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The Book Club series profiles good reads that challenge stereotypes and stigmas – part of our Representations section on pop culture and mental health.
It’s not just gender bias – though that’s a useful umbrella term for the various societal ills, long-held beliefs, lack of data, historical hangups, and stigma that negatively impact mental health care for women.
All In Her Head
Author Misty Pratt is a science communicator and researcher based in Ottawa. She brings in medical research, interviews with practitioners, and her lived experience with mental health care into a book (Greystone Books, May 2024) that dismantles outdated concepts like hysteria, critiques the self-care industrial complex, and examines cultural constructions of mental illness.
It’s not you, it’s capitalism
In chapter 7 – titled Are You Mentally Ill or Mentally Overloaded? – Pratt underlines the link between burnout and depression, based on a study of Finnish employees. It suggests that people suffering from burnout are more likely to become depressed, while those with depression are more vulnerable to burnout.
Within this loop, Pratt notes that when women experience burnout – in a broad sense of being overly exhausted by the mental load and daily life – it is sometimes diagnosed as anxiety or depression. However, this could be a false diagnosis that overlooks larger economic and social issues – such as the patriarchy (Chapter 6) – leading to ineffective treatments.
Pratt asks readers to consider their situation more holistically. In other words, is the reason you can’t get out of bed more about the climate catastrophic world you live in, your economic situation, or a lack of power– rather than about you as a person?
Empowering eye-opener
“Personally, this realization completely changed the way I relate to myself and my mental illness,” Pratt writes. “I believe that misdiagnosing burnout feeds the illusion that mental illness is due to a personality flaw, negative mindset, my family’s genes, or an imbalance in my brain rather than an understanding that is closer to the truth: I’m facing a social problem that has real, lived emotional consequences.”
She found this realization freeing but notes it can be distressing to know you don’t have as much control over your well-being as you may have thought or been led to believe. However, a broader more fulsome view can set you “on a path to rediscover your own capacity, the ways in which you are limited, and what tiny actions of resistance you can make.”
Pratt is careful to not define what that resistance could or should look like for anyone. She checks her own biases in the book, actively avoiding what she calls the trap of “White Woman Wellness Syndrome,” that carries a privilege and often pushes simple fixes that are trendy or culturally appropriative. There are no affiliate links to jade eggs or corny affirmations to be found here. Rather, wellness culture and self-care are reimagined in a way that touches on our multitudes: spiritual, social, relational, cognitive, emotional, and financial.
Rewriting her story
Pratt shares her story of a nervous breakdown, anxiety, and depression; her strategies, sessions with therapists, and how these intersected with life stages, such as the birth of her children. She weaves in her lived experiences with trenchant analysis of contemporary research through a biopsychosocial lens (a model that looks at biological, psychological, and social factors that influence our lives).
Another through line is the story of Pratt’s grandmother, Dorothy Mavis Buckler, who was contending with bipolar disorder in the 1980s, a time when we knew much less, stigma was painfully and systemically strong, and treatments were rudimentary. Pratt recalls her view as a then-five-year-old observing her grandmother’s state.
“When we lose our mind, where does it go?” she writes. “As our mind drifts past, do we jump and try to grab at it, as a young child would chase after a wayward balloon on a windy day?”
Clinicians acted as if her grandmother’s symptoms were exaggerated. Pratt explores the narrative of hysteria and wonders what might be different now for her grandmother. Contrasted with Pratt’s own experiences and research, the reader is left with a hopeful feeling – that things have improved, even if there is so much more to do.
For example, when Pratt gets lightly “manifesto-y” toward the end, her call-to-action is so sensible and straightforward that one wonders – why aren’t we there yet?
“My wish is for all women to have access to effective biopsychosocial treatment options, to consent only once properly informed, to receive support for their preferences and values, and to have better care in coming off medication,” she writes.
“This can be done in collaboration with psychiatrists, psychologists, social workers, patient advocates, and anyone else working toward better mental health care. In other words, we can find common ground to stand on, a place where the door opens to choices for each and every individual who wants them.”
Further reading: Lifeline: An Elegy: Stephanie Kain’s novel changes the narrative on supporting someone with mental illness.
Resource: Where to Get Care – A Guide to Navigating Public and Private Mental Health Services in Canada.
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Canadians may assume that health-care workers have ready access to all the help and care required for psychological health and safety issues in the workplace.
It is not necessarily so.
That perhaps incongruous truth is the motivation for the Psychological Health and Safety Toolkit for Primary Care Teams and Training Programs — the PH&S Toolkit.
It’s a new and broad collection of adaptable tools created in partnership by the Canadian Health Workforce Network, the Mental Health Commission of Canada (MHCC), and Team Primary Care (the latter an initiative of the Foundation for Advancing Family Medicine, funded by Employment and Social Development Canada).
Karina Urdaneta, Program Manager for Prevention and Promotion Initiatives with the MHCC.
“The PH&S Toolkit is a bilingual website with more than 120 resources to support health-care leaders, HR representatives, workers, trainees, and educators enhance psychological health and safety in their working and learning environments,” says toolkit team member Karina Urdaneta, the Program Manager for Prevention and Promotion Initiatives with the MHCC.
“Psychologically healthy and safe health-care workplaces can help improve health-care workers’ well-being, decrease absenteeism and turnover, boost productivity, enhance organization’s reputations, increase patient satisfaction, reduce medical errors, and lower health-care costs.”
Strengthening the workforce
Canada has a health workforce crisis, particularly in primary care. Even before the pandemic ratcheted up the pressure, health-care workers were screening positive for stress, depression, anxiety, burnout, and risk of suicide.
Psychological health and safety, which addresses those risks, is defined in the toolkit as “the systematic support provided within an organization and within teams to actively prevent and minimize the risk of psychological harm from work-related causes and promote mental health.”
It goes to the very core of health-care operations, the authors say, “embedded in the way people interact with one another, and the way working conditions and management practices are structured within the organization or team.”
The toolkit recognizes that health care is not a monolith, and the specifics of psychological stresses and challenges vary from one sub-sector of health care to the next — the challenges for employees in a long-term care facility can differ from those in a hospital emergency room, for example, and both may differ from psychological health and safety in a research program or in health-care education.
Even within professions the pressures can be complexly varied. For example, paramedics see traumatic injuries, “the things you see that people in normal life don’t see,” says Peter, a paramedic in Halifax, who asked to be identified only by his first name.
He notes they also bear tremendous stress from elsewhere, such as working with chronic abuse of the system by people who don’t need urgent care but habitually call for ambulances, or by bureaucratic inefficiencies that help lead to backlogs and delays in delivering care.
“That kind of wears on you, because there’s not enough ambulances; there’s not enough resources to deal with this, but we have to keep going,” Peter says. “It kind of wears you down.”
Essential concepts to support the sector
These challenges are among many examples throughout the health-care sector that demonstrate why the toolkit, which is online and available for free, was made to be broad and adaptable.
It is arranged around seven key themes:
- Organizational and team culture
- Workload management and work-life balance
- Clear leadership and expectations
- Psychological protection
- Protection of physical safety
- Protection from moral distress
- Support for psychological self-care.
