Canadian Nurse Mental Health Series

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


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


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.


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.” ■


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


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.

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