Speaking Notes for
President and CEO
Mental Health Commission of Canada
4th Nursing World Conference
August 19, 2019
Title of talk: Stigma in health care settings: a barrier to care, for providers and patients alike
Good afternoon everyone.
This is quite a crowd. I’m honored to be here today – with an opportunity to put a difficult topic squarely on the agenda.
My career has been long – and it’s been almost exclusively in mental health. When I started out as a young nurse people would say to me, “What a shame, you’re not going into real nursing.” Or, “I guess there weren’t any other jobs?”
That attitude stung, but it didn’t deter me. I knew that helping people manage their mental health was every bit as important as treating physical illness.
That’s a truth I learned from personal experience. And that’s partly what I’m here to talk to you about.
As a licensed RN myself, I have so much admiration and respect for what you do. Your days are long, the demands are grueling and the decisions you make save lives. That’s why I am here to encourage you to think a little bit differently about your own mental health.
When I was in Boston finishing my master’s in nursing, my best friend Mar-Cha died by suicide. I was devastated and grief-stricken. But I was adamant I didn’t need any professional help.
After all, I worked in mental health. I knew the signs and symptoms of what mental illness looked like, and when I looked in the mirror, I would say to myself: “You can handle this. You’re tough. You help people, you don’t need help.”
Of course, reflecting on that time with the benefit of so much hindsight – and the insight born from years of therapy I might add! – I realize my fear of asking for help was because of self-stigma.
I didn’t want to admit that I saw in some of my own patients what I was experiencing, because at that time, I still didn’t fully understand the complexity of recovery from mental illness.
If I asked for a show of hands, I wonder how many of you can relate to the idea that as care providers, we are expected to be immune from mental health challenges?
Of course, mental illness is indiscriminate. We know that some 40 per cent of physicians are reporting advanced stages of burn out. We also know that substance misuse is as at least as prevalent among nurses as it is in the general population.
Somewhere deep inside, I believed that people who were living with a mental illness were “other.”
Of course, I wanted to help them.
Of course, I wanted to show them compassion.
But I can tell you right now… I didn’t want to be “one of them.”
I’d had an episode of hospitalization as a young person. I grew up with a lot of adverse childhood experiences. That’s a fancy way of saying we were poor, and I was shuffled in and out of the foster system. When I was 13, I spent three weeks as an in-patient, under the care of a psychiatrist.
He changed my life, and, so many years later, I was “cured.” Of course, recovery from mental illness doesn’t work like that. It’s a long and winding road, with ups and downs.
There is no finish line.
We’re all messy, hopeful works in progress. But back in Boston, as a successful professional who’d “made it,” I didn’t want to admit, even to myself, that I might still be vulnerable.
I wasn’t like the young man living with schizophrenia I met my first day on the job, who later drowned himself in two inches of bathtub water. I wasn’t like the woman without a home whom I treated regularly because she didn’t have access to the dignity of a safe place to live, and the treatments she needed to get well.
I was a nurse, for Pete’s sake. I didn’t have a mental illness!
Thankfully, the Dean of Nursing in Boston called me into her office and told me I should speak to a psychologist before returning to school.
I waved a hand in dismissal and said to her, “Oh, thanks for the offer but the best thing for me will be to get right back to work.”
She laughed. And said, “Oh, it’s not an offer. It’s a requirement.”
I balked. But I did as I was told, despite being convinced it would be a total waste of time. Far from being an exercise in name only…it was the best thing I ever did.
I wish I’d been brave enough to take the step without prompting – but it’s a clear example of the value of having a mentor invested in your wellness.
As nurses, we need to look out for one another. If you see a colleague struggling, give her a safe place to confide. If you notice a change in your own moods, behavior or thoughts, reach out.
It will change your life.
The psychologist I saw so many years ago remains one of my closest friends and confidants today. Her counseling shifted my worldview in such a profound way that not only was I able to practice better self-care, but I was able to translate that new insight into a renewed compassion and insight in my work as a nurse.
My time in Boston reoriented my life trajectory, and I credit that experience with helping to build the resiliency that allowed me to overcome other adversities I would encounter in later years.
Building resiliency isn’t simply about bouncing back from an adverse or traumatic experience. It’s about learning coping skills, figuring out how to manage in challenging situations, and being better prepared to face the next obstacle than we were before.
