks for the questions that you raised and we hope to see you at the next seminar lecture which is Friday, March 4th when Claire Horne will speak to her work on justice and the use of novel artificial womb technologies right so thanks again and goodbye thank you very much everyone