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The purpose of this community assessment is to determine if a basis existed for the perception of community mental health service providers that a shortage of care level appropriate affordable housing existed in the New Westminster area. In particular, for those clients currently attending the New Westminster Mental Health Centre (NWMHC) and who is part of the NWMHC Community Residential Program (CRP). This perceived lack of care level appropriate and affordable housing has by various health care providers been offered as an explanation for the high use of emergency mental health services by the clients of the NWMHC CRP program. Overall, the purpose of this community assessment is one of problem clarification. Is the problem a lack of available community resources or a lack of care level appropriate affordable housing?

Several steps and considerations were required before the commencement of the community assessment. Five identifiable considerations were the scope of the assessment, the number of investigators involved in the assessment, time line restrictions, ensuring the relevancy and availability of data and formal and informal approval required to collect the necessary data. A description of these considerations is described individually for clarification.

Narrowing the aggregate to clients serviced by the CRP provided a clearly definable population. I felt this would increase the validity of the assessment findings due to statistical information gathered by a variety of agencies providing mental health services to this population. Another consideration was that New Westminster is the location of my work area. Admission statistics indicate that 52% of the admissions to the Community Residential Emergency Short Stay Treatment Program (CRESST) is from the city of New Westminster (1997, Pioneer Community Living Association).

Although information was gather from a variety of sources, agencies and health care providers, all information being gathered and collated would be done by myself.

This consideration was necessary as two lengthy assessments of a community were course requirements. The timely completion of these assessments were required to allow for adequate time frames for feedback and marking of both assignments before the end of the academic semester.

In determining the relevancy and availability of the necessary data, a number of considerations required examination. I had to look at any available relevant data related to my access to housing information for the aggregate as well as availability to access relevant information on services available for the aggregate. My ability to gather relevant data is enhanced by my employment at the community level within the CRP. Front line first hand experience of what client's report as being their most pressing issues during the admission process to my service provides me with insight as to the core reason of clients admission to CRESST. Knowledge of available community resources related to housing and access to a computer with Internet connection enhanced my ability to gather information related to the present housing situation for this aggregate. At my disposal, I had full and unrestricted access to admission records of the clients to my place of employment, an emergency psychiatric care facility. Further, I had unrestricted access to statistical information, which indicated that the majority of clients accessing my service were from the New Westminster area. Those clients most frequently accessing the service were clients of the NWMHC and were part of the CRP. The number of clients currently involved in the CRP was readily available, as were the number of available beds and housing units which is known amongst local care providers and readily available.

Before the collection of the data, I made a formal request of my employer to use the admission records and the statistical information collected by my service. This request received an unqualified approval. A similar request was made of the CRP Coordinator for the NWMHC and this received equal enthusiasm and support. In conferring with my peers, all agreed that such an assessment would be beneficial. The benefactors of this data would be the service provided for the clients and a clarification of current perceptions of the need for housing and the over use of emergency services of clients from the Community Residential Program.

The conceptual models used in this assessment are a blend of the descriptive, epidemiological and ecological.

The major strength of the descriptive model is the focus on the community being assessed. It allows for objective observation of a community in its natural setting. This is supported by the view of Mossing that "an objective observation of the residents of a community in their natural setting provides invaluable input in a community assessment" (1997, p. 5-19). The descriptive assessment as described by Mossing "is a very flexible approach" (1997, p. 5-20). The major weakness of this model is that preconceived notions and biases of the assessor may result in inaccurate value judgements being made about the community being assessed.

The major strength of the epidemiological approach is it can be used when a recognizable problem has been identified and requires follow up or attention. Preventative techniques can be developed to deal with the identified need and future preventative actions can be taken. Another benefit is the ability of the model to aid in identifying resources and the kinds of intervention, which would be most beneficial in addressing the need. The major weakness of the model is an inability to elicit a community's perception of a problem. The model also does not address the strengths of the community and does not provide a wholistic view of the community.

The strengths of the ecological approach is that it is systems oriented and is congruent in this respect with the Neuman Health Care Systems Model, of which this course is based. The model is effective for determining the focus of a particular community assessment. Its weakness is that it is not specifically used in community assessments but rather allows for a focus on a particular aspect of a community assessment.

The resources used in this assessment include statistical information from CRESST admission records, the NWMHC, federal, provincial and city agencies including their respective world wide web sites, health units and through information found in the "Red Book". Other resources included windshield surveys, walking surveys and key informant interviews.

The tools used in this community assessment included the use of the five variables (biologic, sociocultural, economic, political and spatial) as defined by Braden and Herban (cited in Mossing, 1997). Another tool used is the one encompassing eight community variables as described by Anderson and McFarlane (cited in Mossing, 1997). These eight variables were incorporated into the earlier mentioned five variables of the spatial, biologic, sociocultural, economic and the political. It should be noted that not all eight variables were incorporated into the assessment. Of the eight variables, the physical environment, education, transportation, politics and government, health and social services economics and recreation were used. The variable of communication was not incorporated into this assessment nor was consideration given to the issue of public safety. I felt that the inclusion of these variables was irrelevant to the stated purpose of this community assessment.

Prior to the commencement of the community assessment, recognizing that I had some preconceived notions about the community being assessed, I decided to first gather information related to the type, quantity and accessibility of services that are available in the area. I conducted a search of the "Red Book" for a listing of the type and location of resources in the area. An examination of accessibility followed. Having examined the resources of the area I then began compiling information related to the services available in the area. This examination included determining the type, location and accessibility of those services. This fact finding assisted in determining the quantity of resources and services and their accessibility. It was fundamental to make this determination to deal with the question of is there adequate services available to mental health clients living in New Westminster? Answering this question was essential to determining one of the main purposes of the assessment. That being were services in fact being over used by mental health clients?

Having gathered this information, I conducted a windshield and walking tour of the various areas of the city of New Westminster. This allowed me to gain a first hand knowledge of the exact location of resources and services and allowed for a topographical view of the location of housing available to mental health clients of the NWMHC CRP. My interest was the location of housing other than those provided by the boarding home program of the CRP. This included the location and accessibility of retail services and transportation routes.

Receiving the full support of my employer, I used all available resources at her disposal to provide supporting documentation for my data collection and my later analysis of the data collected. In addition to my employer, I also had the support of the CRP Coordinator, which I used to further collect data information, which would also assist in my analysis. The information provided by these two sources, was felt, would ensure a high degree of accuracy and validity of the information and the relevancy of my analysis.

Having a computer with Internet connection provided the means of gathering pertinent information in a short period of time that would be relevant to my community assessment. Information that would normally take perhaps days, weeks or even months was available for my interpretation in a matter of minutes. This information was easily and readily accessible from web sites of all levels of government.

Having determined the type, quantity and accessibility of services, combined with windshield and walking tours of the area, the gathering of information from key informants and access to government documents via the world wide web provided a good quantity of relevant and timely information for the community assessment.

The next section begins the summarization of the collection of the relevant data.

Compilation of information for this assessment comes from a variety of sources. Sources include windshield surveys, statistical information from CRESST admission records, the NWMHC, federal, provincial and city agencies including their respective world wide web sites, the "Red Book", health units and through interviews with various health care professionals.

The aggregate assessed is of interest to a number of service providers. An attempt by health service providers is the facilitation of flow through of client care from emergency services to hospitals to community living.

The assessment information will be oriented towards individuals currently diagnosed with a major mental health disorder on Axis I or Axis II as defined by the multiaxial assessment of the Diagnostic and Statistical Manual IV (1997, p. 37) and are current clients of the NWMHC. Level appropriate refers to clients that are suitable for the CRP offered through the NWMHC. These programs include boarding homes, three-quarter way housing, semi-independent living situations and independent living situations. The focus of my assessment concentrates only on the area of New Westminster. This is the location of my work area and admission statistics indicate that 52% of the admissions to the CRESST facility is from the City of New Westminster (1997, Pioneer Community Living Association.).

The city of New Westminster situated in the centre of the Greater Vancouver Regional District and is referred to as the Lower Mainland (Appendice A). The city, roughly fifteen square kilometres in area, exclusive of bodies of water, is located on a hillside overlooking the Fraser River, 20 kilometres east of the city of Vancouver. The city centre slopes down from Royal Avenue to the waterfront. The city of New Westminster is divided into five distinct areas. These areas are the Westend, Uptown, Sapperton, Downtown and Queensborough (appendices B).