Users of the website can click on any category for a definition — “Protection from moral distress,” for example, includes “providing access to bioethics consultations and training, and developing policies and guidelines to address morally distressing events.”
A resources tab leads to drop-down menus that users can use to filter the 120-plus resources available to fit the specific needs of their team and organization. Users can filter for theme, format (websites, articles, workshops); along with sector, setting, identities, audience (HR, employees, managers), cost, country and language.
Teams in the workplace can use the resources directly from the website — it could be, for example, “Reflections on the Mentor-Mentee Relationship,” an article from the Journal of the Pediatric Infectious Diseases Society, or “Resources for Team Building,” a workshop of materials and tools to help “create an action plan with your team to improve psychological health and safety.” The resources and other videos, articles, webinars and more have been compiled from dozens of sources to ensure the toolbox is stocked with high-quality, evidence-informed tools.
How it’s being used
Workplace teams have even incorporated elements of the toolkit into their own existing psychological health and safety programs.
“We developed a curriculum for nurse practitioners who will be delivering primary care in long-term care settings, and the psychological health and safety component was an actual piece of our final module,” says Ontario nurse practitioner Carrie Heer.
“A number of team members from the psychological health and safety group, their team, actually put that piece together for us. We wove it in there.”
The curriculum can be used by nurse practitioners across Canada or elsewhere and is also available for use in education settings.
Michelle Acorn, the CEO of the Nurse Practitioners Association of Ontario, says that “emphasizing mental health from the outset,” ensures that nurse practitioners are not only equipped with the skills to support residents, but also with support and self-care strategies that are needed to thrive in our challenging environments, which ultimately enhances both our professional performance and overall job satisfaction.
This improves outcomes for residents of long-term care centres, Acorn says. “It’s a critical step towards building a more resilient and effective healthcare workforce.”
To aid facilitators in doing no harm while attempting to do good, the Equity in Health Systems Lab at Bruyère Research Institute have created a suite of equity, diversity, inclusivity, and accessibility tools as an additional resource that is useful in this work.
They are succinct, introductory tools to help educators, teachers and facilitators as they develop and facilitate educational activities. Guiding questions help to mitigate harm, the authors say.
They focus on three R’s: representation, roles/relationships, and responsibilities – essential tenets because of the “real risk of either perpetuating or even creating harm through the sharing of stereotypes, stigma, bias, micro-aggressions, and more.” These can be inadvertently transmitted through cases, stories, videos, and other forms of prompts in education activities, if the resources are not considered through an equity framework.
Thus, integrating these frameworks into health-care professionals’ learning activities is a significant stride towards promoting fairness and reducing harm within educational settings. It can improve the quality of work and life for employees throughout the health-care sector and improve outcomes for their patients.
Further reading: A free course on dismantling structural stigma in health care aims for meaningful change for people experiencing mental health and substance use issues.
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When Kristen Parks delved into the Mental Health Structural Stigma in Health Care eLearning Course this past summer, she soon had a distinct feeling of déjà vu.
It didn’t take long for her to realize, though, that some of the material was familiar because she’d seen it before. More than ten years ago, when she was in nursing school, she took an entire course on mental health.
“It was like flexing muscles that I hadn’t used in a long time,” says Parks, a registered nurse in the cardiac care unit at a hospital in the Atlantic provinces. “When you work in a hospital setting, you have a specialization. That’s what you have the most expertise in and it’s also usually what you focus on the most.”
The course – released a year ago by Canadian online healthcare learning provider HealthCareCAN, in partnership with the Mental Health Commission of Canada – is free, takes about 1-2 hours, and is available to anyone. The goal is to raise awareness about structural stigma, which can have a particularly negative impact on people experiencing mental health and substance use issues.
A type of stigma
In health care, structural stigma occurs when laws, policies, and practices result in the unfair treatment of people with lived and living experience. Such unfairness leads to inequitable access and a lower quality of care for these individuals, whether their concerns relate to physical health, mental health, and/or substance use.
This past decade has seen researchers—many of them Canadians—build a robust body of literature that investigates the impact of stigma in health care, more recently with a focus on structural stigma. Educational initiatives, like the course that Parks enrolled in, are based on that research, as well as insights from people with lived and living experience of mental health and substance with the aim of increasing understanding and awareness.
“With the material I already knew, it was more about bringing it to the forefront of my mind,” Parks explains, “but some of it was new. I took that course about 12 years ago and, since then, the insights and recommendations have changed, which is good. We want things to change.”
What changed?
More than 40 percent of respondents who took the course over the past year said they could describe the problem, as well as its impact on clients, identify where it existed in their organization, and “describe factors that contributed to the enablement of structural stigma in health care.”
Although there’s more than one problem created by structural stigma in health care, the central issue is that it creates a barrier for many marginalized populations. Not only has it been shown to discourage people from seeking out preventative care or early treatment, once people finally do seek treatment, stigma can lead to both poor treatment plans and missed diagnoses, the latter of which is often the result of “diagnostic overshadowing.”
Gretchen Grappone, a training consultant and clinician specializing in structural change, works with health-care professionals on dismantling structural stigma.
For example, someone with a substance use disorder could be be seeking help for anything from a broken arm to kidney stones but, once medical staff learn of the patient’s previous diagnosis of substance use issues, that diagnosis can overshadow other medical issues. That shadow can cloud the judgment of caregivers who suddenly only a “drug-seeker,” even though the patient might clearly be in pain and in need of medication.
“It’s super harmful,” says Gretchen Grappone, a licensed independent clinical social worker, whose work is now focused on training health-care professionals about structural stigma. “Because of diagnostic overshadowing, many people with mental illness or substance use disorders don’t get the treatment they need.”
Grappone recalls one example where someone went to the emergency room with serious chest pain but, because they’d been to that emergency department before and had been treated for borderline personality disorder, they weren’t taken seriously, Grappone says. “Then they died because they didn’t get the care they needed.”
Serious consequences
Incidents like this were part of Grappone’s motivation to shift her practice away from counselling individuals and towards providing education and training about stigma in health care settings. Another reason is that she has lived experience of depression.
“I didn’t get diagnosed until I’d experienced various forms of discrimination over many, many years,” she says. “That discrimination was related not only to seeking treatment for depression, but also because I’m openly gay, so it’s intersectional stigma.”
That personal experience, combined with her work as a clinician, Grappone says, gave her a front-row seat to many specific types of discrimination within the health-care system. That’s made her a valuable resource in the growing movement to dismantle structural stigma in health care, since research has shown that marginalized people who have experienced stigma have essential insights into that process.
Often, people with lived and living experience are the only ones who can see the problems that are baked in to practices that many take for granted as standard protocols. A good example is the code blue/code white dichotomy, that sees doctors paged to intervene in physical health crises (code blue), while the first responders to a code white, (violence or aggression) are often security personnel.
For example, in a follow-up survey, a course participant said they had experienced many code whites in their hospital (where a situation could be met with non-violent crisis intervention or physical restraint) but had not considered the patient perspective before taking the course.
De-coding the message
A patient in a mental health crisis, who may already be stressed and confused, may become agitated because of their experiences before the code white is called, they noted. “I can see why security being the first to arrive on the scene of a code white may not actually be the best option for the patient, as it may confuse or agitate them more, putting them on the defensive and escalating the situation further.”
