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This piece is part of the Mental Health for the Holidays series. Our annual literary collection delves into various seasonal subtopics. We’re looking at good tidings, bad partings, and new traditions — things that emerge from estrangements, changes, and major shifts. While end-of-year celebrations can be joyful, they can also trigger feelings of stress and loss. Read the collection to learn how others were able to meet those challenges. Here’s a previous series on moping, coping, and hoping. Warm wishes for the holidays.
It’s been a long journey, this band. Rheostatics’ first show was in October 1980, at The Edge in Toronto and I remember the tears as often as I remember the screams of delight. It comes with the territory: the battles, the distress, the close-to-the-bone existence between four kids, who became four adults, who became four older adults. Scars heal and wounds mend, and the triumphs of shows, albums, and tours recede giving way to time passed, but the essence of simply surviving is the element that I stand behind lo these forty-plus years. Somehow, we made it.
For many musicians and people working in other disciplines, art gives us our point of emotional release. And with that release — with the doors of the heart flying open and the head swimming in an ocean of ideas and dreams — you’re never sure what will flow forward: ecstasy, anger, staggering bouts of laughter, and peals of distress. Being in a band is like playing in an endless field occasionally laid with mines and an unseen river of pathos. The hard times might not seem healthy, but they are, and the good times might feel like they’ll last forever, although anyone who’s experienced them long enough knows they will not.
Soul proprietor
Playing music with others means navigating, spiriting, and occasionally bartering with the depths of another person’s soul. If the art is any good it has to hurt a little coming up, and that vulnerability can be trying, even when it’s cresting over beautiful melodies created by someone you know closely and well. In Rheostatics, there was always the knife’s edge of nervous tension when a person brought in a new song. Minutes later, you’d be honouring and celebrating its existence by working hard to get it where it had to be, fully grown, but we were always aware of the author’s tender struggle to present it and bring it to life.
Still image from a video by Mark Sloggett.
“The sound of the crowd cheering came at me like a magnificent cloud of singing, crying birds. I’ll never forget it for as long as I live.”
We live, mostly, in a world where we’re taught to conform and suppress artistic expression— the greater forces of commercial society would have us behave “normally” rather than scream into a microphone at top volume with an army of friends raging behind you — but music and art dares your voice to be heard. As a mental health exercise, it leaves you happy and free, but as a social gesture, it’s still unsettling to many. There’s a clip I saw recently of Yoko Ono wailing over a Chuck Berry song performed on the Mike Douglas show, and its fearlessness left me staggered. It was pure release, pure voice, pure personality without a worry about how it would be processed by the host, the crowd, or the band. It was a sterling musical gesture; unencumbered by worry or comportment; unafraid by what anyone other than the singer would feel.
Playing in a band is easy. Playing in a band is hard. You have to learn how to get along, but you also have to learn to honour the release. Of course, there’s the functional and technical side about assembling a song so that it, more or less, makes sense, but the best times are when you’re on that wave and you’re unconscious of how or whether it’s working. The worst part is when others can’t find the wave, leaving the writer defeated, forlorn. But embracing failure is as important as achieving success. Not every song is going to create that shared feeling, but when it does: woah. You’re pulling people into your vulnerability and, if you’re lucky, you’re sharing it with dozens, hundreds, maybe thousands of strangers who are also pulled to it.
One time, during a performance at Massey Hall, I could feel all of these things happening — it was an ethereal moment, shroud in light and joy — and after the song ended, I told myself to stop and listen. The sound of the crowd cheering came at me like a magnificent cloud of singing, crying birds. I’ll never forget it for as long as I live.
Hello darkness, my old friend
With performers, there’s always darkness married to the light and, in the ‘90s, I recall, that darkness was rarely acknowledged as something to be addressed, wrestled with, and met head on. If someone had a worrying performance, or behaved worryingly, we lapsed into the mythology that the person was merely artistically petulant or troubled; they were bearing an artist’s soul through the difficult process of making good art. But recent musicians from Menno Versteeg of Hollerado to Kendrick Lamar to Big Boi of OutKast have been bold faced in recognizing the unhealthy environment in which so many musicians exist: endless touring hours, booze delivered nightly into your dressing rooms, unhinged schedules, the pressure to be better than your last creation, a stigma that haunted Van Halen’s Eddie Van Halen to his last days.