Assessment of the variables that can influence the health of a community can be varied and complex. Braden and Herban (cited in Mossing, 1997) note five ecological variables which influence the health of a community. These are spatial, biologic, sociocultural, economic and political variables. These variables are the basis for collection of data related to the variables at which influence the health of a community. My presentation of the five variables in the next section will be assessed individually. The first variable for assessment is the spatial variable.

As reported in Mossing "Spatial variables consist of geophysical factors that affect the community system" (1997, pp.4-22). Mossing further notes that "In health care and mental health care systems, there are actual geographic boundaries such as health regions, school districts, municipal regions, etc" (1997, pp. 4-22 - 4-23). The current health care system, which encompasses the mental health system, is undergoing a number of changes. Regionalization of health care services is currently underway. Regionalization of health services attempts to provide geographically drawn communities with health services that meet the needs of the population of that community. An appointed Regional Health Board oversees the regionalization of services. The board determines the financial allocation of resources to meet the health needs of the community. Further, through public consultation with the community, the regional health board makes determinations of the kinds of health services needed and desired by the region.

The health authority for the City of New Westminster is the Simon Fraser Regional Health Board. This regional health board encompasses the areas of Burnaby, New Westminster and the Tri-Cities area that is made up of the communities of Port Moody, Coquitlam and Port Coquitlam (appendices C). Within the next section, I will begin by assessing the placement of services and resources located within the New Westminster area.

The placement of services for those with a mental health disorder living in this community are located in the Sapperton, Downtown and Uptown areas of the city. No services for the mentally ill are located in the Westend or Queensborough areas. A general description of the service, agency or institution will be covered in this section.

The Sapperton area contains the Royal Columbian Hospital (RCH), the only tertiary care facility and provincially designated trauma centre within the community. The Maple Cottage Detoxification Centre serves the community of New Westminster as the only medically oriented chemical withdrawal treatment program. This service has been included under the hospital heading due to the medical model orientation of the facility. Queens Park Hospital (QPH) is a resource for the New Westminster area, providing specialized geriatric services. Saint Mary's Hospital (SMH) provides general surgical care and chronic care management of debilitating illness and diseases. SMH also provides palliative care for their patients. Having provided a description of the hospitals located within the New Westminster area, I will now provide a description of community residential facilities.

The CRP administered through the NWMHC, oversees the operation of government licensed facilities that provide housing and programming for mental health clients. These facilities are known as boarding homes. There are two exceptions to the boarding home program. The CRESST unit falls under the umbrella of the community residential program yet is not a boarding home. The other exception to the boarding home program is a facility known as Bluebird House. The house designated as 3/4 housing receives funding and is operated under the auspices of the Canadian Mental Health Association (CMHA). The facility serves as a resource for the Simon Fraser Health Region. The clients served under the boarding home program attend the NWMHC and reside in the New Westminster area. The clients of CRESST do not necessarily live in New Westminster; rather they reside within the designated health region. Consequently, the Mental Health Centre of the client's origins services these clients. The residents of Bluebird House while maintaining contact with a worker from the NWMHC are also monitored and visited on a weekly basis by a worker from the CMHA.

Located behind RCH is the Pioneer Community Living Association (PCLA). This non-profit association provides the services of a twenty- bed rehabilitative psychiatric care facility for young adults. The Pioneer House boarding home is the only non-profit home located in New Westminster. The association also provides a ten-bed emergency psychiatric care facility. The Pioneer House program is a resource for the lower mainland while the CRESST program is an exclusive resource for the Simon Fraser Health Region. Another resource within the Sapperton area is the Blue Spruce Cottage. This privately owned and operated facility is located in a residential area of the district of Sapperton. This facility is twenty beds and serves clients between the ages of nineteen and forty.

In the uptown area of New Westminster, two other boarding homes for mental health clients are located. These facilities are Victoria Home and Patterson Lodge. Victoria Home is a twenty bed facility which serves mental health clients forty years of age and older. Patterson Lodge is a fourteen bed boarding home which provides care to mental health clients aged forty years and older.

The Downtown and Uptown areas of New Westminster offers a multitude of social, vocational, counselling, educational and comprehensive psychiatric services for mental health clients. Sixth Street from the bottom of Columbia Street to Fourth Avenue has the densest concentration of community services and resources for mental health clients living in New Westminster. Fraserside Community Services offers a wide range of services to people with physical and mental health issues. Their programs include suicide prevention, substance abuse services including post detoxification counselling and supported employment programs. This agency also provides the Mental Health After Hours Emergency Services (M.H.A.H.E.S.) (Redbook, 1996). Continuing up Sixth Street, the Alano Club provides social and recreational activities for recovering alcohol and drug addicts (Redbook, 1996). Counselling services on Sixth Street include the NWMHC. The centre provides comprehensive mental health services to residents of the New Westminster area (Redbook, 1996). The centre is also responsible for most mental health services in New Westminster through a variety of contracts for service that is arranged with an array of non-profit societies. Another counselling service located on this street is the Family Mediation and Consultants Practice. This service is provided on a sliding scale fee for service and deals exclusively with matters requiring family mediation (Redbook, 1996). Near the NWMHC, the Message Relay Centre BC Tel provides TTY and TTD services for the deaf. This service is available twenty-four hours a day (Redbook, 1996). Bisecting Sixth Street on Seventh Avenue is the Cameray Counselling Service. The agency provides comprehensive service to those with issues of sexual abuse. This service is a non-profit society (Redbook, 1996). Located on Royal Avenue, Douglas Community College through the Consumer and Job Preparation for Adults with Special Needs Program offers mental health clients personal, social and human awareness skills training. Students of this program have the opportunity to investigate their career options though job explorations and training (Redbook, 1996). Friendship House, operated by Fraserside Community Services, located on Fourth Avenue, provides prevocational, social, and recreational activities for mental health clients. Referral to this service is made through the NWMHC (Redbook, 1996).

The area served by these services as stated earlier is 15 square kilometres. The topography of the City of New Westminster is hilly. The services available are best and easily accessed by the local transit system, which is part of the transit system of the GVRD. The transit system for this city is comprised of diesel buses and routes are conveniently located on major arteries throughout the city. The Skytrain, a light rapid transit system presently runs the entire length of the downtown area to the edge of the westend of the city. The Skytrain system presently runs from the Waterfront of Vancouver City to the Surrey Centre Shopping Mall. The Handidart, a transit system for those with physical disabilities or limitations is available throughout the entire city. The Handidart system forms part of the GVRD transit system. All forms of transit within the GVRD, which includes New Westminster, are wheelchair accessible. Accessibility is subject to scheduling and in some cases, reservations for service are required. With the close proximity of many of the services, specifically, those on Sixth Street, walking or bicycling is a transit option for those so inclined and physically capable of such exercise. According to an information circular published by the Corporation of the City of New Westminster which describes bike paths in the city report that "New Westminster is connected to Burnaby and Vancouver through the 7-Eleven bike system that runs under and beside the Skytrain guideway" (1997, p.4).

The area of Sapperton is strictly residential with a mix of commercial and business units. The main artery being Columbia Street resembles that of a small city with shops and businesses lining both sides of the street. As of 1996, according to the City of New Westminster, the housing units in this area are predominately single family dwellings. There is also a mixture of low rise, high rise apartments and townhouses (Appendices B). Also found in this area are low income and co-operative housing units (Housing Registry, 1997). Statistics are unavailable that represent ownership of these housing units. I would assume that most single family dwelling units would be owner occupied. In a windshield survey of the area, it appears that most of the low-rise apartment units within this area are privately owned and are owner occupied. This assumption is based on for sale signs for individual suites posted outside of the buildings. In the same windshield survey, the high rise apartments appear to be rental units. This is indicated by rental and vacancy signs posted out front of the apartment buildings. Pioneer House, a twenty bed rehabilitative psychiatric boarding home and Blue Spruce Cottage a twenty bed psychiatric boarding home are both located within Sapperton. This housing is reserved exclusively for mental health clients.

