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Discussion, Wednesday

On stigma, doctors and mental health

Researcher takes your questions

Globe and Mail Update

Just as lawyers can face a barrage of bottom-feeder jokes, psychiatrists, both in film and real life, have long been seen as doctors of a lesser science, Carolyn Abraham writes in her article on the stigma psychiatrists face within the medical profession.

Even their own physician colleagues can view their patients as difficult and time-consuming, Ms. Abraham writes. The negativity, experts say, is contributing to a national shortage of psychiatrists and shoddy care for mentally ill people.

Heather Stuart, professor of community health and epidemiology at Queen's University, consults for both the Mental Health Commission of Canada and the Canadian Medical Association. Both groups are working to erase the stigma mental illness carries in the health care profession and Prof. Stuart has conducted crucial research on effective strategies.

Over the past decade, the Geneva-based World Psychiatric Association, with 20 member countries, has evaluated about 250 interventions to combat stigma, Prof. Stuart said. They have looked at everything from mass media campaigns to local intervention efforts.

Canada was the site of three pilot projects, she said, in Calgary, Edmonton and Drumheller Alta. Prof. Stuart said they found that factual-based information, such as brochures and posters were much less effective in erasing negative attitudes than personal exposures to people with a mental illness.

Bringing in speakers with mental illness to address health care professionals and in medical schools had a high impact, she said. Also powerful was a play about what it's like to have schizophrenia, performed by people with schizophrenia.

We're please to have Prof. Stuart join us Wednesday at noon ET for a live discussion on psychiatry, stigma and mental health. What would you like to know about her research? What can be done to prevent stigma, in the profession and in general? Send your questions now and join us Wednesday to read Prof. Stuart's answers, which will be posted below.

Prof. Stuart received her PhD in Epidemiology from The University of Calgary. She is an Associate Professor in the Department of Community Health and Epidemiology, and cross appointed to the Department of Psychiatry and the School of Rehabilitation Therapy at Queens University in Kingston, Ont.

Prof. Stuart's main research interests are in the areas of psychiatric epidemiology and community mental health research. She has worked in both hospital and community based mental health treatment systems and with international agencies such as the World Health Organization, the Pan American Health Organization, and the World Psychiatric Association.

Prof. Stuart is co-founder and co-chair of the Scientific Section on Stigma and Mental Disorders for the World Psychiatric Association and the Founding Editor of the International Federation of Psychiatric Epidemiology Bulletin.

Editor's Note: globeandmail.com editors will read and allow or reject each question/comment. Comments/questions may be edited for length or clarity. HTML is not allowed. We will not publish questions/comments that include personal attacks on participants in these discussions, that make false or unsubstantiated allegations, that purport to quote people or reports where the purported quote or fact cannot be easily verified, or questions/comments that include vulgar language or libellous statements. Preference will be given to readers who submit questions/comments using their full name and home town, rather than a pseudonym.

Christine Diemert, globeandmail.com: Thank you Prof. Stuart for joining us today to talk about stigma against people with mental health issues and the doctors who care for them. In your interview with The Globe's Carolyn Abraham you spoke about the forces that shape prejudice being old and powerful. Can you explain that a bit further?

Heather Stuart: Christine: Thank you for the opportunity to share my views with your readers. When I spoke about the forces that shape stigma as being old and powerful I was thinking about the deep historical roots of mental health related stigma and discrimination, and the manner in which stigma and discrimination have pervaded so many aspects of our culture, ranging from the way in which people with mental disorders are portrayed in the mass media to the way in which we consistently fail to find ways to help people with mental disorders and their families obtain the basic things that the rest of us take for granted: safe housing, adequate health and social supports, and social inclusion.

Jung Frau from Switzerland: 'Even their own physician colleagues can view their patients as difficult and time-consuming, Ms. Abraham writes. The negativity, experts say, is contributing to a national shortage of psychiatrists and shoddy care for mentally ill people'.