The signs of struggle are clearer now than they’ve ever been to the point that musicians are more aware of the demons, and fans tilt on the side of forgiveness rather than wanting their favourite bands to be wild and raw at all costs. People like Miranda Mulholland have advocated for venues with more non-alcoholic products, and, at the West End Phoenix newspaper storefront where we hold shows, we’ve staged “sober” gigs without alcohol sales. It’s taken generations, but we finally understand the danger and absurdity of an occupation where, the moment you show up for work, a tray of iced Bud is laid at your feet. We had — and continue to have — a great career, but I wonder if we could have fought through the hard gigs if we weren’t often relying on booze to get us to the end. But that scar has also healed.
Surviving has allowed us to look back at this life, this career, in the fullness of its landscape, but that’s not to suggest that, for newer musicians, it has to be the same. Maybe the cover has been torn off the facade; the seal removed from the prescription. Maybe now it doesn’t have to be as rough and dangerous as it is smooth and beautiful. Maybe you can get near the end without feeling you’ve paid too much for it.
Further reading: Common Mental Health Myths and Misconceptions.
Resource: How Alcohol and Suicide are connected – A Fact Sheet.
Author: Dave Bidini, has had countless sobering realizations as publisher of the West End Phoenix community newspaper in Toronto. He has so many favourite songs.
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This story is part of the Mental Health for the Holidays series. Our annual literary collection delves into various seasonal subtopics. In 2024, we’re looking at good tidings, bad partings, and new traditions — things that emerge from estrangements. While end-of-year celebrations can be joyful, they can also trigger feelings of stress and loss. Read the collection to learn how others were able to meet those challenges. Here’s a past series on moping, coping, and hoping. Warm wishes for the holidays.
It was in May 2021 that my sister announced she would not be getting a COVID-19 vaccination, despite the fact that most of us over age 60 were relieved, if not joyous, that we could do so. I was stunned. It was difficult to believe that my older and only sibling, a vibrant, well-educated, well-travelled woman in her 70s, would make such a reckless and, to me, foolish decision.
It was also the moment when the wider meaning of it hit me full force: the emotional connection we’d had my entire life would never be the same again.
My tears watered the vegetable seedlings I’d planted in the garden boxes my partner built during the lockdown days when everyone was doing backyard improvements and baking bread. I thought about all the things my sister had meant to me throughout my life and about how much I had admired and loved her. Although we live in different countries, we always kept in close touch and routinely visited each other over the years. It was viscerally sad to me that somehow, propaganda machines had hooked her better angels and rerouted them onto a hellish path she did not see — one that looked strewn with hazards to me. I worried. I did not think it unreasonable that she could die a miserable, preventable death, with no vaccination against a virus that was killing millions of people in every part of the world, particularly in her age group.
Outrage machine
Yet I really shouldn’t have been surprised by my sister’s decision to refuse vaccination. For years, I had watched with increasing horror as her left-leaning politics gradually and then precipitously veered from a desire for social justice and a willingness to stand up for the underdog toward a vortex of far-right talking points that cast doubt on anything found in “the MSM” (that is, the mainstream media; the world of conspiracy theories is full of loaded jargon), preferring instead rants generated by blatant mis- and disinformation. I felt constantly sideswiped by her increasingly angry, irrational messages, coming via email, text, Facebook, Twitter (X), and WhatsApp. It pained me to think of someone spending their retirement years watching alarmist YouTube videos and sharing them with others (who most likely would not watch them) in a constant attempt to spread the outrage.
My sister, seeing herself as a committed peace activist, was causing a lot of conflict in her personal relationships. In her mind, it was those who did not believe as she did who were the problem. It was her job to relentlessly try to convert them to her way of seeing. Bombarded by this constantly, I began to feel like collateral damage, a casualty of what has come to be known as the culture wars.
I’m hardly alone in this experience. Many family relationships have been fractured in recent years by political polarization largely engendered by social media, which is used by those who seek wider audiences for political or financial gain and have discovered that extremism sells. Stories of people who have lost a family member or friend to conspiracy thinking now abound on the internet. Support groups also exist for those trying to come to terms with what has happened to a loved one. Therapists now see greater numbers of people who either believe in conspiracy theories or are dealing with someone close to them who does. Some psychologists suggest that, while belief in conspiracy theories is nothing new, it should now be treated as a public health issue.