This is the main area of commerce. Recent developments of this area include the renovation and refitting of previous retail and office buildings into strata titled condominium units. Development of high rise and low-rise apartments are occurring as well. A windshield survey of these developments indicates that these new high and low rise apartments will be owner occupied. Signs indicating offerings of these units for sale evidence this. I assume that some of the units will be available as rentals at market value by their owners. The New Westminster Quay forms part of the downtown area. In years past, the Quay area served as a large industrial area for the pulp and paper and fishing industries. This area of downtown presently offers a combination of high end, mid-range, low income and co-operative housing units. As of 1996, according to the City of New Westminster, the housing units in this area are predominately apartments (Appendices B). This section of downtown is situated on waterfront property on the banks of the Fraser River. Amenities of the area include a large shopping complex and an esplanade used for walking, bicycling and roller-blading. There is no CRP mental health housing units located in this area.

This area provides for a variety of commercial and business enterprises mixed with a variety of housing units. The housing is a combination of low rise, high rise and single family dwelling units. This area is home to many of the heritage homes in New Westminster. Housing in this area is a mix of rental and owned units. Through a windshield survey of the area, the low rise and high rise apartments in this area are mainly rental units with some owner occupied units. The rental units are noticed by the rental signs located at the front of the buildings. I assume that some of the owner units within this area would also be rented at market values. As of 1996, according to the City of New Westminster, the housing units in this area are predominately apartments (Appendices B). Two mental health boarding homes are located within the uptown area. These homes include Victoria house a twenty bed facility, Patterson Lodge a fourteen bed facility and Bluebird house which provides a four person 3/4 way housing program.

The area of Queensborough is set on lands of former industrial sites. The area is a mix of residential and industrial sites that still function in this community. Industries include pulp, paper, and chemical products. The residential area, as of 1996, according to the City of New Westminster is predominately single family dwelling units (Appendices B). Using a windshield survey, no low-rise or high-rise housing units were seen. As of 1996, according to the City of New Westminster, there are four apartment units located in Queensborough (Appendices B). There are few commercial or retail facilities within this area. Residents are required to travel to the downtown, uptown or Sapperton areas of the city for the purchase of market goods.

The area of the westend is a combination of single family dwellings; low rise apartments and town homes. There are a few co-operative housing units as noted by signs outside the front of the buildings. As of 1996, according to the City of New Westminster, the area is predominately single family dwelling units (Appendices B). There is little in the way of commercial or retail operations in the area. Close proximity to the Uptown and Downtown areas makes shopping services accessible. A significant portion of the westend contains a variety of industrial sites. These sites are mainly related to the manufacturing of paper goods.

A sub-committee from the New Westminster Mental Health Advisory Board examining present housing resources for mental health clients within New Westminster noted that at present all designated boarding homes (Pioneer House, Victoria House, Blue Spruce Cottage and Patterson Lodge) were at capacity. This board also noted that sixteen clients were living in semi- independent living situations in rental subsidized regular market housing. The report also noted that fifteen clients have rental subsidy in regular market housing funded through the Canadian Mental Health Association (Housing Plan Committee Report Revised, 1997). From this report, forty clients reside in boarding homes in the Sapperton area and thirty-eight clients reside in the Uptown area of New Westminster. The location of clients in receipt of rental subsidies through the New Westminster Mental Health Centre and the Canadian Mental Health Association is unknown. Dewar noted that "an estimate of the number of people who immediately require an apartment unit or subsidized apartment in 1996 was 120 individuals. In one year we see a 50% increase to 191, which will only continue to increase creating a greater crisis" (1998, p.3).

A number of government and non-profit agencies were contacted in efforts to determine the number of homeless in New Westminster. The City of New Westminster, The Greater Vancouver Regional District and the Provincial Governments report that no such numbers are available. When an enquiry was made requesting this number from the Provincial Government Department of Vital Statistics, I was told that "the homeless don't complete census forms" (personal communication, March 09, 1998). As part of the 1998 Mental Health Plan put forward by the Government of British Columbia, the following statement made by a consumer of mental health services illustrates the plight of the mentally ill that are homeless. This client stated that "I managed to get a van (to live in). The police checked me out one day…and said, "Find a place when you can". It's been four years now" (1998, p. 12). I considered contacting the missions and soup kitchens of the area, however, they serve not only the homeless but the indigent as well. I can only assume that a persons housing status is not asked before entry. In considering the issue of the homeless, I felt that a windshield survey would provide some clues as to the extent of homelessness in New Westminster. This survey was most telling. In the downtown and uptown areas in the evening, people can be seen sleeping in parks and in the doorways of retail shops. This is particularly noticeable in the downtown area of Columbia Street. A walk through the area is even more telling. The streets leading off Columbia Street heading towards the uptown section of the city contain numerous people in sleeping bags sleeping in front of retail businesses but also in the back alleys. On one walkabout, I noticed people rummaging through dumpsters located in the alleys behind retail and commercial businesses. From the windshield and walkabout surveys, I find that there are a great number of homeless people in New Westminster. The number of homeless with a mental health illness is undeterminable. I did notice a number of people talking to themselves and gesturing with their arms walking about these areas. These solo individuals talking and gesturing to themselves I would assume could be experiencing a mental health illness in addition to being homeless.

Throughout the areas of New Westminster a number of parks, playing fields and green spaces exist. In Sapperton there is Hume Park located on Columbia Street near the Coquitlam border. In uptown, QueensPark is located on the main artery of McBride Boulevard. In downtown, there is the area of Quay. This area while being densely populated offers large tracts of green space. The Westend and Queensborough areas while having no large parks have a variety of playing fields and green areas.

Having presented the components of the spatial variables, the next section will assess biologic variables for this community.

Biologic variables as reported by Mossing "refer to the core of the community or the people within the community. Variables such as age distribution, sex, genetic makeup and disease entities are considered. Ethnic distributions, marital status, household types, etc. are also considered" (1997, p.4-23).

Gathering data for this variable is difficult. Statistical information is available for the population as a whole. In efforts to gain statistical information related exclusively to mental health clients within this community I discovered that no government agency including C.R.E.S.S.T. maintain records as to age distribution, family size and type or mortality rates. As noted in the section dealing with the homeless in the distribution of mental health clients in New Westminster, no such records are kept.

The NWMHC reports that currently they serve a client base of four hundred and seventy five. In seeking information as to age and sex distribution of this population, I was told that "New Westminster Mental Health Centre isn't completely computerized, therefore, such statistics would be difficult to maintain" (personal communication, March 09, 1998).

As of the 1996 Statistics Canada Census Data, the total population of the City of New Westminster was 49, 350. This represents an increase of 13.2% over the 1991 census when the population was 43, 585. At the 1996 census, the population of the GVRD, of which the City of New Westminster is part, was 1,831,665. This represents an overall increase of 14.3% from the census of 1991. In the 1996 census, the population of British Columbia was 3,724,500. This was a 13.5% increase since the 1991 census. This indicates that the growth of the City of New Westminster is slightly below that of the other areas of the GVRD and that of the province of British Columbia as a whole. The distribution of this population for the City of New Westminster according to the 1996 census is (appendices D):

• Females age 65+ = 4,645
• Females age 35 - 64 = 9,355
• Females age 20 - 34 = 6,755
• Females age 19 and under = 4,425

• Males age 65+ = 2,845
• Males age 35 - 64 = 9,775
• Males age 20 - 34 = 6,990
• Males age 19 and under = 4565

As reported by the Corporation of the City of New Westminster, the population is expected to increases to 56,000 by the year 2001 and to 78,000 by the year 2021 (Appendices D).

Using the census and the number of clients reported to be serviced by the NWMHC, mental health clients represent .014% of the total general population of New Westminster. It should be noted that the CRP of the NWMHC services clients that are between the ages of 19 - 64. Clients under the age of 19 are serviced through a separate branch of mental health services that deals exclusively with adolescents. Those clients 65 years of age and older are also serviced through a separate branch of mental health services that deals exclusively with senior citizens. The census information indicates that 32,880 residents of New Westminster would be the maximum numbers of persons eligible for service in the CRP using the age criteria of the mental health centre.

Information related to morbidity, causes of accidents, causes of death and health statistics related to the prevalence and incidence of disease while being important, is irrelevant to my assessment of this community as no data exists for this information and speculation would be of no benefit.