Protocols like these are referred to as “coercive policies and practices,” and they represent an erosion of rights for patients experiencing mental health and substance use issues, who may be involuntarily admitted, physically restrained, and denied agency in decision-making about their health care.
It’s not easy to become stigma-free overnight (or, possibly, ever), but a good first step in challenging this discrimination is learning to see how the system works through the eyes of the people it’s failing. Many who took the Mental Health Structural Stigma in Healthcare eLearning Course said that the individual examples of stigma helped open their eyes to the issues.
It also helped them to recognize opportunities to address stigma, demonstrating that mobilizing knowledge to make positive change may be on the horizon. Nearly half of respondents said it encouraged them to make a change or take action to address structural stigma. Roughly the same number of graduates had gone so far as to plan ways to implement this new knowledge. At the same time, though, many expressed concerns that challenging the status quo might be an uphill battle.
“Yes, incorporating what I learned in the course into my work environment may mean I’ll face barriers such as institutional resistance, resource constraints, organizational culture, legal and regulatory constraints, and resistance from stakeholders,” says another survey respondent. “Overcoming these barriers will require persistence, advocacy, and creative problem-solving.”
Kristen Parks says that regular reviews and certification updates would also help people who want to transform the culture of care in any institution, citing annual CPR training as a standard practice. For example, everyone in a hospital from kitchen staff to administrators has to have CPR training. They may be in an elevator with a patient in an emergency, for example. Parks says this course could also be beneficial in a whole-of-healthcare manner.
“This course helped remind me that we always have to see the whole person, not just, say, the substance use,” Parks says. “There’s new knowledge out there and, if you’ve been out of school for 15 or 20 years, it may be completely different from what you learned.”
Take the course (free; 1-2 hours): https://chalearning.ca/programs-and-courses/structural-stigma-training-for-health-care-leaders/
Resource: What is structural stigma?
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What prevents people from seeking help?
For some, it’s a lack of resources—usually time or money. Others may not even be aware that help is available.
Sometimes, people postpone seeking help for a totally different reason, namely, that they’re worried about how they’re going to be treated by the health-care system. They worry about stigma.
“Stigma is something that we deal with every single day,” says Dr. Eileen de Villa, Toronto’s Medical Officer of Health. “Toronto, like many other areas, is grappling with the intertwined challenges of homelessness, pervasive mental illness, and untreated addiction.”
She hosted an event called Diverse Dialogues: Stigma & Breaking Barriers in Toronto in May as part of the annual Charles Hastings Lecture series.
Dr. De Villa calls this an unprecedented “triple crisis” that demands a solution from all three levels of government, listing stigma as one of the major roadblocks in the path to addressing this crisis.
“People say ‘If only they could get their act together’ or ‘If only they had made better life choices,” says Dr. de Villa, “but addiction is a complex disease, not a moral failing,” she says.
Types of stigma
“Stigma creates a web of shame, fear of judgment, and isolation,” she continues. “The fear of criminalization makes it far less likely that someone will seek help and, when they finally do work up the courage to seek out help, the discriminatory attitudes they can face within our health-care system don’t support the path to recovery.”
And, as Dr. de Villa points out, this is just one of the ways in which stigma impacts our population.
What, exactly, is stigma? Well, it’s as complicated as it is pervasive. At face value, most of us know that stigma is in the same family of words as “stain,” “scar,” and “mark of shame,” and generally means something along the lines of “an unfair belief about a person or a group of people.”
Current research frames stigma as the presence of a socially undesirable characteristic which signals ‘otherness’ according to research from the Mental Health Commission of Canada (MHCC). That research focuses on four types of stigma, explains MHCC president and CEO Michel Rodrigue, who was part of Toronto Public Health’s Diverse Dialogues event.
There is individual stigma which is largely about internalizing negative messages. The second is interpersonal stigma, which, he says, can arise in relationships with friends, family, and colleagues.
Structural stigma encompasses organizational rules, policies, procedures, laws, and cultural norms that perpetuate and increase stigmatization. Intersectional stigma, which happens when stigma related to mental health or substance use overlap with other forms of inequities.
Thanks to a growing body of research that’s built up a taxonomy of stigma, it’s been easier to identify the ways that stigma, particularly structural and intersectional stigma, have been used to marginalize populations.
Lived experiences with stigma
“Stigma does not exist without marginalization and discrimination,” explains Dr. Notisha Massaquoi, assistant professor in the Department of Health and Society at the University of Toronto Scarborough, who spoke at the event and participated in the panel discussion. “Stigma is a core and essential tool within anti-Black racism.”
Dr. Massaquoi says we can’t separate stigma from other tools of oppression, notably erasure and invisibility, but also marginalization and isolation. Stigma serves to distract us from systemic barriers to health and has a profound negative impact on the health of the population.
“Stigma undermines every aspect of the health-care cascade,” says Dr. Massaquoi, “It undermines diagnosis, it undermines treatment, it undermines equitable access to care, and it undermines successful outcomes.”
Before working at the university, Dr. Massaquoi worked in public health, first as a service provider for continental African people in Toronto newly diagnosed with HIV. That was in the late 1980s, before medical treatment was available. She says that every day, she hoped nobody would walk through her door because every client she saw would pass away within a year.
“When we did get medication, when AZT (a type of anti-HIV retroviral drug) first arrived in Canada, what I saw were the effects of stigma,” she recalls. “African people were blamed for bringing HIV to Canada and stigmatized in terms of being accused of having unusual sexual practices. All kinds of stigmatizing labels were given to this community.”
That led to people losing their jobs. And, Dr. Massaquoi adds, if they were discovered to be HIV-positive, health-care providers dropped them from their rosters. Toronto’s Black community was the last to access medication.
Sometimes discrimination comes from structural barriers that are difficult to perceive, such as the lack of HIV/AIDS clinics in parts of the city with large Black communities, even though the incidence of HIV infection is higher in those populations. That disparity is finally being addressed now, but it persisted for years.
Other times, though, discrimination and stigma in the medical system is blatant and undeniable.
“On my first day of residency as a physician in the Victoria General Hospital, a nurse chose to stop me from going in to deliver a baby by grabbing my braid and yelling at me,” recalls Dr. James Makokis, two-spirit family physician in Saddle Lake Cree Nation, Alberta, and season seven winner of The Amazing Race Canada, who also spoke at the event.
“When we think about what happens to Indigenous patients who have far less power than me as a physician,” says Dr. Makokis, “then it makes sense that we have people like Joyce Echaquan who literally filmed her death on social media while she was being called the exact stereotypes that Indigenous peoples are often labelled with. Like that she was only good for sex.”
Echaquan, a 37-year-old Atikamekw woman, died of a pulmonary edema in a hospital in Joliette, Quebec, in September 2020, after being restrained and given morphine. Her family claims she was allergic to morphine and had expressed concerns over a potential adverse reaction.
As she was dying, she recorded and live-streamed a seven-minute video of nurses insulting her, calling her “stupid as hell” and blaming her health problem on “bad choices.”