I came to understand that the arrival of COVID-19, with its public health measures, mandates, and lockdowns, was more like a final straw for people like my sister, not a freshly discovered reason to hate governments and the evil cabals behind them. It was I who had been in denial about how monumental the shift was and how long it had been in the making. For a long time, I did what I thought was right. I tried to show her evidence that the information she was basing her views on was largely flawed, that reputable sources had thoroughly debunked the junk science and plain lies she now espoused, and that social media algorithms had perniciously infected the internet, planting falsehoods and manipulating opinion by exploiting people’s confirmation bias, placing them in filter bubbles that just keep reinforcing the worst, most extreme, usually wildly off-base beliefs. I even sent her academic papers by scholars who had studied the nature of contemporary propaganda coming from “news” sources my sister admired.
Persistence is futile
I am sure she did not read them, and I eventually understood that this “rational” approach was never going to work. Her views are based on belief and emotion, not fact or evidence. It was easy for her to dismiss all of my sources — and me along with them. She’d done her “research,” cherry-picking material that supported her pre-existing notions and rejecting as false anything that did not accord with these views. Others in her circle, lifelong friends, were as alarmed as I was and tried similarly to reason with her, again to no avail. It saddened me to see her alienate people she had known and loved for decades.
The barrage of falsehoods and rage intensified as the pandemic stretched on. She and a small number of brave, enlightened “dissidents” had “the truth” that others for some reason could not see, and she did not hesitate to tell us all this, over and over with monotonous, obsessive regularity. Nothing would change her mind. Arguing was pointless. When I asked her to stop sending anti-vax material, it offended her, serving only as proof of my closed mind and an unreasonable dismissiveness toward non-mainstream but perfectly valid ideas. While 30-second Google searches were enough to find ample evidence to debunk whatever or whoever she was defending, telling her this made no difference.
To be truthful, I was not always rational in my responses. I called nonsense many times, was dismissive of what I knew was insidious propaganda, and could not believe my sister did not see what was obvious to me. I regret some of my lashing out. So I changed tack at one point and told her simply that I loved her and was worried about her health while asking that she reconsider her sources of information. In response, she told me she was worried about my health (she believed vaccinations could damage DNA) and staunchly defended her sources. She stubbornly doubled down, no longer responding to friendly, non-political messages, which made me feel slighted and resentful. In her zeal, all that mattered was politics, and any other discussions were superficial and useless. One result was that we corresponded less often, but in the absence of communication, I continued to worry.
It affected my mental health — I lost sleep ruminating on how it was possible that this had happened and what I could or should do about it. I regaled my partner and friends with endless rants of my own whenever a new message arrived filled with wild untruths. I could not accept the reality and felt helpless to change the trajectory it seemed my sister was on — I didn’t know toward what, but in my mind, it was something bad. And it sometimes felt like boundaries were being crossed, as one person felt free to express themselves while the other knew they could not respond without having an argument. I got a lot of pounding headaches keeping my thoughts to myself.
At times, I wondered if my sister could continue this way. But I have learned that it is possible to believe in what seems preposterous, even damaging things, and still be able to function in the world. I have also learned, through therapy and time, that it is possible to have a relationship with my sister despite our differences, even if it is strained, even if she doesn’t always respond as I would want. It certainly makes for clumsy communications during the holiday season, as we swerve away from testy topics, but that will have to be the new normal if I want any sort of relationship with her.
It’s not possible to unpack every complexity of a family relationship in a short article. I am a kid sister, probably forever a hapless teenager in my sister’s mind. Why would she take seriously any criticism or concern I might have toward her choices and beliefs? There is nothing new about her doggedness, her willingness to stand up for what she thinks is right, and her comfort at being marginal in her opinions. (We do need to remind ourselves that, as amplified as the voices of disinformation are (thanks to social media), these voices remain a minority; in the case of COVID vaccination in Canada, 83.2 per cent of us did get shots; in older age groups and some regions, more than 95 per cent did).