The government of British Columbia maintains statistical information related to deaths from accidents and violence. This information is collated by health area. Suicide falls under this broad category. The number of suicides for the City of New Westminster for 1996 was seven (Appendices E). Using the general population, the rate of suicide amongst the residents of New Westminster for 1996 was .0001. The numbers provided by the government make no differentiation between men and women or age in the presentation of their raw numbers. In an interview with W. Pauley CRP co-ordinator NWMHC (personal communication, March 13, 1998), when asked for the number of suicides by N.W.M.H.C. clients for the year 1996 she reported three. In a later interview with W. Pauley (personal communication, March 13, 1998) she reported the number as zero. When asked about this discrepancy she reported that the mental health centre does not keep such statistical information. She stated that she was informed that giving such information could possibly breach the guidelines of confidentiality. I can only infer that the NWMHC preferred not to release such information. The reason for this reluctance is not known. My request for the suicide rate of the NWMHC clients for 1996 did not include a request for names, dates, places or methods used. The request was for the raw number. With the discrepancy in the numbers reported by the NWMHC the suicide rate amongst their clients could range from none to .006%. In comparison to the general population, the suicide rate amongst mental health clients could range from zero to 42.85%.

Having presented the biologic variables that could affect this community; the next section will be an assessment of the sociocultural variables.

This section assesses those experiences, values and attitudes that are at the core of the community being assessed. Mossing states that "an effective mental health care system considers the attitudes and values or culture of its community members" (1997, p.4-24). This builds upon the beliefs of Braden and Herban (cited in Mossing, 1997) "culture is the sum total of our experiences, language, values, and attitudes--our way of life" (1997, p. 4-24).

The sociocultural variables examined relate to education, health services, social services, recreational facilities, religious groups and cultural centres and special programs. The first to be assessed is education.

Varieties of educational opportunities exist for mental health clients in the New Westminster area. Programs are offered through public facilities such as Douglas Community College and the New Westminster School Board, non-profit societies such as Fraserside Community Services and Friendship House. There is access to the New Westminster Public Library as well as a range of technical and private educational institutions. The Ministry of Human Resources, formerly known as the Ministry of Social Services and Housing, provides funding for education, vocational, technical or trade training for mental health clients that are in receipt of the Gain for Handicapped Pension. The ministry however will not provide a travel allowance for clients to attend those programs. This can present a barrier for some mental health clients who are not yet in receipt of the Handicapped Pension and are receiving regular Gain. The difference is those on handicapped pension are eligible for an annual transit pass that bears no ridership restrictions for a $45.00 fee.

Douglas Community College offers programs in job readiness and preparedness as well as programs of skill enhancement for everyday community living. Other programs offered include trade and technical training for mental health clients. These programs include areas of commercial food preparation and building service workers. Referrals to these programs are not required, although an interview of the client by the college is mandatory. From my experience at Pioneer House, I am aware of at least two dozen clients that have attended Douglas Community College and have successfully completed programs of study. I know of three former Pioneer House residents that are now cleaners working for RCH. Several other former residents now are working in food preparation in either institutional or restaurant type facilities. One former Pioneer House resident completed the Pharmacy Technician Program and is currently employed by a local area pharmacy. From the perspective of this knowledge, the programs offered by Douglas Community College are successful.

The New Westminster School Board, through their department of continuing education offers a variety of job placement and job readiness programs. Also offered are adult education upgrading and computer training programs. Using Pioneer House as the example, several current and former residents have attended these programs. Some residents have received a G.E.D. equivalent to grade 12 and one resident after completing a computer training program became gainfully employed as a part-time bookkeeper.

Fraserside Community Services offers similar job readiness and preparedness programs to Douglas Community College. Their service is geared towards a more chronic and lower functioning mental health client. The service also provides courses and education in enhancement of everyday life skills. The training programs offered are geared towards clients achieving employment in a more supported work environment. The NWMHC must refer participants in these programs.

Friendship House functions as a friendly community house type atmosphere aimed at providing structured activities for mental health clients. The clients of Friendship House publish a monthly newsletter. The house is divided into a number of work areas. These include kitchen work, house maintenance, secretarial and reception duties and improvement of social and verbal skills. The NWMHC must refer participants of Friendship House.

Other technical and trade schools are located in New Westminster. Generally, their admissions criteria preclude many mental health clients from attending such institutions. Graduation from a Secondary School is usually required and the cost of the courses and the course schedules are prohibitive. The Ministry of Human Resources will not approve financial funding for attendance at a private for profit educational institution. The client would be required to meet the educational entrance requirements and the financial obligations of the program.

RCH, a tertiary care facility offers a range of psychiatric services. These services include a day program, inpatient care on one of two units, emergency psychiatry located in the emergency area of the hospital and a Hospital Admission Diversion Program. These services all fall under the Department of Psychiatry. Five psychiatrists are currently on staff at the hospital and provide coverage in the emergency room and the psychiatric units. The day program offers mental health clients the opportunity to attend the hospital during the daytime hours and participate in a variety of life skills enhancing groups. The day program is staffed by a combination of nurses, social workers and an occupational therapist. This provides ongoing monitoring of clients that have recently been in facility care for acute psychiatric symptoms. Acceptance to this program is done through a referral process. Presently the day program can accommodate thirty clients. In an interview with Dr. C. Kogan (personal communication, March 13, 1997) he reports that the day program is no longer serving it's original intended purpose. He reports that the program was established as a means of providing ongoing monitoring of first break schizophrenic patients. He reports that at present the day program is clogged with clients having a personality disorder. The psychiatric emergency area is segregated off to one side of the emergency department. In this area, there are five seclusion rooms. It is staffed by one-nurse twenty-four hours a day. This area is the mental health clients first contact point with the hospital when a psychiatric illness has been detected or reported in the client. After being seen by a psychiatrist, a decision is made to either admit the client to one of the two units, to refer the client to other psychiatric services or to discharge the client. If the decision is made to admit the client and there are no beds available on one of the two units or if there are more clients than seclusion rooms, the client is sent to an area known as Emergency Overflow Department (EOD). From here the clients waits for admission to the hospital, referral to another psychiatric facility or through treatment received while in this area is then discharged back into the community. The two psychiatric units total twenty-nine beds. Once on one of these units, the client is treated and discharge plans are made once, the client's condition has stabilized to be either discharged from the hospital or transferred to another psychiatric care facility. The Hospital Admission Diversion Team (HAD) is comprised of three nurses and one health care worker. The mandate of this program is to follow clients that make repeated visits to the emergency room of the hospital with a variety of complaints. This team provides supervision; referral to community agencies including mental health centres and conducts home visits. The goal is for the client to avoid coming to the emergency room of the hospital. By having this additional support, it is felt that many repeat users of emergency room servers can be curtailed in their visits to the hospital. The Hospital Admission diversion team operates from 10:00 hours to 22:00 hours Monday to Friday. At a recent meeting between RCH and the PCLA, it was reported that 78,000 visits to the emergency room in 1997 were psychiatric related. It was further reported that in 1997, 15,000 psychiatric admissions occurred at the Hospital, which placed them at 120% of capacity.

QPH and SMH are both tertiary care facilities that provide highly specialized care and service to the elderly and to those with chronic debilitating illnesses. Both hospitals offer specialized psychiatric services and assessment for mental health clients over the age of forty-five. The programs offered are aimed at degenerative illnesses such as Organic Brain Disorders, Alzheimer's and dementia. Access to these services must be done through a referral process. The referral is usually made by another health care facility or through the client's family doctor or psychiatrist.

Maple Cottage Detoxification Program is a twenty-bed facility that provides medical management of acute withdrawal from alcohol and drugs. While no statistics are maintained on the number of mental health clients that have substance abuse issues, my experience and that of my colleagues is that the number would be high. Clients are accepted to the program only through client self-referral, which later must be supported by a medical doctor or psychiatrist. The client is taken off all addictive medications before admission to the facility, and if possible, weaned off the addictive medication while awaiting a bed or approval for admission. Waitlists of up to two weeks is not uncommon for this service. Post detoxification care is provided through other community services. This service is a resource for the entire lower mainland which could explain why waiting lists exist for entry to this program.