Dr. Makokis says acts like this, which blatantly expose structural racism, are enabled by dehumanization. In turn, dehumanization is supported by stigma. It’s all part of the same logic of white supremacy that justified and enabled colonization and genocide.
“Part of dehumanization is suggesting that a group of people has less intelligence or morality,” he says. “And we can think about that in terms of Indigenous people who were often taught only up to grade six in residential schools because they were thought to only have the mental capacity to achieve that level.”
There are other components of dehumanization—suggesting that a population is an “infestation” and characterizing those people as “savages” or “cockroaches.” All of this helps to justify violence, injustice, and systemic inequity.
“You are not the same as me,” continues Dr. Makokis. “I am better than you. You are less human than me. And when that happens, it’s a core component of dehumanization, which means that we can do anything to a group of people, and they just become a collection of stereotypes.”
What can we do?
Dr. Makokis says that Canadians like to (falsely) believe we live in a post-racial nation of kind peacekeepers and that discrimination is a thing of the past. He, as well as Rodrigue, Dr. de Villa, and Dr. Massaquoi, all point to education as the first step in dismantling systemic racism.
We learn little or nothing in public schools about genocide, residential schools, or the contributions made to society by Black Canadians—and that invisibility and erasure are the first steps towards stigmatization. If we start there, we can help stop dehumanization and stigma before it starts. After that, Dr. Massaquoi says race-based data is key, so we can advocate for stigma-free services that are truly accessible to the communities that are most in need.
Viewing stigma through a public health lens is an excellent way to understand that public health is a key pillar to the fabric of society. As the pandemic demonstrated, we are all connected in ways we don’t always understand until we are in crisis.
“We have always worked towards justice,” says Dr. Makokis. “And it’s important to remember Dr. Luther Martin King’s words on the matter. ‘Injustice anywhere is a threat to justice everywhere. We are caught in an inescapable network of mutuality, tied in a single garment of destiny. Whatever affects one directly, affects all indirectly.’”
Video: See the 2024 Charles Hasting Lecture on the Toronto Public Health YouTube channel.
Resource: Structural Stigma: An implementation guide to making real change for and with people living with mental health problems or illnesses and/or substance use concerns.
Photos: Courtesy, Toronto Public Health
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World Suicide Prevention Day is held annually on September 10. The theme for 2024 is Changing the Narrative on Suicide to transform how we perceive this complex issue. It’s about shifting from a culture of silence and stigma to one of openness, understanding, and support.
If you are feeling like you have lost hope and are struggling to cope, if you are dealing with thoughts of suicide, or if you are worried about someone else, call or text 9-8-8 at any time.
One night a few years ago, Aja Sax found herself alone in her apartment and completely overwhelmed with suicidal thoughts. It wasn’t the first time she’d experienced this feeling, but it was, by far, the most intense.
“The few days leading up to my most serious episode, I lived with this feeling that I wanted to take my own life because I just couldn’t see things ever getting better,” she recalls. “I couldn’t imagine ever being happy again.”
Sax says she’s had bouts of depressive thoughts for as long as she can remember. She had asked her parents about getting professional help when she was 12 years old, only to have her concerns dismissed. “My father laughed in my face. And my mother said, ‘You’re so young, what could you possibly be depressed about?’”
As a young adult, when she confided in friends, she felt that many “invalidated” her feelings and suggested the answer for her was meditation or sunrise yoga. Fortunately, she also had support from people—online and in person – who took her seriously and seemed to know exactly how and when to check in with her. One even stayed with her through her worst night and helped her take action to seek help in the morning.
“Those online relationships saved my life,” she says.
Sobering statistics
According to the World Health Organization, globally, more than 700,000 people die by suicide every year. In most regions, youth suicide rates are higher than other demographics, including in Canada where suicide is the second leading cause of death among people aged 18-34—youth and young adults.
A key piece in addressing this epidemic and reducing suicide rates is steering conversations about suicide away from those that can create more harm and, instead, in the direction of the kind that Aja credits with saving her life. To that end, the Mental Health Commission of Canada (MHCC) recently launched #ChatSafe, a resource designed to change the way we talk about self-harm and suicide.
Developed by a suicide prevention team under the guidance of professor Jo Robinson at Orygen, an Australian research institute focused on youth mental health, #ChatSafe is the world’s first evidence-based set of guidelines designed to support peer-to-peer communication about suicide and self-harm between young people aged 12-25. There is an additional resource for caregivers, and both tools include comprehensive and straightforward guidelines to avoiding unsafe language, imagery, and emotional triggers when having conversations about suicide and self-harm.
“There are a lot of misconceptions when it comes to the way we intervene with people and some of that comes from the language itself,” explains Nagi Abouzeid, a member of the MHCC Youth Council who is currently pursuing a Master of Science in rehabilitation sciences at the University of Montreal. “There’s a section in the #ChatSafe guidelines that outlines unsafe language, such as ‘commit suicide’ as opposed to the safer phrase ‘dying by suicide’. People use this old terminology and don’t realize where it comes from.”
Language matters
Prior to 1972, when it was decriminalized in Canada, suicide was a criminal offence that people “committed,” and non-fatal suicide incidents could be prosecuted. Although the legal status changed over 50 years ago, the words “commit” or “committed” still link it to immoral behaviour, which can lead to feelings of shame. In turn, that can discourage folks in distress from seeking help.
One of the first people to draw attention to the role language plays in our perceptions of suicide was Toronto writer Doris Sommer-Rotenberg, who, in a 1998 issue of the Canadian Medical Association Journal, specifically called out the use of the phrase “commit suicide.” Driven by a wish to “keep alive the vitality” of her son, a physician in his thirties who died by suicide, as well as a desire to help prevent similar tragedies, she helped kickstart a movement to overhaul the language of suicide.
In addition, she campaigned for a research chair in suicide studies in her son’s name, Arthur Sommer Rotenberg, at his alma mater, the University of Toronto, which was the first of its kind in North America. “This fact, in itself, attests to the silence that has historically surrounded the issue of suicide,” she observed.
In 2016, Sommer-Rotenberg was awarded the Governor General of Canada’s Meritorious Service Medal for her work in raising awareness of the silence and stigma surrounding suicide. In the roughly 25 years since she wrote her editorial, silence has become less of a problem, thanks, in part, to social media. There’s still plenty of fine-tuning to be done when it comes to language, however.
“While social media can be a source of connectedness for young people, it can also pose a risk to the safety of young people,” explains Nitika Rewari, Director, Prevention and Promotion Initiatives at the MHCC. “So, it is our responsibility to support young people to have the right tools and knowledge they need so they can safely communicate online about suicide and self harm. #ChatSafe guidelines can help.”
Often, as was the case with Aja Sax from our opening paragraphs, well-moderated virtual forums can help members get support and sage advice from others with lived experience of suicide and self-harm. However, the digital mental health landscape is also home to some influencers, how-to suicide sites, and even big budget productions that can veer into unsafe territory.
“The Netflix series 13 Reasons Why was developed in a way that really highlighted some of the things that we say not to broadcast, for example, means by which people attempt suicide,” Rewari says, noting that the series tackles some of society’s most complex mental health topics, such as adolescent suicide, bullying, and problematic substance use. She says such topics, especially as they relate to suicide and mental illness, could be raised in a more safe, sensitive, and responsible manner to avoid stigmatizing suicide and to encourage viewers to seek or offer help when needed.