While I cannot say I am at peace, I have edged toward acceptance. As a mutual friend wisely observed, your sis is an adult who has made her own choices and must live with them. They further suggested that I continue to send my newsy family messages, to not take the bait when she throws down what feels like insults to my intelligence — to keep the heat down as much as possible — and just carry on. It is difficult sometimes, and I still worry, but I do accept this as a necessary strategy.
And I do, and always will, love my sister.
Further reading: Five Tips for Starting a Conversation About Mental Health
Resource: Better Supporting the Mental Health of Older Adults in Canada
Eleanor Sage
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December 3 marks the annual International Day of Persons with Disabilities, a UN Day to promote the rights and well-being of persons with disabilities.
I live with bipolar disorder, a chronic psychiatric condition characterized by extreme variations in my mood, energy, activity levels, and cognition. Despite these extremes of mood and energy, I am fairly high functioning in life and at work, where I hold a senior level knowledge-economy position. I have developed a variety of coping mechanisms, such as masking, to accompany these mood states and make me perform like I am “normal,” but many days it is an uphill battle, and I feel like I have to try twice as hard as anybody else to succeed. I have even had to change my career path and goals because of my struggle with this mood disorder.
Throughout my life, I have struggled, thinking that this was a “me problem,” that I had to change the way that I interacted with the system so that I could be successful. I ran myself ragged trying to succeed in a system that is made to be equal for everyone – a laudable goal – but was ultimately disadvantaging due to my mental illness.
Eye-opening discovery
Then I discovered the Employment Equity Act (EEA). The broad purpose of the act is to achieve equality in the workplace so that people are not denied employment opportunities or benefits because of their identity or level of ability. Moreover, the act exists to “correct the conditions of disadvantage in employment experienced by women, Aboriginal peoples, persons with disabilities and members of visible minorities.” (My emphasis).
I had always thought that a disability was, you know, like the symbol. Physical. Wheelchair ramps to allow access to buildings, or maybe even screen readers for people with low or no vision, but a mental illness? I did a deep dive into the act and found this passage:
“A person with a disability has a long term or recurring physical, mental, sensory, psychiatric or learning impairment and:
- considers themselves to be disadvantaged in employment by reason of that impairment
- believes that an employer or potential employer is likely to consider them to be disadvantaged in employment by reason of that impairment.
This definition also includes persons whose functional limitations owing to their impairment have been accommodated in their current job or workplace.”
Well, that tracks. In fact, it kind of describes my experience of the workplace to a tee. So, my mental illness qualifies me as a person with a disability? What does that actually mean?
There are a few things to unpack here:
Stigma and labels
First, there is the stigma associated with a label like “disabled.” This stigma is rooted in ableism, which is an attitude that views and treats people without disabilities as the “normal” ones and those with disabilities as somehow inferior or “other.” This stigma, which I summed up earlier as a “me problem,” (self-stigma) challenged my view of myself as a capable person and employee. It also made me worry that, if I were to self-identify as a person with a disability, managers would be hesitant to hire me based on that stigma and fear around how difficult it would be to work with me.
Disadvantage
Why would I try to overcome that self-stigma, risk the stigma of others, and choose to self-identify, and declare that I am a person with disability? Because of the disadvantage in employment that my mental health causes. Living with bipolar disorder can cause me to struggle to do my job within the “one-size fits all” system of work. The way that my brain and body functions when I am in a mood episode can limit my ability to succeed. I feel that these functional limitations caused by my mental illness disadvantage me in terms of achieving my goals at work and advancing in my career.
Not a me problem
The EEA doesn’t just stop at identifying that a barrier or disadvantage exists, however, it goes one step further: accommodation, which says, “employment equity means more than treating persons in the same way but also requires special measures and the accommodation of differences.”
Through various measures of accommodation in the workplace, I have found that I can achieve my potential and excel at my job. These accommodations are tweaks to my work environment (this could be physical, temporal, or social) and processes that help me to meet expectations. The key here is that instead of those disadvantaging barriers being a “me problem” they become a systems problem that the system needs to make space for and offer opportunities to remediate.
