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35JANUARY 2014 VOLUME 110 NUMBER 1
In a lecture she gave last
June, Heather Stuart spoke
about a colleague who had
breast cancer treatment and
woke up in a hospital room filled
with flowers and cards and
visitors, thrilled with the support.
Sometime later, this woman was
hospitalized for depression. She
woke up sad and alone in an empty
room. “This is what stigma is and
what stigma does,” said Stuart,
the Bell Canada mental health and
anti-stigma research chair at
Queen’s University and senior
consultant to the Mental Health
Commission of Canada (MHCC).
“The most disturbing part is that
my colleague is a psychiatrist and
works in a mental health facility.
You would think that mental
health professionals would be
more understanding.”
Health-care providers may be
aware that they should not perpetu-
ate stigma, yet people who seek help
for mental health concerns report
that some of the most deeply felt
stigma they experience comes from
front-line health-care professionals.
The desire to avoid stigma is one of
the key reasons people who meet the
criteria for mental illness may not
seek care.
Stuart, who is also a professor in
the public health sciences depart-
ment at Queen’s, is co-author of a
paper that provides an overview of
the nature of stigma associated with
mental illnesses, with a focus on the
stigma demonstrated by health-care
providers. The authors cited a review
of general nursing literature, which
revealed that some emergency
department and intensive care unit
nurses behaved in openly unsympa-
thetic and demeaning ways toward
people with mental health issues.
These nurses felt that dealing with
such issues was not their job, and
they viewed people who had self-
harmed as wasting resources meant
for saving lives.
Many health-care providers do
not realize that their own language
and behaviours are harmful, says
Stuart. “Every one of us is part of
the problem, because we’ve all
grown up in a society that has taught
us to stigmatize mental illness. Even
though we don’t want to admit it, we
all do it. It’s unconscious and can
come up particularly when we’re
Stigma, according to the MHCC, is a complex social process that marginalizes and dis-enfranchises people who have a mental illness and their family members. Prejudicial attitudes and discriminatory behaviours fuel inaccurate notions that people with mental illness are violent, unpredictable and can never recover. There are three kinds of stigma: self-stigma, public stigma and structural stigma, which occurs at the level of institutions, policies and laws and results in inequitable or unfair treatment.
Stigma defi ned
“We’ve all grown up in a society that has taught us to stigmatize mental illness. Even though we don’t want to admit it, we all do it”
BY JANE LANGILLE
Reducing Stigma in Health-Care Settings
34 CANADIAN-NURSE.COM
FEATURE | THE MENTAL HEALTH SERIES
Interference“People are interfering with me, putting labels on me as if I am the guy with so many problems. It is a cruel approach to dealing with me. No empathy and lots of judgment.” — Almier
36 CANADIAN-NURSE.COM
busy or harried. It takes a fair bit of
energy to overcome this behaviour.”
According to the MHCC,
concerning behaviours in health-
care settings include diagnostic
overshadowing (wrongly attributing
unrelated physical symptoms to
mental illness), prognostic negativity
(pessimism about chances for
recovery) and marginalization
(unwillingness to treat psychiatric
symptoms in a medical setting).
Stuart says that derogatory labels
like psycho, crazy and frequent fl yer or
code words unique to a particular
setting are highly stigmatizing
because they serve to defi ne clients
by their mental illness rather than
regarding them as whole people.
The MHCC’s major initiative to
reduce stigma is Opening Minds. It
identifi es and evaluates existing
anti-stigma programs and works
with a growing number of partner
organizations across the country to
share projects that are eff ective. To
date, more than two dozen programs
designed for health-care providers
have been evaluated. Participants
were tested before and after the
program, and in some cases again a
few months later to see if changes
were sustained.
APPROACHES THAT WORK“Our evaluations show that
stigma can be reduced signifi cantly,”
says Mike Pietrus, director of
Opening Minds. “Among the most
successful programs for health-care
providers are those that incorporate
recovery-oriented contact-based
education or skills training, or both.”
Recovery-oriented contact-based
education involves having people
who are living hopeful, satisfying
lives and who have a mental illness
talk about their experience in either
live presentations or videos. Skills
training gives health-care providers
appropriate methods to treat and
interact with people who have
mental illness.
Ontario’s Central Local Health
Integrated Network (LHIN) has been
identifi ed as having a high-
performing anti-stigma program.