If this quote is true (and I believe it is accurate), then the problem is not with the patients, it is with the doctors. Difficult?

Perhaps learning to respect the patients is a first step. For example, Dr Marius Romme of The Netherlands, the founder of Intervoice, was accused by a patient of not respecting the reality of her voices. He thought about that, and changed the direction of his work.

Most doctors tell their patients that they are delusional and the voices need to be suppressed, not understood as having a deeper message. Time consuming?

Medication has become the accepted treatment since the 1960s. This means that any time spent with the patient is spent with a disproportionate percentage of the focus on the medication, not actually coaching the patient in how not to continue being a patient. If I were a mainstream psychiatrist today I would be bored silly.

Changing the practice of psychiatry to make it meaningful to the patient would make it much more meaningful to the psychiatrist. Perhaps their numbers would increase. Your comments on this are appreciated.

Heather Stuart: Thank you, Jung Frau, for your observations. I would take your argument even farther and suggest that our entire health and mental health care system must change to provide recovery-oriented supports and services for people with mental health problems and disorders. By recovery-oriented, I mean supports and services that are respectful and empowering for those who access them.

Toshio Ushiroguchi from Toronto: I think both patients and doctors experience a great deal of discrimination in the mental health sector mainly because a racist attitude exists towards patients suffering from ailments that affect their social behaviour.

Is it safe for a doctor to back someone a little strange? I think that there is cause for concern if a doctor is backing an offender, but often the mentally ill are branded criminals in court and the doctors that care for them become accomplices to some people as well.

Does the stigma change even more for doctors who work with the mentally ill and thus also become entangled in the legal system?

Heather Stuart: Toshio, you have put your finger on an important characteristic of stigma which is it's ability to affect not only the individual who has a mental heath problem, but all of those around them, including their family and friends, their mental health professionals, and their doctors. We think that people with mental disorders who are in the criminal justice system experience a double stigma which makes it even harder for them.

Marlene W from Hamilton: Kudos to Dr. Shah who has been incredibly candid about the ingrained systemic discrimination he faces from his own family and peers regarding his choice of medicine. I was taken aback when he was told 'But your so smart!' as a rationale to discourage him from going into psychiatry. That basically says to me that those with the worst grades in med school enter into psychiatry, aren't expected to excel and aren't expected to do much for their patients.

Have you found that to be true?

Heather Stuart: Marlene: Some of the most profoundly committed, compassionate, and wise people I have ever met have been those who have chosen a career path in mental health, and they have done this, like Dr. Shah, in spite of the stigma that surrounds this choice.

Having said that, we need to do much more to make mental health professions as an attractive career choice. Perhaps a way to do this is to start highlighting the important contributions made by mental health professionals through good news stories.

Secondly, we need to consider how we should change the way in which we train health professionals to ensure that they see mental health as rich and rewarding. Finally, we must ensure that mental health programs and professionals are appropriately funded as this will certainly underscore the point.

Christine Diemert, globeandmail.com: Prof. Stuart, I'm going to pull a portion of a comment from one of the people who commented on the article about stigma in the medical system and get you to respond.

This man spoke of his wife, who "works for CMHA as a crisis worker. She is a certified RNA that worked for years in the Psych ward of one of our local hospitals. She would confirm a lot that is in this article. It is not just the psychiatrists, but all people who work with the mentally ill, including RNs, RNAs, Social Workers, Psychologists, as well as the supporting agencies and the patient's families. The stigma is huge, even among the professionals.

"During cut backs in Ontario, and lay offs, the hospitals reassigned nurses to the Psych department who had ZERO training in psychiatry! That alone was incomprehensible."

My question is, in your research have you learned that when hospitals face cutbacks, the mental health services are the first to be cut?

Heather Stuart: With respect to funding, I think that all mental health services -- not only hospitals -- are seriously under funded and, yes, they are typically the first to be cut when budgets are tight, and the last to be funded when they are not. When new funding comes into mental health, it is difficult to protect and sustain it over the long run.