What accommodation can look like
The trick is identifying the functional limitations, and the changes that could help overcome those limitations. So, if a medication change is making me super groggy in the morning, perhaps a change of my work hours to a later start time is in order. If working from the office is too taxing on my energy during a depressive episode, maybe the place of work needs to change to allow for working from home. If my motivation or decision-making is reduced, more frequent and structured direction from my boss, and slightly expanded deadlines might be in order. If I am having trouble concentrating while reading complex documents, a screen reader could help.
Whatever the functional limitation, there is often an accommodation that can help me work through and balance out the disadvantage caused by my disability. Beyond that, my employer actually has a duty to accommodate, meaning that they cannot refuse a reasonable accommodation up to the point of undue hardship. The goal is to level the playing field – not confer any advantage – where equity, which differs from equality, is the aim.
Representation and changing the narrative
There is one final, very significant piece to the EEA. It aims to correct underrepresentation of members of designated groups in the workplace. That means that employers are encouraged and supported by the Act to hire and retain members of designated groups, including persons with disabilities, in an effort to balance out the systemic barriers that have prevented persons with disabilities from participating fully in the workforce.
Stigma and ableist attitudes persist in society and in the workplace, but the EEA gives me the legislative background – and the courage – to advocate for myself. It has empowered me to be assertive and forthright about the tools and conditions I need to succeed in the workplace as a person living with mental illness. Ultimately, it makes me a better employee, ensuring that I am consistently able to work to my full potential and contribute to the aims of my organization.
Further reading: Mental Health at Work — It Matters. How to Start the Conversation.
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Is spirituality back? Can micro-messages delivered via WhatsApp offer measurable improvements on well-being? These, and other ideas, were on the table at the 9th annual Electronic Mental Health International Collaborative (eMHIC) congress, hosted in September in Ottawa by the Mental Health Commission of Canada. Hundreds of delegates from dozens of countries came together to expand their thinking under the theme Digital Building Capacity: 24/7 Mental Health Support for All. The Catalyst team drew selected snack-sized insights and concepts for inspiration.
1. The Big Three
If you’re a young person, this likely comes as no surprise: their top three concerns are jobs, mental health, and climate. This finding from UNICEF guided the development of USupportME, an on-demand psychological support platform for youth. Piloted in several Eastern European and Central Asian countries, the platform is flexible and can be branded for use in different regions. With GDPR compliance and security support, it offers scalable white-label mental health services.
2. Ending the Google Loop of Despair
SANE, an Australian health organization for people with complex mental health issues, coined the term for a familiar cycle: being sent to a website, then a helpline, then a primary care physician, and finally referred to a psychologist—only to face a six-month wait, leading people back to “Dr. Google.” To break this cycle, SANE created a new model of psychosocial support focused on choice, continuity, open access, and quick response. Their approach includes self-referral, telehealth, digital programs, and group sessions, with an Indigenous-governed online learning space in their recovery community. They offer ongoing care, eliminating the traditional discharge model. “The future is in blended care models,” says CEO Rachel Green. It’s tech in service of people.
3. Soul Decisions
“Where did the soul go in clinical psychology?” asks Allan Donsky, a professor in the Department of Psychiatry at the University of Calgary and consultant at the Canadian Institute of Natural and Integrative Medicine (CINIM). He advocates for more contemplative therapeutic practices, beyond strictly diagnosis driven interventions, aimed at fostering self-awareness. Developing inner literacy can help people transition from languishing to flourishing by addressing big questions of self-acceptance, purpose, freedom, and relationships. Donsky notes that existential therapy was largely discarded in the 1970s, but there is a renewed interest in exploring inner dimensions—what might be called the heart, spirit, or soul. “What does it mean to be human?” he asks? It’s a universal question. “Every culture around the world has its ways of contemplating the deeper aspects of life.”
4. Family First
Mental health advocate Nicole Waldron referred to family caregivers as the very first responders. They are first on the scene to help family members, and they are often the unseen link in mental health care. Waldron gave a powerful address calling for better data collection and ecosystem support for family caregivers for their wellness, advocacy, and education. “What does a CTO mean? What does an SDM mean? How do you navigate a system where your loved one has been criminalized?”
(A CTO refers to a community treatment order and an SDM stands for substitute decision-maker).