Seventy per cent of the hospital
workers and support staff who
participated in the two-hour
program experienced a reduction in
stigma. “Booster” sessions were
introduced after evaluations at the
three-month mark showed that these
positive changes were not
maintained. The sessions, which
feature role-playing, videos and a
web-based program, are held a few
months after the initial training, and
they help maintain the reduction in
stigma.
To date, the Central LHIN
program has been rolled out in three
other Ontario LHINs, the Vancouver JANE LANGILLE IS A HEALTH AND MEDICAL WRITER IN RICHMOND HILL, ONT.
Island Health Authority, IWK
Children’s Hospital in Halifax,
Alberta Health Services, and seven
community hospital emergency
rooms in British Columbia’s Interior
Health.
North York General (NYGH) in
Toronto was one of the test sites for
the Central LHIN program. Mental
health staff initially felt they didn’t
need anti-stigma training, explains
Mary Malekzadeh, clinical team
manager for the adult inpatient and
geriatric psychiatric units and
anti-stigma program site manager.
“However, as the program
progressed, people found there were
things they could work on, and they
gained a better understanding of
how stigma may present in our
setting.”
NYGH’s mental health staff
discuss stigma frequently and
continue to share their learning. In
recent policy-setting meetings, they
were able to dispel the belief of the
other staff that mental health
patients would have the most
diffi culty adjusting to a new no-
smoking rule on all hospital grounds.
“In fact,” says Malekzadeh, “our
patients did better than even we
expected. This indicates to me that
we need to keep talking about
stigma.” ■
Online exclusive! In February, we will be sharing readers’ personal stories of mental health challenges.
In the March issue, we take a closer look at suicide prevention and the profound impact of suicide on family and friends left behind.
Seventy percent of the hospital workers and support staff who participated in the program experienced a reduction in stigma
32 CANADIAN-NURSE.COM
Suicide is so fi nal,” says Judy
Dunn, whose son died by
suicide. “You can’t take it
back. It leaves a wake of
devastation and countless people in
great pain, becoming part of your life
forever.” Dunn is an outreach man-
ager with the Mood Disorders
Association of Manitoba and co-
founder of AndrewDunn.org, which
works to raise awareness and reduce
stigma about mental illness and
suicide through education and
fundraising activities.
Nearly 4,000 Canadians die as a
result of suicide each year, according
to Statistics Canada, and about 90
per cent of these individuals were
dealing with a mental health problem
or illness. Suicide rates are highest
for people age 40-59 years and three
times higher for males than females,
at 17.9 per 100,000 versus 5.3 per
100,000. Suicide among Aboriginal
Peoples is a particularly critical
issue. For example, the rate among
First Nations is about twice that of
the total Canadian population, while
for Inuit it is 11 times the national
average.
Organizations across Canada are
spearheading eff orts to reduce the
number of people who die by suicide
and to help those left behind learn
how to cope better with their loss.
Calgary-based LivingWorks
Education is a private, for-profi t
corporation that off ers community-
based suicide intervention training.
Over the past 30 years, nearly one
million people in 22 countries have
FEATURE | THE MENTAL HEALTH SERIES Canadian Nurses Association/Mental Health Commission of Canada
Health-care professionals need to pay particular attention to the language they use when talking about suicide. Certain phrases can further hurt and stigmatize people in tragic situations by increasing their sense of shame, isolation and secrecy and making it even more diffi cult for them to reach out for help. Committed suicide and completed suicide imply a negative judgment or a criminal off ence, while successful suicide implies accomplishment. Death by suicide or died by suicide are preferred phrases that can off er comfort and provide support for healing. Suicide survivor can refer to those who have experienced their own suicidality or those who are bereaved by suicide. Some survivors prefer the terms suicide attempt survivor, survivor of suicide loss or survivor bereaved by suicide. More important than using correct terminology is capturing a tone of compassion and understanding.
Talking about suicide
BY JANE LANGILLE
Suicide Prevention and Postvention Initiatives
participated in its 14-hour ASIST
(Applied Suicide Intervention Skills
Training) workshop. Through group
discussions, videos and simulations,
participants learn how to connect
with, understand and help people who
are at immediate risk of suicide.
According to a 2010 report that
summarized 20 formal and informal
evaluations from Australia, the U.S.,
Norway, Scotland and Canada,
ASIST participants were very
satisfi ed with the training and showed
greater relevant knowledge, more
positive attitudes and better interven-
tion skills, compared with pre-train-
ing states and non-trainees.
Trainers have tailored the
program’s experiential learning
components such as role-playing and
simulations to suit the professional or
cultural needs of participants,
including First Nations and Inuit.