Useful tools
Although there’s still plenty of debate as to the cause of the increase in monthly suicide rates the month that series was released, one study in the United States established that it was associated with a significant increase in suicide among youth. The researchers concluded that “caution regarding the exposure of children and adolescents to the series is warranted.”
#ChatSafe guidelines make it easy for participants in threads and content creators to learn when to use trigger alerts and how to avoid unsafe imagery, themes, or terms, thanks to its extraordinarily clear and plain-spoken language.
“Something I really appreciate, as a youth, is the practicality of the suggestions,” says Alisha Haseeb, currently in the health sciences undergraduate program at McMaster University and a member of the MHCC Youth Council.
“The guidelines go beyond identification of best and unhelpful practices by offering concrete and actionable alternatives, while also providing insight into why certain methods of engagement and communication are more effective than others, which really shows that this is rooted in evidence-based practice and encourages us to make decisions that are reflective of our intentions.”
She adds: “I think that reading through these guidelines is a great way to just be mindful of the language that we’re using and also to be mindful of the impact that it has and what kind of messaging we’re sending.”
The accessibility is also owing to the methodology professor Jo Robinson used to develop #ChatSafe. The suicide prevention team at Orygen consulted a diverse range of people representing different cultures from regions around the world, taking it way beyond the usual peer review system that’s generally limited to other academics and research scientists.
“I think there is certainly a disconnect between the generation that is designing services and guidelines for young people, and the way in which young people actually engage with those services,” says Haseeb. “Something that gives me a lot of confidence in this resource is that it is co-designed by youth who had living or lived experience of self-harm or suicide or had supported someone who was self-harming or suicidal.”
That has also made it easier to adapt it for use in 14 countries outside of Australia, including South Korea, Nigeria, Finland, Brazil and, of course, Canada.
“I’m delighted to have collaborated with MHCC to release the #ChatSafe guidelines across Canada,” says Orygen’s Jo Robinson. “There’s never been more need to empower young people to talk safely online about self-harm and suicide, along with the parents and carers in their communities. Together, we hope to see a safer internet for young people and successful help-seeking for those at risk.”
Resource: #ChatSafe: A guide to communicating safely online about self-harm and suicide.
Further reading: Surviving Suicide Loss: Navigating stigma, grief, and loss and finding healing, hope, and community support after a death by suicide. A personal story.
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Are you reading this in the bathroom? You wouldn’t be the first.
Digital culture has invaded intimate parts of our lives – bedrooms, dinner tables – and in those formerly stolen moments like the line at the grocery store or, dangerously, sneaking a glance while driving.
Those notes, texts, scrolls, and posts add up until it becomes a habit – and that becomes the stuff of your life. Your mental space is crowded.
Increasingly, I hear friends and strangers say they want their brains back. They’re looking for meaningful ways to do that – a new hands-on hobby like the piano – or they’re installing concentration apps.
Thinking in Facebook posts
I remember reading a think-piece where the author talked about missing important life moments, such as observing a toddler’s first steps, and how his brain was already focused on filming it or even mentally drafting a tweet about it. I’ve caught myself doing something similar and missing the beauty of the moment. It’s insidious. Suddenly we think more about performing our lives over living them.
So, what can we do? Johann Hari’s book Stolen Focus: Why You Can’t Pay Attention (2022) notes that simplistic solutions like, “just don’t touch your phone” don’t reflect the realities of how these devices are engineered.
They are designed to release dopamine making us spend way more time than we intended to, says Sophie H. Janicke-Bowles, a media psychologist and associate professor at Chapman University in California, in Psychology Today. Janicke-Bowles says, we need to know what “healthy” tech use actually looks like to foster it.
Technology differs in each of our lives
That’s why we’ve called this piece “design your digital diet.” It reflects the differing natures and needs of our technology use. Yes, we know – we’re online telling you to go away from the screen. However, is that not the challenge of our times? A digital diet means different things to different people. For example, a colleague uses the saying “sunshine before screen time,” to start and set the tone for the day. It works for her.
Making plans, ordering food, requesting a lift, looking for a date, finding a new shirt, or applying for a job requires interaction with a screen. It also taxes our mentality, time, focus, sense of self, and relationships.
To be sure, there are positive aspects. At the Mental Health Commission of Canada, we develop, promote, and encourage the use of quality, safe, culturally appropriate electronic mental health tools to bridge gaps in the healthcare system. Instant mental health care in your pocket. That’s a plus.
All to say, we can’t stop technology, but we can advocate for more control in the way it’s used so that we don’t ruin our capacity to pay attention.
Pay attention to your friends
The watering hole in my neighbourhood has a “pay attention to your friends” sign on the wall and printed on the menu. It’s part scolding and part invitation to disengage and reengage in a lost art – eye contact and conversation. The place is moody, low lit, and has great service – that should be enough to take us away from the vortex of our phones, yet it’s not. This nudge is kind of like holding up a mirror – um, duh, when did this phone thing become so normalized? If we need to be reminded, then it’s hard to wonder why we have a loneliness epidemic. I try to frequent that place. Elsewhere, it feels like everyone is always looking down, more engrossed in screens than in other humans’ expressions.
Surgeon says
When the U.S. surgeon general weighs in, you know stuff is serious. In June 2024, Dr. Vivek H. Murthy called for health warning labels on social media to address youth mental health issues. An advisory is reserved for significant public health challenges that require the nation’s immediate awareness and action – though, I’d argue it’s not confined to America, social media crosses borders.
The advisory notes that because adolescence is a vulnerable period of brain development, social media exposure during this period warrants additional scrutiny. Extreme, inappropriate, and harmful content continues to be widely accessible by children and adolescents, it notes, while underscoring the fact that social media also provides positive interactions and social support, especially for youth who are marginalized, including racial, ethnic, sexual, and gender minorities.
It notes that researchers believe that social media exposure can overstimulate the reward centre in the brain and, when stimulation becomes excessive, can trigger pathways comparable to substance use or gambling.
The features that keep us hooked are burrowing our brains: push notifications, autoplay, infinite scroll, likes and hearts, and algorithms that continually serve us the things we want. Ding! Ping!
Feel it
This technological invasion can manifest in strong responses: periods of complete disconnection or an engagement with more haptic elements – hands-on woodworking, say, or a new vinyl collection. For many, it’s also about re-engaging with in-person experiences like live theatre or concerts.
I like those shows where phones are banned. An early 2024 Trevor Noah comedy gig made me feel really present. I observed the design details of the old theatre, people’s reactions, the stage set up, and the issues being dissected through trenchant comedic bits. It took a security-endorsed phone ban to feel that good.
There was relief in taking in the experience unmitigated by a sea of small screens and feeling that collectivity. I admit wanting to steal a snap for my feed or personal memories. I also remember the olden days when we simply bought the t-shirt to say, ‘I was there.’
