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Reducing stigma in health-care settings

CNA/Mental Health Commission of Canada

Jan 24, 2014, By: Jane Langille

Mental Health Series: Part 1

How important is mental health? Nearly seven million Canadians will experience a mental health problem or illness this year. To put that number in perspective, more than two million Canadians will be diagnosed with type 2 diabetes; another 1.3 million with heart disease.

Canadian Nurse readers understand how important this issue is. By sharing your letters, questions and stories, you have demonstrated the nursing community’s interest in being part of a wider dialogue. In fact, it was your personal and professional experiences with mental health that were the catalyst for this joint CNA/MHCC series.

My first job as an RN was in mental health. At the time, many people were surprised to learn I had purposely chosen this area of practice. Over the years, I’ve worked in positions all across the health sector, including forensics and corrections, research, teaching and large-scale hospital administration. I have encountered people living with mental health problems and the associated stigma in every job I’ve had.

In May 2012, the Mental Health Commission of Canada released Changing Directions, Changing Lives, Canada’s first mental health strategy. It presented a blueprint for change to improve the mental health of Canadians.

Nurses know, better than most, that research and resources are little more than words on paper until we turn them into action. The aim, therefore, of this six-part series is to build knowledge that will foster change. In Part 1, we focus on reducing stigma. Suicide prevention, workplace mental health, mental illness and the law, nursing education and recovery will be examined in subsequent issues of the magazine. A feature article will report on the At Home/Chez Soi project and the new evidence on services for people who are homeless and living with mental health problems.

I hope you will find that this series helps you support patients, residents and clients who are living with mental health challenges. Equally as important to me is that you will be inspired to take good care of your own and your loved ones’ mental health.

Louise Bradley, MS, RN, CHE
President and CEO
Mental Health Commission of Canada

Drawing of a head with tiny men opening windows to inside of it.

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 perpetuate 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.

Stigma defined

Stigma, according to the MHCC, is a complex social process that marginalizes and disenfranchises 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.

Stuart, who is also a professor in the public health sciences department 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 unsympathetic 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 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 likepsychocrazy and frequent flyer or code words unique to a particular setting are highly stigmatizing because they serve to define clients by their mental illness rather than regarding them as whole people.

The MHCC’s major initiative to reduce stigma isOpening Minds. It identifies and evaluates existing anti-stigma programs and works with a growing number of partner organizations across the country to share projects that are effective. 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.


Collage of various works by Almier.

About the artist: Almier studied art, photography and filmmaking in his native Poland. He immigrated to Alberta, where he worked for years for the provincial government. After being diagnosed with schizophrenia in his 40s, he joined 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.

“Our evaluations show that stigma can be reduced significantly,” 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 identified 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 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 difficulty adjusting to a new no-smoking rule on all hospital grounds. “In fact,” says Malekzadeh, “our patients did better than even weexpected. This indicates to me that we need to keep talking about stigma.”

Online exclusive!

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 effect of suicide on family and friends left behind.

Jane Langille is a health and medical writer in Richmond Hill, Ont.