“People who have taken the workshop
have told me they found it very useful
and are quite confi dent they have
actually prevented some suicides,”
says Terry Audla, national Inuit
leader and president of Inuit Tapiriit
Kanatami (ITK), an organization
representing Inuit across Canada.
The community-initiated
Ilisaqsivik Society in Clyde River,
Nunavut, provides a wide range of
programs promoting wellness among
residents. Counselling, counsellor
training, a youth drop-in, land-based
programming, and workshops on
topics such as trauma, grief and loss,
and addiction give community
members a greater connection to
“
their culture and sense of identity,
along with skills and assistance to
deal with issues surrounding self-
harm and suicide. “We need more
33MARCH 2014 VOLUME 110 NUMBER 2
Falling into Abyss“I felt like there was no escape from what I was experiencing. Nobody can help me. Strange forces were on the path to destroy me. I don’t fi t into society and lost all hope.” — Almier
About the artist: Almier is a member of the Out of the Shadows Artists’ Collective, an Edmonton community-based program that promotes recovery and wellness through the arts. For more information on the program, contact Erin Carpenter, occupational therapist, or Cathy McAlear, recreation therapist, at 780-342-7754.
34 CANADIAN-NURSE.COM
JANE LANGILLE IS A HEALTH AND MEDICAL WRITER IN RICHMOND HILL, ONT.
initiatives like this one,” says Audla.
“We’re desperate for readily available
and accessible mental health and
wellness programs and services for
Inuit, especially since new numbers
show suicide rates among Nunavut
Inuit are now 13 times higher than the
national average.”
The Suicide Prevention Education
Awareness Knowledge (SPEAK)
program of Winnipeg’s Klinic
Community Health Centre has
integrated trauma-informed practices
into the design and delivery of its
services. Trauma-informed care for
suicide prevention and postvention
(support for those bereaved by
suicide) is a fairly new approach in
Canada that recognizes the role
trauma has played in the lives of
those at risk of or aff ected by suicide,
says Tim Wall, Klinic’s director of
counselling services. “It promotes
relationships between caregiver and
client that are grounded in trust and
compassion, provide physical and
emotional safety and minimize the
risk of re-traumatization.” Wall, who
is also executive director of the
Canadian Association for Suicide
Prevention (CASP), explains that
taking this approach results in a para-
digm shift that looks at trauma not as
an illness or weakness but as an
injury. “It changes the caregiver
question from ‘what is wrong with
you?’ to ‘what has happened to you?’”
SPEAK focuses on increasing
public awareness and education, and
provides bereavement counselling
individually or in groups for people
who are dealing with the loss of
someone who has died by suicide.
“Our clients have told us that through
counselling they often experience a
signifi cant reduction in the symptoms
of post-traumatic stress,” says Wall.
“While survivors are still saddened
and aff ected by their loss, they
develop new ways of coping that have
a positive impact on many diff erent
aspects of their life.”
Canada’s approach to suicide
prevention involves a mix of roles and
The MHCC partners with a number of organizations to help raise awareness of the importance of acting to prevent suicide and to enhance understanding of eff ective suicide prevention programs and resources that can be deployed within mental health settings and health systems. These partners include the following:
Canadian Mental Health AssociationCanadian Psychiatric AssociationCanadian Psychological AssociationUBC Institute of Mental Health Ontario Association for Suicide PreventionAssociation québécoise de prévention du suicidePublic Health Agency of CanadaFirst Nations and Inuit Health Branch, Health CanadaCanadian Association for Suicide PreventionCanadian Coalition for Seniors’ Mental HealthCentre for Suicide PreventionCanadian Centre on Substance AbuseAssembly of First NationsInuit Tapiriit KanatamiCanadian Alliance on Mental Illness and Mental HealthNative Mental Health Association of CanadaCanadian Institutes of Health Research
The Centre for Suicide Prevention and the Canadian Association for Suicide Prevention provide hundreds of resources for health-care professionals on their websites.
Working in partnership
responsibilities found at all levels of
government and within communities
all across the country. As an example,
the federal government invested in
the establishment of the Mental
Health Commission of Canada to
develop Canada’s fi rst national mental
health strategy, which incorporates
suicide prevention. As well, in
December 2012, the Federal Frame-work for Suicide Prevention Act came
into force, requiring the Government
of Canada to consult with its federal,
provincial and territorial counter-
parts and non-government organiza-
tions to create a federal framework
for suicide prevention.