This is a generational bridge. Ensconced in a Gen X frame of reference, I straddle virtual and offline worlds. I know what it is to have made a call on a dial phone using a number I memorized – sometimes from a phone booth. I write in cursive, mail letters on paper, handled and paid in cash, read newspapers, found a location on a paper map, a phone number in the phone book, looked up something on microfiche, made mixed tapes as a form of flirtation and social currency, and took photos on film and had to wait until they came back from the camera shop – or 1-hour photo for the impatient – to see how they turned out. I often wonder about the different experiences of digital natives.
Another longing from an older era would be the craft of storytelling – whether it be oral histories or the written word – to convey meaning or share personal narratives. The essay The Crisis of Narration by Byung-Chul Han traces the change in storytelling. Once a communal bond over campfires that connected us to our pasts and provided a picture of the future, now those settings have been replaced by screens. The author calls this a transition to storyselling, a distinction that removes the artfulness and puts our personal lives into a commercial frame, which is, in essence, what we are doing. Like the saying goes, in social media, you are the product.
Ultimately, our relationship with technology is personal. We have to design our digital diet to reflect our realities, values, and needs – and consider the way it can enrich our lives. Mindful choices and intentional pauses can mitigate some of the nefarious effects of technology to support our mental well-being.
Log in, share your ideas for better digital engagement, and then log out for another activity. Books, friends, outings, or a digital pause. We’re crowdsourcing ideas on maintaining a balance. What do you do? Tell us on social media or via email: mhcc@mentalhealthcommission.ca. (We aren’t accepting postcard submissions, but we probably should).
Further reading: Tech Support: Online mental health support is breaking down barriers. We look at the potential of artificial intelligence and strategies for avoiding pitfalls.
Fateema Sayani is constantly re-examining her relationship with technology. She is the Manager, Content, at the Mental Health Commission of Canada.
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This is a story for any day of the year – but we want to note the 2024 theme for International Overdose Awareness Day – held annually on August 31 – which is “Together We Can.” The topic highlights the power of communities standing together to end overdose.
I have a kit that reverses opioid overdose, and I am not ashamed.
It is not only those members of the population who live with substance use concerns who could owe their lives to naloxone; it is also people who live with chronic pain and take prescription pain medications – like my wife. Or people like my son who could get into that pain medication by accident. It is all of us who, in our daily lives, could come across other people who – for whatever reason – have overdosed on opioids.
This can happen anywhere – including in the workplace.
In 2021, there were 2,129 cases of opioid poisoning out of 1.7 million workers in Ontario, according to Ontario Health. Tradespeople, service industry professionals, healthcare, and office employees – all workers – along with customers and contractors that enter businesses can be affected. With such a wide reach, it makes sense that a workplace first aid kit would contain a naloxone kit.
“To me it’s a no-brainer,” says Stephanie Fizzard, a former harm reduction worker. “When you’re grabbing your first aid kit, you’re grabbing your defib[rillator], and you want to be prepared with everything you need to handle that situation.”
Making naloxone part of our workplace first aid kits should be standard – along with training on how to administer it.
About opioids
Opioids like fentanyl, oxycodone, heroin, and morphine, are drugs with pain-relieving properties that can induce euphoria and have significant potential for addiction. They can be prescribed medications, or they can be obtained or produced illegally. According to the Canadian Centre on Substance Abuse, synthetic opioids are fueling the opioid crisis. Fentanyl and fentanyl-like substances that are of non-pharmaceutical origin and are illegally manufactured are the most widely available opioids in Canada’s unregulated drug supply. These drugs increase the risk of drug toxicity deaths because they are extremely potent and can be fatal, even in small amounts. Often, unrelated classes of illegally manufactured drugs contain fentanyl in an effort to increase addiction potential, leading to opioid overdoses even in people who did not knowingly use opioids.
What an overdose might look like
Opioids can cause an overdose and symptoms may present as difficulty walking, talking, or staying awake. It may show up as:
- Blue or grey lips or nails
- Very small pupils
- Cold and clammy skin
- Dizziness and confusion
- Extreme drowsiness
- Choking, gurgling, or snoring sounds
- Slow, weak, or no breathing
- Inability to wake up, even when shaken or shouted at
How naloxone works
Naloxone is a medicine that blocks the effects of opioids – that’s why it’s known as an “opioid antagonist.” When opioids enter the body, they rapidly bind with opioid receptors. Naloxone blocks the effects of opioids by kicking the opioids off those receptors – and binding to those receptors itself.
Naloxone is not a treatment for opioid use disorder. It is used to temporarily reverse the effects of opioid overdoses. It can restore breathing within two-to-five minutes and is active in the body for 20-90 minutes, whereas the effects of most opioids last longer. In other words, the effects of naloxone are likely to wear off before the opioids are gone from the body, which causes breathing to stop again. Naloxone can be administered multiple times as needed until help arrives. If naloxone is administered to someone who is not overdosing on opioids there will be no ill effects. So, naloxone is a low-risk, high-yield treatment.
The effects of stigma
I remember the first time I was given a naloxone kit. I had surgery in 2018 and needed a course of narcotic pain medication. I practically threw the kit back on the counter. “I’m not a drug addict,” I spat back at the pharmacist. I was concerned about how I would be seen and resistant to the idea that a person like me could even need naloxone. I know much more now – that opioids can affect anyone of any walk of life. The stigma that surrounds substance use can spill over into the use of naloxone.
“A lot of people feel like they’re enabling substance use if they reverse an overdose,” says Fizzard, who is also a person with lived experience of substance use. “I tell them ‘You’re helping people breathe and stay alive – you’re not doing anything else; you’re not helping them take drugs.’”
Fizzard notes that public services have not kept pace with issues of opioid use and overdose, meaning there aren’t enough services out there to meet needs. She makes the case for everyone having awareness of and access to a naloxone kit – noting that the largest barrier to using naloxone is not administering the medication, but the stigma surrounding its use, including in the workplace.
How naloxone is administered
Naloxone comes in two forms: injectable and nasal spray. The injectable form can be intimidating if you are not accustomed to needles. The nasal spray is quick and easy, according to Fizzard.
“The nasal is much more user-friendly,” she says. “In a pinch, you just pull it out of the packaging, put it in the person’s nostril and push the button. Simple. There’s no way of messing it up.”
Naloxone at work
Naloxone is not mandated in the workplace across Canada. Ontario has laws, embedded in the Occupational Health and Safety Act, requiring businesses that employ people who are at risk of overdosing to keep naloxone on hand and train staff how to use it. However, this is only a partial mandate, as those businesses who determine that they do not “employ people at risk” are not required to provide naloxone at work.
In British Columbia, naloxone is not required in the workplace, but tools exist to help identify where it should be employed. In Alberta, employers can choose whether or not to authorize the use of naloxone in the workplace, but if they do then the employer and worker must comply with a set of requirements established by the government.
For workplaces in Canada, health and safety mandates are the jurisdiction of the provinces and territories, meaning that a Canada-wide mandate is not likely. Instead, provinces and territories will have to decide to overcome the stigma and challenges and legislate the inclusion of naloxone in the workplace individually.
Are there barriers to keeping naloxone in a kit at work? It has a shelf life of around two years (or until used) after which it would need to be replaced and repurchased at around $100 per kit; this could pose a challenge to some businesses. (Ontario is providing kits free to businesses, for a limited time, to ease this burden). There could be training costs and stigma is an additional barrier that may prevent workplaces from acquiring naloxone kits.