Some of us seem to be born with more resiliency than others…but none of us are without the ability to improve.
I’m sharing this story with you today because I want you to know that I understand. I understand what it means to be the stoic, calm presence who holds it together no matter what.
I know what it’s like to go to work and become slowly depleted of compassion. To be burned out, exhausted physically and mentally, and to work in a place where mental illness is synonymous with weakness.
I’d like to share a story with you about my very first days on the job as Senior Operating Officer with a major teaching hospital.
Let me begin by saying when I got a call about applying for the job, my first response was, “I think you’ve got the wrong Louise Bradley…I’m a mental health nurse and I’ve never worked in a tertiary care facility…”
After they confirmed they were indeed speaking to the right person, and after I’d signed the offer, I had this niggling feeling that I’d made a mistake.
In my first few weeks, I carried that sense of doubt around with me like a little suitcase. One day I was walking through one of our three intensive care units, and I ran into a nurse working a late shift. She was at the bedside of a patient covered in so many wires and tubes it was hard to see the humanity beneath.
I chatted with her for a while, asking her how she managed to cope when treating a patient with whom she couldn’t communicate. I asked her to tell me about the biggest challenges of her job…
At first, she just looked at me as if I’d fallen from another planet. Then I put my hand on her arm and said, “All I want to know is how you’re feeling, and if you’re okay?”
Do you know what happened? She burst into tears. When she was finally able to collect herself, she said, “In all my years working here, not one single person has asked me that question.”
Over the next few weeks, slowly but surely, I started to feel the ground solidify under my feet. At the time, I couldn’t quite articulate it, but I was beginning to believe taking the job was the right decision.
One afternoon, I was in a meeting with some of the hospital’s most respected surgeons. The conversation devolved as the surgeons began to deride a colleague who’d taken leave for mental health reasons.
Suddenly it was like everything I’d ever absorbed about mental health came to a rushing zenith.
I heard my young self say, “I don’t need help.” I felt the shame of judgment I’d silently passed on patients. In my mind’s eye, I saw that nurse crying saying, “No one has ever asked me if I’m okay,” and I heard these brilliant, life-saving doctors disparaging their friend for his “weakness.”
I looked around the room and said “ENOUGH!”
Startled, a surgeon turned to me and by way of explanation said, “Oh, right, you used to work in mental health…”
I looked him in the eye and said, “What makes you think I ever stopped.”
And from that day forward, I knew what I was there to do. I wasn’t there to tell people how to do their jobs. I was there to help them change the culture in which they carried out their work.
Let’s talk about that culture for a minute.
It’s a culture we’ve all been steeped in.
As a healthcare provider, my heart sank to learn that our anti-stigma research unearthed that patients saw me – and others working in the field – as a barrier to treatment – not a bridge to services.
From family physicians, to chronic care management, to specialized care, the thread of mental health is stitched through every aspect of the medical profession. Treating a person living with a mental health problem isn’t a stand-alone proposition.
So often, mental health is just one piece of a far more complex puzzle.
Which came first, the heart disease or the depression?
A colleague with whom I work closely at the Commission recently lost her father to ALS.
She told me that the care he received at an integrated clinic was thorough – he had a physical therapist, respiratory therapist, occupational therapist, nurse coordinator and the list goes on…
My colleague said to me, “My Dad was being robbed of his abilities, his dignity, his autonomy, a nickel at time.”
“I’m not an expert, she said, “but under those circumstances who wouldn’t feel anxious or depressed…yet, while he had a specialist for every bodily function, who was getting inside his head? Who was tending to his perfect brain in his ravaged body?”
It’s a good question.
And it’s one that underscores what research tells us. Simply put, doctors and nurses feel ill equipped, lack confidence and are uncomfortable supporting a patient experiencing a mental illness.
So, the two realities, that of the patient, and that of the provider, are the flip side of the same coin. And one could argue in both cases, the blame can be laid squarely at the feet of stigma – both the self-stigma I described earlier, and structural stigma, which I’ll touch on now.
Structural stigma, by its very definition, refers to injustices woven into the fabric of our culture. This includes laws, policies, regulations and standard practices.
Opening our eyes to these inequities is the first step in addressing them in a meaningful way. I have long believed that our role, as health care providers, isn’t to simply accept the status quo.
We should be operating as influencers.