RCH, QPH and SMH are all non-profit societies operated through the Fraser Burrard Hospital Society under the management of the Simon Fraser Regional Health Board. Funding for these facilities is negotiated with the Regional Health Board, which receives a block allocation of funds from the Ministry of Health. The Ministry of Health receives their funding directly from the Government of British Columbia, which is disbursed through the treasury board, which is part of the Ministry of Finance.

The Maple Cottage Detoxification Program receives funding through the Ministry of Human Resources formerly known as the Ministry of Social Services and Housing. This ministry receives it's funding directly from the Government of British Columbia. The government disburses these funds through the treasury board, which is part of the Ministry of Finance.

In New Westminster, there is one mental health centre. It is located on Sixth Street in uptown New Westminster. The mental health centre presently serves a client base of four hundred and seventy five. The centre has a manager and services are divided into Adult Community Support Services, Adult Short-Term Assessment and Treatment, Geriatric Services and the Community Residential Program. Each department has a co-ordinator of service. Each branch of service will be assessed separately.

This program is designed for new walk-in clients to the mental health centre. After intake, the clients are seen by one of three therapists that form the treatment team. The program provides short-term counselling, therapy and connection to community services for clients that appear to be experiencing a mental health crisis. This crisis does not always meet the criteria for an Axis I or Axis II diagnosis. Clients may access this service for a period of not more than six months. This program may, when necessary, refer the client to other branches of services for longer-term treatment and follow-up. A sessional psychiatrist provides the prescribing of medications for these clients when necessary. The number of clients served by this program is not available as the mental health centre declined to provide this information.

This program serves mental health clients on a long-term ongoing basis. The clients of this program live in the community independently. The program provides ongoing counselling and therapy, connection to community services and a service called Assertive Case Management (ACM). The ACM team works with more challenging clients that require intensive support and follow-up. Clients of the ACM team typically present to the emergency room on a regular basis are unable to manage their own finances and have difficulties with medication compliance. The ACM team has a staff of three. There is also access to a sessional psychiatrist for the prescribing of medications. The goal of the ACM team is to maintain clients in the community with a minimum of visits to the hospital or other psychiatric care facilities. The Adult Community Support Services Team, exclusive of the ACM team has a staff of six. The number of clients serviced by this program is unknown as the mental health centre declined to provide that information.

This program provides mental health services to clients sixty-five years of age and older. The program serves mental health clients that live independently and require ongoing treatment, support, counselling or therapy. The team consists of one staff member. There is a sessional psychiatrist available for the prescribing of medications. The number of clients serviced by this program is unknown as the mental health centre declined to provide that information.

This program provides services to mental health clients that currently reside in one of the boarding homes located in New Westminster. Clients within the CRP program are between the ages of nineteen to sixty-four. All clients have a long psychiatric history and require a supported living environment. The level of support required is determined by the life skills possessed by the client. The program has three staff members described as therapists, one staff member referred to as the CRP assistant and one staff referred to as Bed Utilization Management. A sessional psychiatrist is available for the prescribing of medications. Referral to the CRP program must be made by other mental health centres, hospitals or through a private psychiatrist. The number of clients serviced through this program is seventy-eight. This is the number of CRP beds available in New Westminster. Currently, all beds in the CRP are occupied. There are six facilities that fall under the umbrella of the CRP program. Each of those facilities will be assessed individually.

Pioneer House is a non profit society operated by the PCLA. This twenty-bed facility is located in Sapperton directly behind the Royal Columbian Hospital. The age range of the residents is nineteen to forty years of age. Residents have their own private rooms. Residents are involved in an in-house work program, vocational training, supportive employment or attend a college or educational program. The average length of stay is approximately one year. The goal is for the residents to gain the necessary life skills to live independently or at least at a level requiring less support and supervision. Dewar reports that "Twenty-three residents were discharged from the Pioneer Program in 1997. Ten of these were in need of supported housing, but only three SIL apartments were available. The other seven were forced into living arrangements that proved unsuccessful due to either financial or otherwise inappropriate housing to their specific needs" (1997, p.3). The staffing of the facility is in accordance with local licensing regulations. There is one nurse on during the day and a part time nurse that works three evenings a week. This nurse provides group activities for the residents geared towards enhancement of life skills. There is also a weekend nurse on staff during the day. All other staff is mental health workers. In this facility, these workers are referred to as Community Psychiatric Care Counsellors (CPCC).

Blue Spruce Cottage is a privately owned and operated facility. The facility is located in Sapperton and serves mental health clients between the ages of nineteen and forty years of age. The house offers the residents programs of life skills, crafts and recreational activities. The staff assists residents in accessing community vocational and recreational programs. The average length of stay is between two to three years. Many of the residents work towards more independent living, although this is not a formal goal of the program. The staffing of the facility is in accordance with local licensing laws. There is one nurse working during the day Monday to Friday. A part time nurse works Monday to Friday in the evenings. This nurse provides life skills, craft and recreational activities for the residents. All other staffing is mental health workers (MHW).

This privately owned and operated facility is located in the uptown area of New Westminster. This twenty bed facility serves clients that are forty years of age and older. A variety of programs is offered to meet the social, recreational and rehabilitative needs of the residents. There is no average length of stay. The house is designed for the longer-term client and independent living is not a goal of the house. The staffing of this house is in accordance with local licensing laws. A full time nurse Monday to Friday and a part time nurse staff the house on the weekends during the day. All other staffing is provided from mental health workers.

This privately owned and operated facility is located in the uptown area of New Westminster. The home serves clients that are forty years of age and older. A variety of programs is offered to meet the social, recreational and rehabilitative needs of the residents. There is no average length of stay. Residents of the facility are long term clients that require ongoing care and supervision. Independent living is not a goal of the home. The staffing of this house is in accordance with local licensing laws. A full time nurse staffs the house during the day Monday to Friday and a part time nurse on the weekends during the day. Mental health workers provide all other staffing.

Bluebird House is a non-profit program, which is operated by the CMHA. While falling under the umbrella of the CRP program, the house receives all direction from the CMHA. This house is designed for clients that have the skills and abilities to live independently yet require a minimal level of supervision. There are no structured programs of life skills for the residents. It operates as a communal house with each resident participating in the maintenance and operation. The residents shop independently for groceries, pay the utilities and share in maintaining the cleanliness of the house. The CMHA worker visits the residents on a weekly basis. There is no limit to the length of stay; however, full independent living is encouraged.

CRESST is a non-profit society operated by the PCLA. The facility is located in the Sapperton area of New Westminster. The unit is physically attached to the Pioneer House boarding home. While under the umbrella of the CRP CRESST does not operate as a boarding home. The unit is ten beds and is designed as an alternative to hospital for stabilizing clients experiencing a psychiatric crisis. CRESST endeavours to prevent hospitalization and maintain client autonomy in a safe and supportive environment. The focus of the program is on resolving the crisis and achieving stabilization and readjustment to community living. Efforts are made to minimize disruption with the client's ties to family, friends and the community. Referrals to this service can be made from general hospitals, mental health centres, the After Hours Emergency Service or through a private psychiatrist. Once referred and admitted, the client is interviewed by an on-call psychiatrist whom then prescribes any necessary medications. Two psychiatric nurses during the day Monday to Friday and one Crisis Program Worker staff the unit. In the evenings one psychiatric nurse and two, Crisis Program Workers staff the unit. Night staffing is one psychiatric nurse and one Crisis Program Worker. On the weekend the unit is staffed by one psychiatric nurse and two crisis program workers during the day and the evening. Night staffing is one psychiatric nurse and one crisis program worker. A care assistant works seven days a week during the day. This staff provides assistance to clients in maintaining their grooming and hygiene and maintains general cleanliness of the unit. Admission records indicate that for the year ending 1997, CRESST provided service to three hundred and fifty nine clients (PCLA Admission Records, 1998). The average length of stay in 1997 was six days (PCLA Admission Records, 1998). Dewar reported that "Three hundred and fifty nine clients were admitted to the CRESST program in 1997. One hundred and ten of these clients were suitable for a semi-independent living situation. Twenty-four were discharged to hostels and many returned to undesirable living situations because there was no suitable accommodation available to them" (1998, p.3). Funding for this program comes from a variety of sources. There is a partnership agreement with RCH other funds are provided through the Ministry of Health and the Ministry of Human Resources. The program acts as a resource for the Simon Fraser Regional Health District.