In 2004, CASP released a blue-
print for organizations and all levels
of government to work together to
prevent death by suicide and support
those who have been aff ected by
suicide. The document, updated in
2009, has helped inform provincial
and territorial suicide strategies.
“We need to shift the current
discussion that suicide is an indi-
vidual problem. Suicide aff ects
families, communities and Canadian
society as a whole. With a sense of
shared responsibility, we can
conquer the fear of addressing
mental illness that grows out of the
myth that it’s untreatable. There are
many treatments currently available
that are eff ective,” says Dr. David
Goldbloom, chair of the Mental
Health Commission of Canada.
“Suicide is preventable.” ■
28 CANADIAN-NURSE.COM
FEATURE | THE MENTAL HEALTH SERIES Canadian Nurses Association/Mental Health Commission of Canada
My View from Inside“Walking across the High Level Bridge, overwhelming thoughts pushed me into thinking that I could not fi nd solutions to my problems. I wanted to vanish, I was so confused and tormented.” — Almier
BY JANE LANGILLE
When Mental Illness and the Justice System Intersect
29JUNE 2014 VOLUME 110 NUMBER 5
B rett Batten has been living
with bipolar disorder with
psychotic features for most of
his 45 years. About 14 years
ago, he came into contact with the law
and spent three years in various jails
before getting treatment for his
mental illness. Batten says, “In jail, I
was making disturbances because of
my delusions, so they put me in ‘the
hole’ [solitary confi nement]. When the
psychiatrist fi nally came to see me, he
ordered my move to a medical cell.
Only then did I receive the right
medication and become aware of time
and place.”
A disproportionate number of
people with mental illness get caught
up in the justice system. In his annual
report for 2011-2012, Howard Sapers,
the Correctional Investigator of
Canada, states that rates of serious
mental health problems among
federal off enders upon admission more
than doubled between 1997 and 2008.
Patrick Baillie, a lawyer and a
consulting psychologist with the
Calgary Police Service and a member
of the Mental Health Commission of
Canada (MHCC) advisory council,
says that there are marked
inadequacies in how people with
mental illness are handled by the
justice system: “This notion of people
falling through the cracks? They’re
not cracks. They’re gaping crevasses.”
Baillie comments that better
coordination between the mental
health system and the justice system
is the single most important need for
people living with mental health
problems and illnesses involved with
the law. The forensic division in which
he works includes a mental health
diversion program, through which
off enders with mental illness are
diverted pre-charge so that they can
be assessed and receive treatment.
Those who need support have access
to physician referrals, emergency
housing and medication. As a result,
more people with mental illness stay
out of jail. “Our program has some
unique features, but the concept is
not at all unique to Calgary.”
One of the benefi ts of the diversion
model is its cost-eff ectiveness: court
costs are reduced because there are
fewer hearings involving judges,
prosecutors and lawyers; policing
costs are lower because more people
are assessed and supported before
they get into crisis; and hospitaliza-
tion costs are reduced because
intervention typically occurs in
outpatient settings. Baillie says the
model also translates well to smaller
communities, where social workers
and other mental health profession-
als can work with local police to help
people with mental illness access
community support programs.
The role of nurses in the Calgary
forensic outpatient programs is
signifi cant on several levels, Baillie
says. “The nurses have their own
client caseloads and provide
individual therapy, monitor
medication and act as community
liaison. They may also assist
psychologists and psychiatrists
in conducting more formal
assessments.” Because they have
ongoing relationships with clients,
Baillie adds, the nurses also play a key
role in assisting the provincial review
board with decision-making [see
sidebar].
Arlene Kent-Wilkinson, who
worked in forensic and psychiatric
nursing for 21 years, is an associate
professor at the University of
Saskatchewan. She led a research
team that recently conducted a
province-wide needs assessment of
programs and services for off enders
with mental disorders. Too many, she
says, are incarcerated without being
assessed. “It’s not people with
extreme mental illness that slip
through. It’s those who are marginal
or who have addiction problems.”
Once in correctional facilities,
people with mental illness have
limited treatment alternatives
available. Baillie cites issues such as
understaffi ng, budget cutbacks and
policies that don’t allow certain
prescribed medications over concerns
about addiction, making it diffi cult for
those who need medication to follow
Under Canadian criminal law, if an accused cannot understand the nature of the trial and its consequences and cannot communicate with his/her lawyer due to a mental disorder, the court will fi nd that the person is unfi t to stand trial. Later, if the person becomes fi t to stand trial, he/she is then tried for the off ence.