Your kit
For individuals, naloxone is free in many provinces and territories and is available at pharmacies over the counter, or by ordering online, without a prescription. Online tutorials demonstrate how to use the kits.
As workers, we can inquire whether a naloxone kit is available at work and, if not, whether a kit and training could be made available. Naloxone kits are small, easily stashed in any workplace, and take minimal training to use. In Ontario, it should be enough to identify oneself as a person at risk of overdosing to trigger the requirement that a kit be provided.
In sum, it’s simple: naloxone can save lives – but only if it is available and people are trained how to use it.
Infographic: Do Drugs Contain What We Think They Contain? (Canadian Centre on Substance Use and Addiction)
Further reading: How compassionate health care can alter the trajectories of people who use substances.
The author at the office with her workplace naloxone kit.
Author: Jessica Ward-King (she/her) is the StigmaCrusher, a mental health advocate, speaker and author who is a loving ally to many in trans and non-binary communities.
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It is midnight where you are, and you need immediate mental health support – but there are no services open. You find an app that offers culturally adapted peer-supported services from those trained in mental health – and you access the support you need.
You are a parent of a young child with little time and would like to access mental health support and counselling. You are able to log in online to an e-mental health session once you have put your child to bed and can get the support you need.
You have newly arrived in Canada from a country that views mental health support negatively and the stigma you feel is preventing you from accessing in-person care. You see that there is an online e-mental health service available where you can maintain your anonymity and you are able to access the mental health support that you need.
Mind the gap
These are just a few of the stories I hear as the manager of e-mental health at the Mental Health Commission of Canada. I lead a team that works closely with experts in Canada and around the world, including those with lived and living experience. Together, we collaborate to develop resources, frameworks, and supports around best-practices for those implementing e-mental health solutions in Canada. We work to demystify technology and focus on how quality e-mental health services have the potential to increase access to mental health services for those living in Canada. Increasing the quality of e-mental health support can also increase trust in these services. This means that people living in Canada have the flexibility to choose safe and effective care, when, where, and how they want.
We have witnessed many stories where gaps to accessing health care were bridged by technology.
Consider someone seeking support for an eating disorder, who does know where to go for help, or may not have services in their area. A service such as Body Peace Canada – a free, online source for those seeking support with eating disorders – provides access to resources and support.
The robots are coming
Maureen Abbott, right, with colleague Sapna Wadhawan, program manager at the MHCC, at a recent presentation of the MHCC Mental Health App Assessment Framework.
The term artificial intelligence (AI) may make some people uncomfortable or bring to mind visions of dubious robots. Hesitation and healthy skepticism are valid stances. With fast-moving technology comes big questions, along with big shifts that can improve access to quality care.
AI is being used in many ways to improve mental health care, from improving user experience navigating online systems, to saving time for practitioners by helping them to develop themes from their notes and connecting them to electronic health records.
The Mental Health Commission of Canada collaborated with CADTH – the Canadian Agency For Drugs And Technologies In Health – to develop reports on the uses and trends of AI in mental health. With the pending Bill C-27, aimed at enhancing consumer privacy, regulating AI, and updating data protection laws, those looking at safety with AI and mental health should be considering potential bias in the programming: think over- or underdiagnosing certain populations based on race or gender and how a reliance on existing data can replicate those harms. Or missing the mark by developing culturally insensitive material because it was not developed in consultation with the end users.
It is essential to involve clinicians and people with lived and living experience in the development and testing along with taking a human-centered approach to user design and testing. This means assuring that the privacy statement is clear, letting the end user know when they are interacting with a bot rather than a real person, indicate how their personal information is being used, and if it will be stored and shared – and if so, the details around that data use. Implementing best practices around data and privacy and promoting this to the general public will help to ensure trust among users and a broader uptake.
This focus on safety and best practices for AI use in mental health care is one of the recommendations being brought forward in the E-Mental Health Strategy for Canada, which will be released at the E-Mental Health International Collaborative (eMHIC) Digital Health International Congress September 19-20, 2024 in Ottawa. Developed with those with lived experience, policy makers, practitioners, and health leaders, the strategy will highlight six key priorities and 12 recommendations for e-mental health in Canada.
It’s important to have standards
When integrated properly and into mental health care delivery, e-mental health is just as effective as face-to-face services, and the technology is improving every day. Not only will this result in more people getting help faster, but it can also reduce the personal costs of accessing services and the costs of organizations accrue in implementing mental health services.
Some people may feel most comfortable accessing mental health services in an in-person environment, while others may choose an app or another e-mental health solution (such as online therapy) to access mental health services. The important part is for those living in Canada to have the opportunity to choose the types of services that work for them and that those mental health services are of a high-quality: safe, accessible, effective, and culturally adapted.
The e-mental Health team at the Mental Health Commission of Canada has been working to ensure the best practices are in place when implementing e-mental health services.
How? One example is the MHCC Mental Health App Assessment Framework. These national standards are meant to improve the quality of apps for people living in Canada. Before its publication, access to safe, secure, and effective mental health apps was largely undefined in Canada. The framework was developed with 200 collaborators in Canada and internationally, including those with lived and living experience, policy makers, government officials, app developers and designers, academic researchers, and mental health service providers to develop the framework.
The Cultural Safety, Social Responsibility and Equity standard within the framework includes content on Indigenous data security and privacy, gender equity, and representation from racialized communities. This framework is currently being used to assess a range of mental health apps in different provinces in Canada that are new or already widely adopted.
Al Raimundo was on the core development team for the framework and is a person with lived experience and an app developer. Raimundo says, the framework provides guidance for a range of products, even those that may not be immediately appealing to clinicians.
“Even if there’s something the professionals don’t love about an app, if people love them, then we should understand why. If a bunch of people are using it, something’s drawing them,” Raimundo says.
To help expand and better understand e-mental health services, the Mental Health Commission of Canada developed the E-Mental Health Implementation Learning Modules in collaboration with the Centre for Addiction and Mental Health (CAMH). The online learning modules are free, self-directed, and designed to give mental health providers, managers, leaders, and students the knowledge and skills they need to integrate e-mental health into their daily practice, and support effective, person-centered e-mental health service delivery.
Electronic mental health options are coming online quickly, and helpful standards and frameworks are being developed in tandem to bridge gaps between quality, demand and access.
The rapid advancement of e-mental health technologies offers immense potential to improve access to care. By prioritizing safety, quality, and cultural sensitivity, we can create a robust and reliable mental health support system that meets the needs of people in Canada.
Resources: Find a number of resources on the MHCC E-Mental Health page.
Guide: Where to Get Care – A Guide to Navigating Public and Private Mental Health Services in Canada
Maureen Abbott is a Masters-educated Manager and Certified Health Executive (Canadian College of Health Leaders) on the Innovation team at the Mental Health Commission of Canada (MHCC). Her work focusses on e-mental health, including the standardization of e-mental health apps in Canada, e-mental health implementation, artificial intelligence and mental health, an e-mental health strategy for Canada, strategic partnerships and stakeholder engagement, and knowledge exchange. Maureen is the Chair of the MHCC’s E-Mental Health Collaborative and a CHIEF Executive member with Digital Health Canada.