The Mental Health After Hours Emergency Service (MHAHES) is a service provided through Fraserside Community Services, a non-profit society located in uptown New Westminster. This service is a resource for the Simon Fraser Health Region. This mobile service staffed by one psychiatric nurse provides on site assessment of clients experiencing an acute psychiatric crisis. Based on the assessment information the worker then makes a decision as to the disposition of the call. The worker if deemed necessary, will transport the client to hospital for further assessment, may refer the client directly to CRESST for admission or make referrals to other community resources. These resources could include crisis lines, suicide prevention or other counselling services. If the worker is called to a situation that is unsafe, there is co-operation with the New Westminster Police Department and they will attend the emergency if necessary. This service operates from 14:00 hours in the afternoon to 02:00 hours in the morning seven days a week. This service is contracted through the NWMHC.

The Ministry of Human Resources is located on Sixth Street in uptown New Westminster and has a sub-office located in the Quayside Shopping Plaza in downtown New Westminster. The ministry provides for the intake of clients seeking public financial assistance. The ministry administers the GAIN program, which is social assistance for employables and the GAIN for Handicapped which is assistance for those unable to work resulting from a physical or mental disability. The ministry provides emergency funds for those requiring immediate shelter or food. One of the downfalls of this ministry is that in order to be eligible for assistance; applicants must have a current valid address. This presents a problem for the homeless. The homeless are then referred on to other community resources such as emergency shelters, food banks or soup kitchens. The current rate of assistance received by a single employable in receipt of GAIN is $510.00 per month. The current rate of assistance received by a single person in receipt of GAIN for Handicapped is $771.00 per month. These rates are all inclusive for shelter, food, clothing, transportation and any other comforts required by the client. I was unable to ascertain how many mental health clients were in receipt of either assistance program. From my experience, the majority of mental health clients receive GAIN for Handicapped. These clients are also eligible for an annual transit pass at a cost of $45.00.

Alcohol and drug services have been covered in the section dealing with community resources. These resources include medical management of withdrawal from alcohol and drugs to post detoxification counselling. Two services not covered in that section is Alcoholics Anonymous (AA) and Narcotics Anonymous (NA). These services operate as a support to the recovering addict and are operated by recovering addicts. Both operate meetings three days a week in an auditorium of the Royal Columbian Hospital. There is no charge to attend these two services.

The New Westminster Action Centre and Food Bank is located on Sixth Street in uptown New Westminster. Food is provided for those in need one day a week (Wednesday). Recipients are expected to register with the food bank before receiving assistance (Redbook, 1996). Other services related to food banks and free meals are provided by different church organizations. Monday to Saturday the Union Gospel Mission provides a free meal at 17:00 hours. This Mission is located on Clarkson in the downtown area. Every Wednesday the Queens Avenue United Church provides a free lunch between 11:00 to 13:00 hours. On Thursdays between 08:00 and 09:00 hours, the Holy Trinity Cathedral on Carnarvon in downtown provides a free breakfast. In addition, on Thursday a free lunch is served at St. Barnaba Hall on Fifth Avenue in the uptown area. Every Sunday the New Westminster Four Square provides a free supper at 17:00 hours.

The Fraserside Shelter is a non-profit society operated by Fraserside Community Services. The shelter is located in the downtown area. Accommodation is available for men, women and those with children. Maximum length of stay is thirty days. The exact location is not known, as this information is kept confidential due to children being allowed into the shelter. Referral to this shelter is made through the Ministry of Human Resources. Stevenson House is a non-profit agency that provides temporary shelter for men only. The shelter is located on Carnarvon in downtown New Westminster. Accommodation is provided for up to fourteen days. Referral is made through the Ministry of Human Resources.

Located in the Sapperton, Uptown and Downtown areas, a number of recreational facilities exist. These include a number of parks and green spaces, all of which are free of charge. The Canada Games Pool located in uptown New Westminster offers an Olympic sized swimming pool and exercise equipment. Mental health clients that receive GAIN for Handicapped are granted admittance to this facility free of charge. The tickets are obtained through the client's worker at the mental health centre. From my experience at CRESST and Pioneer House, I am aware of several organizations that provide free admission to a number of recreational or cultural events. The Massey Theatre on many occasions has provided tickets free of charge for mental health clients to attend live plays, theatre and concerts including the Vancouver Symphony Orchestra. Friendship house also organizes and finances a number of different activities and outings. The CMHA each year sends two groups of fifty clients on camping trips. There is no charge for this activity. Clients are made aware of these offerings through their workers at the mental health centre, the boarding homes in which they reside or through such places as Fraserside Community Services or Friendship House.

All religious denominations can be found in the various areas of New Westminster. These denominations include Catholic, Protestant, Presbyterian, Lutheran, Baptist, Anglican and Jehovah's Witnesses just to name a few.

As mentioned earlier, the rate of social assistance for those deemed handicapped is $771.00 per month. This is inclusive of all living expenses. Also included are full medical, dental and prescription services. The Ministry of Human Resources when contacted would not disclose the number of persons living in New Westminster in receipt of GAIN for Handicapped. The NWMHC also declined to provide the number of their clients in receipt of the Handicapped pension. Drawing from my experience, mental health clients of the NWMHC are in receipt of this benefit.

According to the Housing Registry in New Westminster, in a telephone request for average rental housing costs, the receptionist (personal communication March 12, 1998) reported that a bachelor apartment would cost between $450.00 to $550.00 monthly. She also reported that a one bedroom unit would cost between $500.00 - 650.00 monthly. The housing registry in giving these numbers was not area specific. These were average numbers for the area of New Westminster.

Using my assumption that mental health clients of the NWMHC are receiving the Handicapped Pension, I would also assume that most of these clients are not part of the general labour force. Clients receiving the handicapped pension are eligible to earn up to a maximum of $200.00 per month as a supplement to their pension. From my experience, many clients are unable to advantage of this additional allowance. I am aware that a number of clients do volunteer work, which qualifies them for an additional benefit of $100.00 per month. To receive this amount the client is required to work a minimum of fifteen hours per week.

As mentioned earlier, the area of New Westminster is serviced by the transit system of the GVRD. There is also the skytrain, which runs through the downtown area and connects to the areas of Surrey, Burnaby and Vancouver cities. Clients receiving the handicapped pension are eligible for an annual transit pass for a $45.00 fee. There are no travel restrictions to this pass other than the pass is non-transferable to another person.

The city of New Westminster currently provides no subsidy for housing of persons with a mental health illness living within the city. In searches of web sites and city hall planning documents, no reference can be found for future plans to provide such subsidies. In fact, New Westminster provides no health services for persons with a mental illness. All services within the city are provided through either non-profit societies or the provincial government. Funding of these services are provided either through private donation or through service agreements with various provincial government ministries.

Provincially, the Ministry of Health and the Ministry Responsible for Seniors in their 1998 Mental Health Plan indicate that on a treatment and housing continuum, safe and appropriate housing is a basic issue for people with a serious mental health condition (Mental Health Plan, 1998). According to the plan "a provincial housing partnership, which has been recognized as a best practice model, and is being expanded involves the Ministry of Health and Ministry Responsible for Seniors, Ministry of Municipal Affairs and Housing, BC Housing, non-profit housing societies and the co-operative housing sector" (1998, p.31). This plan has not resulted in any housing starts for the mentally ill in the New Westminster area. In recent years, the regionalization of health services mandated by the provincial government has resulted in a restricted movement of clients amongst the various health regions. Clients are no longer being allowed to choose their service providers. The providers of service are being chosen for them. From my experience, when clients from outside the health region attempt to access services they are either refused service or redirected to the community of their residency. This has resulted in clients being denied access to such things as specialized care and subsidized housing where it currently is available.

This section provides an analysis with respect to the sample size, data sources, data cluster and data accuracy. An assessment of the reliability and validity of these items will form part of this analysis.

As defined in the purpose of this assessment, mental health clients of the New Westminster Mental Health Centre Community Residential Program were the aggregate. The size of this group is seventy -eight. This represents 100% of clients that participate in the Community Residential Program of the New Westminster Mental Health Centre. While the focus of this assessment was on those clients of the CRP much of the data relates to all of the clients of the New Westminster Mental Health Centre, which is four hundred and seventy five. The number of admissions to CRESST and to RCH reflects this. CRESST, RCH and the NWMHC make no differentiation between those clients that are part of the CRP and those that are not. This lack of differentiation makes the reliability and validity of the data as it relates to the sample size questionable. For complete accuracy, reliability and validity CRESST, RCH and the NWMHC would be required to differentiate between those clients when seeking assistance or treatment at these facilities.