With respect to your second point, people outside of the mental health field seriously underestimate the skills necessary to be an effective mental health professional and this undoubtedly accounts for the attempts to parachute in untrained individuals into mental health programs. It's hard to imagine that this would happen in any other area of medicine and underscores the extent to which the entire mental health enterprise suffers from stigma and discrimination.

Christine Diemert, globeandmail.com: One of our commenters raised the issue of labels in our articles on mental health and I wondered if you could comment on it.

kristy williams from Halifax: ... I think we need to carefully consider the language we associate with mental health issues. ... the potentially discriminating label 'mentally ill people' is used multiple times. Calling unique and diverse individuals mentally ill reduces their identify to their illness - we don't refer to people with cancer as 'cancerous people'.

Perhaps terms like people who have experienced mental illness would be a more just and respectful way to describe individuals (which may be any one of use at some point in our lives) who experience such an illness.

Heather Stuart: Christine, this raises an important point. Language counts! It can support, or it can undermine. Greater sensitivity to language is an important starting point in our fight against stigma and discrimination.

Keating Gun from Canada: Hi Dr. Stuart. Isn't it true that mental health care in Canada has often been unnecessarily and detrimentally hospital-based and emanating from psychiatry when community-based services would be more effective and economical? I would like to hear your opinions on who should deliver what kinds of mental health care and in what settings to obtain the best long-term results. And, can mental illness can be prevented or minimized in some through early detection and intervention, as some trailblazing US psychiatrists are now doing, especially with children? Would allowing interested highly skilled clinical psychologists to enrol in medicare insurance plans and creating public officers of mental health to promote mental wellness and head off social ills such as family violence and gang violence and youth suicide by improving public institutions and their responses, also help? What about quality control on services being provided, and research on efficacy

Heather Stuart: Keating: People who have mental health problems or disorders benefit from a wide array of supports and services, ranging from professionally oriented to peer oriented, and from hospital to community. The real challenge is not to pit one sector against the other, but to ensure that a comprehensive continuum of care exists that can be appropriately and easily accessed by people whatever their level of need.

Mary Mary from Canada: I know that to get into certain professions, there is the clause that it must be in the best interest of the public that you be able to enter that profession (ex: nursing). Do you know if this is directed specifically at those with mental illness? Are they considering that when these people are on an appropriate medication and have support they can manage in society, granted they have the intellectual capabilities of going into that profession?

Heather Stuart: Mary: Discrimination on the basis of any disability or illness is against the law, and there are an increasing number of employers who recognize the importance of promoting a mentally healthy work-force and mentally healthy work environments. Having said this, employment discrimination is still the most frequent stigma experience cited by people with mental health problems.

Elisabeth Pereira from CALGARY: Thank you for your work. I have been reading quite a few of your articles. They are passionate, thorough and very well written. Could you describe a bit about the programs/strategies used for an anti-stigma intervention? How easy and accessible are the materials (videos, plays etc) used in anti-stigma interventions? How do you avoid harm from these interventions? E.g. people start conversations that would reinforce stigma?

Heather Stuart: Elisabeth: Thanks for your complement. We have a number of strategies that we can use to reduce mental health stigma and discrimination, ranging from public health programs that target policies and practices that are discriminatory, to contact based approaches that bring people together in positive and empowering ways. Given the pervasiveness of stigma, we think that multi-pronged, multi-level approaches work better than one-shot interventions, but we do not yet have sufficient research in this area. We also know that some of our knee-jerk reactions to fighting stigma can have paradoxical effects. This means that we have to be careful to evaluate our anti-stigma initiatives and make sure that they are improving the lives of people who have experienced mental health problems.

We don't yet have a clearinghouse in Canada for anti-stigma materials so the best thing to do is to contact advocacy groups and large mental health organizations to find out what they are doing and what materials they are using. Be sure to ask if they have conducted outcome evaluations!

Christine Diemert, globeandmail.com: We've come to the end of our time. Thanks again Prof. Stuart for joining us today.

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