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Hands down, Rachel Kingston’s biggest parenting challenge is trying to manage her 13-year-old daughter’s social media use.
“My daughter was diagnosed with general anxiety disorder last year,” Kingston (a pseudonym to protect her family’s privacy) explains, “and I think some of her chronic anxiety is tied back to social media. Unlike some families, we haven’t had to deal with body image issues or being bullied, but I really worry about the lack of down time and true rest she gets.”
Kingston, a Calgary mother of two, says that her daughter’s social media use became a problem during the lockdown, when it represented the only form of social life available. It hasn’t tapered off since, though, and Kingston worries about the impact it might have on her nervous system. If it were entirely up to her daughter, there’d always be a YouTube or TikTok video playing in the background, no matter the activity—baking, drawing or even having dinner.
“If we put on a show to watch as a family, I look over and see she’s also on Snapchat,” Kingston says. “The kids don’t really care about my concerns.”
We know, for sure, that Kingston isn’t alone. Aside from casual banter about wresting kids away from screens in parent circles, five school boards in Canada are taking legal action against social media juggernauts that own Snapchat, TikTok, Facebook, and Instagram.
Neinstein LLP, the Toronto law firm that represents the school boards, has claimed (in a written statement) that social media products are “intentionally designed for compulsive use,” and the “addictive properties of these products have compromised students’ ability to learn, disrupted classrooms and created a student population that suffers from increasing mental health harms.”
Conversation starter
The lawsuits, as well as the even more recent proposal to crack down on problematic smartphone use in Ontario’s schools, have provoked a lot of conversation. Not everyone thinks measures like these are warranted, especially the young people in question, some of whom feel their freedoms are being curtailed.
One CBC Toronto story found several East York Collegiate students didn’t support the lawsuits. One student said if she was still doing well in school, she couldn’t see how it was affecting her negatively. Another said he didn’t want to be told whether of not to use social media and argued that it was up to him to choose. He went on to say that teachers should try taking phones away instead of suing a company. A little over a month later, the provincial government did just that, when it announced a partial ban on smartphones in schools. That policy is roughly in line, incidentally with UNESCO recommendations, which last year, advocated for school smartphone bans, arguing that they were distracting and bad for students’ mental health and well-being.
There’s a mounting pile of evidence to back this up. Jonathan Haidt, author of the new book, The Anxious Generation: How the Great Rewiring of Childhood is Causing an Epidemic of Mental Illness, was moved to write on the topic when he discovered a “surge” of mental illness diagnoses in the undergraduate population of the United States. Between the years 2012 and 2019—roughly the period in which smartphone ownership became ubiquitous—anxiety and depression rates more than doubled (by 134 percent and 106 percent, respectively).
This evidence, of course, is based on correlation—not iron-clad causation. That said, neuroscientists have been working on figuring out the mechanisms that might make children more susceptible to problematic social media use, as well as more likely to experience negative mental health impacts.
This is your brain on social media
“The pre-frontal cortex, which is the part of the brain that tells you, ‘I should put this device down now’ develops much later and children are really lacking that ability,” says Emma Duerden, Canada Research Chair in Neuroscience and Learning Disorders and Assistant Professor at Western University in the Faculty of Education.
Having trouble controlling impulses and not knowing when to put a device down is only one piece of the problem. Another factor has to do with the fact that children learn a lot through rewards-based learning, which makes them particularly susceptible to compulsive use.
“With children, you can see behaviour change very quickly if you offer them a candy or a cookie to get them to do something they don’t want to do,” Duerden continues “Children’s brains are hard-wired to respond to rewards and social media really acts on that system, because it’s designed to be highly rewarding with all the likes, comments and notifications.”
She notes that exposure to stressful images at a young age is a well-characterized pathway to serious mental health issues in late childhood.
“Content is basically completely unregulated in social media,” says Duerden. “Television, movies and even video games have to undergo some sort of examination from regulatory bodies.”
Although his focus is on children at present, Jonathan Haidt’s research into adolescent mental illness grew out of his work on the role smartphones have played in amplifying the “long-known weaknesses of democracy.” Although harder to measure than mental health diagnoses, as everyone knows who talks about living in the “stupidest timeline,” political dysfunction is clearly on the rise as well.
“I would say that social media and, more generally, devices, have been an accelerant of the erosion of civil discourse on campus,” says Professor Randy Boyagoda, University of Toronto’s first adviser on civil discourse.
Boyagoda notes that because we use our devices so much, it’s become hard to see how important it is to have in-person interactions.
“I would say that the near permanent mediation of our lives by our devices has made it difficult especially, I think, for students, and in a different way, for faculty, to understand the irreducible importance of embodied face-to-face encounters,” he explains. “We would rather turn to our devices – as either mediums or as shields, frankly – from that type of encounter.”
Boyagoda says that, in his experience, discourse in both classes and faculty meetings was less constructive, more pointed, and more critical when they moved online during the pandemic than when they were held in person.
“You may still have pointed or critical comments, but they are received in a different way because, again, of the unembodied account,” he adds. “I can see the person’s body language and they can see mine. They can hear my tone. I can see their tone. I can tell when someone in a room isn’t fully with me on a point, and I want to understand why. All of that is only possible in person.”
Not going anywhere soon
None of this is to say that the erosion of mental health and civil discourse is monocausal. Or, for that matter, that all young people will react to social media in the same way. University of British Columbia professor of psychology Amori Mikami advises we need to approach social media as merely another form of communication that we figure out how to use it so that it serves us, as opposed to the other way around.
“I feel there’s a lot of talk and discussion about the negatives about social media and how it can harm mental health,” says Mikami. “And let me be clear, I think it can. But I don’t believe it’s an inevitability and I think there are ways in which it can benefit mental health too.”
Mikami feels a lot of problems stem from people who use social media as a passive consumer and just “ride the social media wave” to see where it takes you. “You need to ask questions like, ‘What am I getting out of this interaction?’ ‘What is the benefit?’ and ‘How do I feel afterwards?’ so you can make informed choices about what social media to engage with or when to engage.”
Social media, everyone agrees, isn’t going anywhere. But we need to find ways to use it appropriately that go beyond advice to turn off notifications and change our smartphones’ display screen from colour to greyscale (although these are both very effective).
In The Anxious Generation, Jonathan Haidt prescribes collective action on a number of fronts, including encouraging children to engage in play and immersion in real-world communities in meaningful ways. And, for the sake of civil discourse, this can’t end when we graduate from high school.
“We need a demonstration, to faculty and students both, that there is something irreducibly good about the act of thinking out loud with someone else,” says the U of T’s Boyagoda. “And that can best be done, hands-free, you know, without a device involved.”
He continues: “We need to recognize and reckon with disagreement and difference and see these as good things, insofar as they can lead to mutual understandings and increased shared understandings of a common issue, and ideally contribute to the common good.
“And to the pursuit of truth.”
Further reading: Is E-Mental Health Support Right for You?
Resource: #ChatSafe: A Young Person’s Guide to Communicating Safely Online About Self-Harm and Suicide.