The sources of data included admission statistics from CRESST, the "Redbook", key informant interviews, the NWMHC, government agencies including federal, provincial and city, which encompassed their respective world wide web sites. The majority of these sources provided reliable and valid information. The NWMHC provided only program information. The NWMHC was reluctant to provide any statistical information related to clients of the community residential program. The base for this reluctance is unknown. The number of clients participating in the CRP is known only because the number of beds or housing units is known. At the time of the assessment, it was common knowledge amongst all providers of care that all available beds and housing units within the CRP were at capacity. Data provided by CRESST, RCH and government agencies including their web sites were current and accurate. Personal communications from key informants are of questionable accuracy as there is no data to back up the information provided. Some personal communication is based on subjective observations, which makes the reliability and validity of the information questionable. The best example of subjective observations was the personal communication with Dr. Kogan regarding the day program offered at RCH. The conclusions drawn to make such a statement is unsupported by any documentation, which could reflect his own personal biases. This information needs to be viewed in the context of objective findings and information. Other personal communications such as that with the CRP Coordinator for the NWMHC related to suicide rates would be deemed inaccurate and of questionable validity as the information that was provided changed several times. Conversely, personal communication with the Housing Registry regarding housing costs in New Westminster could be considered as accurate and valid. The information provided could easily be verified by looking through newspapers to determine the actual cost of housing. A search through local and mainland newspapers support the information provided by the Housing Registry.

The data clusters of the spatial, biologic, sociocultural, economic and political variables will be analysed individually.

In examining the spatial variables that can affect the health of the community, specifically, mental health clients living in the City of New Westminster, the information collected is reliable with a high degree of validity. Under different circumstances, the same information could be gathered using the same techniques. The information collected reflects that New Westminster is centrally located within the GVRD and an array of services exists for clients of the CRP. The services are conveniently located, easily accessed and public transportation in different forms is available. The information gathered under the spatial variable is what was being sought, providing validity to the information that was gathered under this variable.

In examining the biologic variables of this community, the information gathered has little reliability. Under different circumstances, using the same tools and techniques very different information could have been collected. The reluctance of the NWMHC to provide information related to the break down of their clients into such categories as male, female and age groups makes the information that was collected and presented unreliable as no base existed for comparison. With respect to validity, I was not attempting to determine if male or female clients used what services and how often, nor was I attempting to discern between the housing situations of male versus female, therefore, on this point the question of validity is of little concern. The information presented of interest is that mental health clients represent a small percentage of the overall population of the city of New Westminster. This information is reliable and relates back to the question of is there sufficient services and agencies to serve the needs of the aggregate?

Information gathered within this variable has gaps in reliability. Under different circumstances, using the same tools and techniques the information presented could be different. As CRESST, RCH and the NWMHC make no discernment as to the client's CRP status on admission to emergency care, the numbers presented by PCLA and RCH reflect the entire client base of the NWMHC. A cue does exist that services are being overused when consideration is given to the base number of clients of the NWMHC and the number of admissions to psychiatric care facilities. There are gaps in the degree of validity of the information gathered and presented. A determination of the type and quantity of services and resources was being sought. It was shown that a full range of comprehensive services and agencies existed. The use of those services however is where the information presented is less than fully valid. As no differentiation is made between CRP and non CRP clients when accessing services, a definitive determination could not be made with respect to whether clients of the CRP over use emergency psychiatric mental health services which are available to them. It could be said, based on the information collected that overall, clients of the NWMHC are over accessing emergency psychiatric mental health services.

The economic variables presented contain high degrees of reliability and validity. Under different circumstances, the same information would be collected if using the same tools and techniques. The information gathered is congruent to what was being measured. This is supported by verifiable rates of payment provided under the GAIN and GAIN for Handicapped programs, which a majority of the aggregate is in receipt of. The housing costs provided by the Housing Registry combined with the remuneration received by the client's supports the idea that affordable housing is out of the reach of most clients of the CRP program. In fact, the information supports the idea that affordable housing is out of reach for the majority of the clients of the NWMHC. Further validity is found in the government's acknowledgement that housing for the mentally ill is a top priority. While this acknowledgement is addressing an entire provincial issue, it has relevance for the clients of the CRP in New Westminster. Additional validity is achieved in the comments of Dewar (1997) which depicts the failure of community placement of mental health clients due to insufficient affordable and care level appropriate housing.

Data collected under the political variable is reliable with a high degree of validity. The only question as to the reliability of the data is the time constraints under which this assessment was performed. Insufficient time to collect information rendered me unable to canvass local politicians as to their views and possible plans for housing of mental health clients in New Westminster. The cues from the information collected however indicate that at the city level, there is little interest in this issue. As mentioned in the economic variable, the provincial government recognizes the need for affordable and care level appropriate housing which lends validity to the original purpose of the assessment. The comments of Dewar (1997) further validates the need for affordable and care level appropriate housing for clients being discharged into the community of New Westminster. One area of questionable validity is my assertion that the Regionalization of Health Services has resulted in the restriction of movement of clients into areas of affordable housing. This assertion is based on cues of my dealings with other mental health agencies in attempts to place clients in housing outside of the health region that I work.

Having examined the reliability and validity of the data assessment collected under the five variables, the next section will provide an explanation of the interrelationship of those variables.

The assessment information shows an interrelationship amongst the variables. Spatially, there is a sufficient variety of services available. The community is centrally located, services are readily accessible and there is easy access to public transportation. These variables would normally have a positive impact on the health of the community. When the data collected in the economic variables is examined, a link can be found between housing costs, income levels and the negative impact this has on the community despite the availability of services. The stress of attempts to live independently or at the highest level of functioning within the economic restrictions affects the well being of this community. Politically, the regionalization of health services has for the time being limited the movement of clients in search of services and affordable care level appropriate housing. This restriction of movement has led to clients being forced to live in accommodations that are not appropriate to their level of functioning or within their range of affordability.

With the explanation of the interrelationship amongst the variables and how this can influence the health of the community, the next sections will identify the strengths and the actual problems facing this community.

In this section, I will be identifying strengths of the community. The strengths identified are of the "community" in which the aggregate resides.

As supported by the assessment data, there is a multitude of services available within the community. The services include comprehensive psychiatric services, psychological counselling, vocational and rehabilitative programs. These services are easily accessible, and in the case of emergency services, are available and accessible twenty -four hours a day. The community is centrally located within the GVRD. This provides ready access to the other areas of the lower mainland. This central location is enhanced by the accessibility of public transportation including the skytrain system that connects New Westminster to several other communities within the GVRD. The small geographic area of New Westminster is a strength in that services are close together and in areas where mental health clients of the CRP and the NWMHC reside. This further enhances accessibility as long distance travel is not required to access mental health services or the other amenities provided within the community. The separation of industrial and residential areas where clients of the CRP reside enhances their quality of life, as the clients are not located in areas of concentrated pollution. The community provides a variety of green spaces, parks and there is a variety of social and recreational activities that can be accessed in many cases free of charge.

Neuman states that "the flexible line of defense protects the normal line of defense, which is the usual wellness state" (1995, p.26). Neuman in her description of the flexible line of defense notes that "it ideally prevents stressor invasions of the client system, keeping the system free from stressor reactions, or symptomatology" (1995, p.27). The action of the flexible line of defense allows for this prevention of stressor invasion by acting in an accordion like fashion. That is, when greater protection is provided, the flexible line expands outward providing increased protection to the client system (Neuman, 1995). Using the flexible line of defense, the strengths presented by this community would serve to extend the flexible line of defense allowing for greater protection of the community.

In this section, identification of the stressors experienced by this community will be presented. After identification, the stressors will be related to Neuman's lines of defense (1995). This will allow for a community diagnosis to be formulated.

The stressors identified for this community is:

1. Inadequate personal incomes
2. Lack of subsidized semi-independent and independent housing accommodations
3. Regionalization of health services
4. Territoriality of mental health service providers

Using the Neuman Health Care Systems Model when applied to this community and to these stressors requires identifying the stressors as being either intrapersonal, interpersonal or extrapersonal. Another aspect of consideration is which level of prevention as intervention would be most applicable in dealing with the identified stressors.