Using our clout to demand better for those people living with severe mental illness – who live on average 20 years less than the general population.
Have you noticed that the mental health wing is often relegated to the oldest, most decaying part of the hospital?
Or what about the triage inaccuracies for patients with mental health histories?
Have you ever stopped to consider the proportionally smaller teams for mental health compared with surgical/medical teams?
And the less thorough medical screening processes for patients with mental illness histories?
These cumulative realities create unsurmountable barriers to equitable care for people living with mental illness – regardless of the best intentions of those working within the broken system.
Treating a person living with a mental health problem isn’t a stand-alone proposition. So often, mental health is just one piece of a far more complex puzzle.
Which came first, the heart disease or the depression?
As healthcare providers, it’s easy to get lost in the intricacies of the disease you are trying to remedy. But in the field of mental health, you can never lose sight of the person who is playing host to the illness.
My very first week in nursing school – and never mind how long ago that was – someone was ahead of the times because we were sent out onto the wards…but we weren’t allowed to do busy work. We couldn’t change bedsheets or take temperatures or listen to heartbeats. Instead, we were told to sit down and talk with the patients.
Well, let me tell you, that was one of the most constructive and memorable weeks of my training as a nurse. It’s funny because the premise of this early training is now being echoed at Brandon University in Manitoba.
The Commission teamed up with the psychiatric nursing school to implement a game-changing learning style.
Students are matched up with a person in the community who is living with, or living in recovery from, a mental health problem or illness. They meet each week, for about an hour, the entire semester.
The students are asked to write a Recovery Narrative Assignment based on these conversations. In short, they piece together a client’s life story and are graded on the demonstrated understanding of this person’s experience. Their grade is largely based on client feedback.
And do you know what?
The project is breaking down barriers and fostering compassion on both sides of the care divide.
Today, in medicine, we must do our best to safeguard the healing human connection, lest it get supplanted by print outs and computer screens. But to do that, your mental health and wellness must rise to the top of the priority list.
Your chosen vocation calls on you to dip into your well of compassion and to mine your inner reserves in service to healing others.
I’ve often said healthcare settings are toxic environments. But it doesn’t have to be that way.
One thing each of you can do, right now, today, is lobby your manager to implement the National Standard of Canada for Psychological Health and Safety in the Workplace.
This set of guidelines, tools and resources is redefining what it means to be a responsible employer. At the same time, it’s saving organizations money and building healthier and more productive workplaces.
It’s free and been downloaded by more than 40,000 organizations.
For example, the Michael Garron Hospital – formerly the Toronto East General – has seen remarkable results in four short years: a decrease in days absent from over ten to less than seven, a seven percent decrease in health care costs, and significantly higher patient engagement scores.
You can set an example by shifting expectations away from the traditional self-flagellant practices that suffuse health care settings and move towards a culture of self-care.
Consider that in Canada, a Labour Force Survey from 2012 noted that an average of 18,900 nurses were absent from work week due to illness and disability.
And nurses’ absenteeism is 55 percent higher than the average rate for all other occupations. And we know from studies conducted by the Mental Health Commission that roughly 30 per cent of short-and-long term disability claims in Canada are attributed to mental health problems and illnesses.
The fact is, some of us are hard-wired to help others. I put front line health care professionals in this group. And it’s a group I’m damn proud to belong to. But if we don’t look after ourselves, we can’t look after others.
With nursing shortages across the board, we can’t afford to neglect the mental health of our invaluable human resources.
Stigma is the reason that many people won’t seek help – and contact-based education is one of the most powerful tools we’ve got to fight it. I know, from personal experience, that coming forward as someone in health care with lived experience of a mental health problem isn’t easy.
Lord knows, as head of the MHCC, I struggled with it. Would people see me differently. Would I be viewed as “other”? The answer was yes, they did see me differently.
They saw our shared humanity. Within five minutes of a speech or a round table, I became a person with a story…someone they could relate to. Suddenly, nurses were coming up to me at conferences, sharing their stories.
I was one of them, and I was also vulnerable.
That was a revelation.
So, share your stories.
Have the courage to be vulnerable.
That’s so important, because mental illness doesn’t discriminate.
Yes, we’ve made great strides with public awareness campaigns. But only when we address structural stigma, and banish self-stigma a relic of the past, can we truly fulfill the promise of person-centered care.
It is a promise worth keeping.