Thomas Ungar is psychiatrist-in-chief at St. Michael’s Hospital of Unity Health Toronto. Louise Bradley is president and CEO of the Mental Health Commission of Canada.
Raising awareness is a good thing, and campaigns such as Bell Let’s Talk should be lauded for their efforts.
Unfortunately, the stigma surrounding mental illness doesn’t begin and end with personal attitudes and behaviours. Like any serious equity issue, truly addressing it will require us to lower the barriers that impede better outcomes and greater investment in mental illness.
So now that we talk the talk, it’s time to walk the walk – even among medical practitioners.
Those of us who practise mental health in our inherently flawed health care system are constantly swimming against the tide. During our respective experiences working in clinical settings and sitting at budget tables, we’ve collected little indignities like souvenirs – unwelcome reminders that mental health simply doesn’t matter as much as physical illness.
The examples are as frequent as they are infuriating.
Imagine going to a meeting with your peers, where you request the equipment you need to practise your specialty. You listen politely while your colleagues rattle off their needs – CT scanners, colonoscopes, cardiac monitors, patient lifts, glucose monitors. When it’s your turn, you look at your scribbled notes, and say you’d like some new furniture to replace the worn-out hand-me-downs inherited from other parts of the hospital, as well as improved safety video monitoring. Everyone shuffles their papers uncomfortably. You’re told to go talk to facility management, or IT.
The message is clear: Your needs aren’t really medical ones at all.
Now, imagine learning that new cost-cutting measures will mean garbage cans in the hospital’s “clinical” areas – defined as having a sink – will be emptied every day, while “administrative settings” will be done every two weeks. The garbage cans in your patient assessment rooms – which don’t have sinks – are going to be overflowing. Translation: In “real” medicine, you need to wash your hands.
Things go further downhill when a hospital decides to relocate or renovate. Time and again, mental health departments are reassured, “You’ll be joining the rest of us or upgraded soon.” But too often, months, and even years, go by. We wait in the purgatory of a crumbling, rundown building for a summons into those lighter, airier, newer spaces worthy of cancer and cardiac patients long before the drawbridge is lowered for those experiencing mental illness
These inequities add up to more than frustrations and inconveniences. Sometimes the cost is incalculable.
Consider a patient who goes to emergency with physical concerns. Perhaps it’s her heart, or she’s having trouble breathing. An emergency room physician takes one look at the file, sees a mental-illness diagnosis, and decides – often, with no physical exam – that it’s just anxiety, so the patient should be triaged to psychiatry. Meanwhile, as the patient waits, her condition worsens. And by the time someone figures out that she was in cardiac arrest, it’s too late.
Too often, having a mental illness stamped in your file is like having it tattooed on your forehead. It biases medical professionals – who, after all, are only human – and overshadows valid and serious physical symptoms, allowing them to be dismissed as nothing more than a figment of your diagnosis.
Structural stigma – how institutional rules, policies and practices unjustifiably and arbitrarily limit the rights of people with mental illnesses – plays on this unconscious bias. It flourishes in darkened corners and it hides in plain sight. To the untrained eye it’s invisible, but the threat it poses is no less real.
Just because someone doesn’t use pejorative terms, for example, doesn’t mean they aren’t unwittingly dismissing a person as unworthy or badly behaved because they are presenting in a way that’s uncomfortable. Alerting providers to dangerous blind spots is important, but it’s not enough. We need to measure and monitor the barriers, big and small, that put treating mental illness at a perpetual disadvantage.
If we can get them on a mandatory quality performance dashboard, or easy to see report card, a red-light indicator will scream out for attention. It’s the only way we can halt structural stigma in its tracks. Building certain patient safeguards into hospital policy may be the quickest route to fulfilling the Hippocratic Oath, while work to change attitudes and behaviours plods along in the background.
A complete paradigm shift is a generational proposition. We don’t have that kind of time.
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