The inadequate personal income levels of this community can be classified as being extrapersonal and intrapersonal stressors that are part of the internal and external environments of the community. The inadequate personal income levels are extrapersonal in that the client is dependent on another for financial support. This financial support is provided by the government through the Ministry of Human Resources in the form of GAIN and GAIN for Handicapped pension. The community has no control over the amount of income provided to them and must make ends meet with what they are provided. This leads the stressor to become intrapersonal. The client is required to provide for their basic life necessities and shelter out of this limited income resource. High housing costs or increased costs in the areas of food or utilities can magnify an already existing problem. The net affect of an inadequate income level can influence the physiological, psychological and sociocultural variables identified by Neuman (1995). In terms of the assessment data, this stressor has penetrated the communities flexible line of defense and is impacting on the communities normal line of defense. Neuman notes that "the normal line of defense is a standard against which deviancy from the usual wellness state can be determined" (1995, p. 30). The stressor of inadequate income levels of the community as indicated in the assessment data has resulted in clients being returned to or sent to undesirable living situations. This can be attributed to the inadequate level of income. The return or being sent to undesirable living conditions has placed pressure upon the provision of emergency psychiatric services as the community is seeking assistance from the only available resource that can provide immediate relief from the stressor. As the community attempts to maintain system stability and utilizes emergency care services, the result is the formation of a created environment. This created environment has resulted in the belief that there is insufficient services being provided to the community. At the same time, the community believes that the emergency services being provided are inadequate and are unresponsive to their needs. At present, the level of prevention as intervention is tertiary. As health service providers are unable to change the income levels of this community, maintenance of stability becomes the outcome. Providers of health services make attempts at secondary prevention by providing clients with information on such things as the location of food banks, clothing banks, budgeting skills and coping skills. This level of prevention while being useful does not address the issue of inadequate personal incomes.

The lack of subsidized semi-independent and independent housing accommodations can be viewed as being an extrapersonal, intrapersonal and interpersonal stressor occurring within the external and internal environments. As an extrapersonal stressor in the external environment, the community has no control over the number of subsidized units that are available at any given point in time. Intrapersonally, living is inappropriate care level accommodations can affect this communities sense of self-esteem and worth. Intrapersonally, the community is faced with living in accommodations with others that perhaps are not at the same degree or level of functioning. This situation of the community interacting with others of lower levels of functioning can have a negative impact on the skills currently possessed by the community. This stressor has penetrated the flexible line of defense and is affecting the communities normal line of defense. This stressor has resulted in the community seeking refuge by accessing emergency mental health services as a means of maintaining the system integrity of the community. Accessing emergency mental health services by this community related to this stressor is the community seeking relief and is an attempt by the community at secondary prevention. The community is seeking secondary prevention as the community as a system is attempting to achieve progress beyond the baseline normal line of defense. The current level of prevention as intervention provided to the community is at the tertiary level. Primary and secondary levels of prevention are currently being developed as the government has recognized the need for this housing and has committed to a plan of action to deal with this stressor.

Regionalization of health services is an extrapersonal stressor with intrapersonal and interpersonal repercussions. The restructuring of health services in an attempt to bring care closer to home and to allow communities to provide for the health services they desire and are willing to allocate funds for has resulted in this community being restricted to seeking or accessing services located within the geographical region in which they reside. This has resulted in the community being denied access to services and programs that are offered in other "communities". Intrapersonally, this restriction has resulted in increased levels of frustration and feelings of isolation by the community. This can also lead to feelings of worthlessness and hopelessness and a sense of powerlessness. Interpersonally, the community is required to work with providers of service that are unable to resolve or provide relief from this stressor. This leads to interpersonal conflicts with therapists, workers and service providers. This stressor has penetrated the flexible line of defense and is impacting on the communities normal line of defense. This stressor has forced the community to access services that are inappropriate to the need. The current level of prevention as intervention is tertiary. The prevention is aimed at maintaining system stability and supporting existing strengths in an effort to prevent further regression.

The territoriality of mental health service providers is a by-product of the effects of regionalization of health services. It can be classified as an extrapersonal stressor in the external environment that becomes an intrapersonal and extrapersonal stressor. Regionalization of health services has made service providers protective of the services available in their individual communities. This has resulted in the restricted movement of the assessed community as different health regions are attempting to provide service to "their" existing client base. Intrapersonally and extrapersonally, the assessed community are required to maintain stability within their designated health region which at present doe not have the means to provide adequate housing for them. This leads to frustration, anger, and feelings of hopelessness and worthlessness. The perception of the community is that the service providers are being unresponsive to their needs. This perception is part of a created environment. At present, there is no level of prevention as intervention being used to deal with this stressor.

Having identified the stressors of this community and relating them to the Neuman Health Care System Model, the next section is the formation of a community diagnosis.

Drawing from the assessment data collected, identifying the stressors and having related those stressors to the Neuman Health Care Systems Model, the formulation of a community diagnosis is now possible. The following diagnoses with respect to this community are:

1. Inadequate personal incomes as related to:

• Inadequate payment rates of GAIN and GAIN for Handicapped Pensions

1. Inadequate supply of subsidized semi-independent and independent housing accommodations as related to:

• Insufficient government funding of housing units for the mentally ill
• Restricted access to services and programs outside of the communities geographical boundaries
• Protective measures of health service providers restricting access to services and programs to only clients within their geographical boundaries

1. Inadequate access to care level appropriate affordable housing secondary to:

• Inadequate levels of personal income
• Inadequate payment rates of GAIN and GAIN for Handicapped Pensions
• High cost market level housing

1. Territoriality of health service providers related to:

• Regionalization of health services
• Services being determined by the Regional Health Authority
• Block Funding of health services by the provincial government

1. Over use of emergency mental health services secondary to:

• Stress related to inadequate housing accommodations
• Inadequate coping mechanisms of the community
• Past emphasis on institutional care
• Full capacity of boarding homes available and accessible to the health region

Mental health clients of the New Westminster Mental Health Centre are in need of improved financial support and access to affordable and care level appropriate housing. The city has a comprehensive range of health services available, which are provided by non-profit and private agencies. The stress of living in inappropriate housing be it unsuitable for reasons of the level of care provided or the cost appears to be resulting in an over use or misuse of available resources. Until the issue of housing and income levels is addressed in a substantial way, there will be an ever-increasing demand placed on hospital and other emergency care services as the population continues to grow.

An equally pressing issue for the clients of the New Westminster Mental Health Centre Community Residential program is regionalization of health services. Until the process of regionalization is complete and while health care providers continue to discriminate against clients based on geographical boundaries, additional strains will be placed upon an already overburdened system of emergency services.

The factors of inadequate income, inaccessible affordable care level appropriate housing and regionalization of health services in their present form, will continue to have negative impacts on the overall health and well being of the clients of the New Westminster Mental Health Centre, especially those within the Community Residential Program.

REFERENCE

American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4^th. ed.). Washington, D.C. : American Psychiatric Association

Corporation of the City of New Westminster. (1997). New Westminster Community Profile. New Westminster, British Columbia: Corporation of the City of New Westminster

Dewar, C. (1997). Pioneer Community Living Association Annual General Report.

New Westminster, British Columbia: Pioneer Community Living Association

Ministry of Health and Ministry Responsible for Seniors. (1998). The 1998 Mental Health Plan : Revitalizing and Rebalancing British Columbia's Mental Health System.

Victoria, British Columbia: Government of British Columbia

Mossing, J. (1997). Community Concepts for Psychiatric Nursing Practice (3^rd. ed.).

New Westminster, British Columbia: Douglas College

Neuman, B. (1995). The Neuman Systems Model (3^rd. ed.). New York: Springer

Pauley, W. (1997). Housing Plan Committee Report Revised. New Westminster, British Columbia: New Westminster Mental Health Centre

Pioneer Community Living Association. (1997). Admission Records and Statistics.

New Westminster, British Columbia: Pioneer Community Living Association

United Way. (1996). The "Red Book": Directory Services for the Lower Mainland.

Vancouver, British Columbia: Information Services Vancouver

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