If a person commits an off ence but lacks the capacity to understand what he/she did, or that it was wrong, due to a mental disorder at the time, the court will fi nd the person “not criminally responsible on account of mental disorder”(NCRMD). He/she is neither acquitted nor convicted.
Those found either unfi t to stand trial or NCRMD are referred to a provincial or territorial review board that makes one of three possible decisions: absolute discharge — only for those found NCRMD and if they do not pose a threat to society, conditional discharge or detention in custody in a hospital.
Source: Department of Justice Canada
Understanding the Criminal Code mental disorder regime
30 CANADIAN-NURSE.COM
treatment plans.
In his annual reports, Sapers has
raised concerns about conditions of
chronic overcrowding and called for
an end to the practice of allowing
prolonged segregation for off enders
with mental illness. Referring to his
own experiences, Batten comments,
“Solitary confi nement is an abusive
practice that does nothing to improve
behaviour and deprives people from
getting treatment. It exacerbates
mental illness and deteriorates mental
wellness.”
Discharges into the community
may occur without treatment or
support plans in place. Baillie says,
“It’s the individuals who are not
receiving treatment that are taking
up police services’ time across the
country.” He has seen some people
with mental illness who were released
at 8:00 a.m. reoff end before the end of
the day because dysfunctional coping
mechanisms like substance abuse and
theft are all they know.
Police have been referred to as de
facto mental health care providers and
the front-line extension of the mental
health system. Although most police
interactions with people living with
mental illness are positive, a few are
negative and a very few are tragic.
Police services across Canada
have been investing in education
and training and using new models
of community safety to improve their
responses and the outcomes to calls
involving people with lived experience
of mental illness. Partnerships with
community mental health agencies
have decreased negative incidents
and improved interventions, averting
crisis situations that are not only high
risk but also labour intensive. There
is also some evidence that these
approaches can contribute to reducing
the overrepresentation of people living
with a mental illness in the criminal
justice system, one of the key
recommendations of Canada’s fi rst
mental health strategy.
The MHCC’s president and CEO,
Louise Bradley, is a nurse who has
worked in both forensic mental health
and correctional settings. She says
that while there are very promising
solutions out there for dealing with
these complex issues, there is a need
for greater coordination.
“The bottom line is that we need
to stop viewing this as a policing
problem or a mental health problem
— and start seeing it for what it is: a
societal problem,” says Bradley. “It’s
an issue that needs to be dealt with
for the health of our communities as
a whole.”
After he was found NCRMD, Brett
Batten was transferred to a forensic
facility for two years, where he
received his first exposure to
comprehensive treatment. He says, “I
look at the forensic system as one of
the best and worst things to happen in
my more than 30-year mental health
journey. In the rehabilitation unit,
I had an occupational therapist, a
vocational therapist, a psychiatrist,
a psychologist, a social worker and
nursing staff .” Ultimately, Batten was
granted an absolute discharge to live
in the community with no restrictions.
He focuses his time on writing and
speaking to help others dealing with
mental illness. ■
JANE LANGILLE IS A HEALTH AND MEDICAL WRITER IN RICHMOND HILL, ONT.
About the artist:Almier is a member of the Out of the Shadows Artists’ Collective, an Edmonton community-based program that promotes recovery and wellness through the arts. For more information on the program, contact Erin Carpenter, occupational therapist, or Cathy McAlear, recreation therapist, from Alberta Health Services, Regional Mental Health at 780-342-7754.
People living with mental health problems and illnesses are more likely to be victims of violence than perpetrators of crime
The MHCC recently partnered with the Canadian Association of Chiefs of Police to sponsor a two-day conference to fi nd ways to improve interactions between police and people living with mental health problems or illnesses. Review the key recommendations contained in A Comprehensive Review of the Preparation and Learning Necessary for Eff ective Police Interactions with Persons with a Mental Illness, which was released at the conference.
While much is known about how police perceive people with mental illness, less is understood about how people with lived experience perceive the police. Read the report of an MHCC-facilitated study of this issue that reveals several interesting trends.
Learn more about the National Trajectory Project, which follows the path of individuals declared NCRMD through the mental health and criminal justice systems.
View the fact sheet About the Not Criminally Responsible Due to a Mental Disorder (NCRMD) Population in Canada.
Collaborative Spaces is a public community of individuals that share work, stories and resources. Sign up for a free account at mentalhealthcommission.ca/mhcc-collaborative-spaces to discuss mental health and the law.
MHCC initiatives