Credit: eMHIC
5. One-Stop Help
Where to start? When there are so many options to choose from and you need support, what is the first step? Kids Help Phone launched Resources Around Me at the conference. It’s a directory of trustworthy resources from all across Canada. Kids Help Phone had 20 million interactions in 2020, and this directory helps them provide more support in more places and in more ways – virtual, text, in-person, and more.
6. Expressing Emotions in Sign Language
In Bangladesh, there are a total of 500 practitioners – 300 psychiatrists and 200 psychologists – for a population of 180 million – that’s a giant gap to fill. That’s where PhD researcher M Tasdik Hasan of Monash University in Melbourne, Australia, is piloting a project co-designed with deaf people, caregivers, healthcare providers, and sign-language interpreters. He notes deaf communities, in Bangladesh and the world over, are historically ignored when it comes to accessible and inclusive mental health solutions. They co-designed culturally and linguistically tailored tools to provide basic mental health terminology – such as PTSD, stress, and depression – in sign language.
7. Building Capacity in Small and Remote Communities
The ATIPAN Project provides telehealth services to Indigenous communities in the Western Visayas region of the Philippines, where access to healthcare is often limited by distance, challenging terrain (including islands, mountains, and agricultural or coastal areas), armed conflict, language barriers, and financial constraints. To address these challenges, the project implemented community-based patient navigators and infrastructure development over two years. Named after the Hiligaynon word atipan (“to take care of”), the project offers free consultations, training for community coordinators, and basic medications.
8. What’s App with That?
The Pode Falar project provides mental health support to Brazilians aged 13-24 through a website, Instagram, and WhatsApp. It features a chatbot named Ariel, who handles automated triage and offers assistance based on the complexity of users’ concerns. Users can access self-care tips (“I want to take care of myself”), read or share anonymous stories about overcoming challenges (“I want to be inspired”), and connect with a human agent for additional support (“I want to talk”). This large-scale initiative addresses mental health in an under-resourced area and was highlighted in a panel discussion: “Are Low to Middle Income Settings Ready to Benefit from Digital Mental Health Tools?” The program supports text, email, and WhatsApp messaging services.
Steal These Ideas
The congress’ regular sessions titled “Brag & Steal” offer permission to take projects that have worked well elsewhere and apply them to your own work. In that spirit, we want to underline a few cool concepts.
Pop Up Mental Health
Those attending a mental health conference tend to be a niche bunch, so why not bring it to the people? The Time to Change program that ran for 15 years in the UK until 2021 campaigned to reduce stigma through social contact. People with lived experiences of mental health issues had two-way conversations with unknown members of the public to debunk myths about mental illness. They went to concerts, libraries, and farmers’ markets, said Sue Baker, OBE, founder of Time to Change.
Of Sound Mind
Composer, sound artist, producer, and DJ Satya Hinduja, founder of Alchemic Sound Environment, taps into the connection between sound, music, technology, and health. Hinduja led a deep listening experience, designed to invoke states of reflection, receptivity, and exchange. Thinking about sound as a therapeutic experience gave participants a chance to reflect on the noises around them, frequencies, vibrations, and their own interiority.
North Star
There are so many mental health apps out there – how do we know what to trust? At the congress, the Mental Health Commission of Canada released Canada’s First E-Mental Health Strategy. This guiding star document has six priorities and 12 recommendations to chart the future direction and development of e-mental health in Canada. Use it to advocate, guide, and develop your work.
Narrative Care
Step by Step is a web application used in Lebanon that provides mental health support through storytelling. In the program, fictional characters with depression visit a healthcare worker, and users learn coping skills from a 15-minute illustrated story, observing how the character applies these techniques in their life. The second 15-minute segment is interactive, with the healthcare professional character delving deeper into therapeutic techniques and offering activities for users to reinforce what they’ve learned.
Overheard at eMHIC
- On getting things done: The words “collaborative action” – shortened to “collaboraction” was the name of the game – working together to advance mental health access.
- Beyond shiny objects: It’s not about technology per se, rather, “it’s about people and trust.” The tools enable this work and digital has no geopolitical boundaries.
- Making space for our work: Ian Hickie, professor of psychiatry, Brain and Mind Centre, University of Sydney, Australia, talked about “the Uberization of mental health.” If those with lived experience and research capacity in this field don’t respond appropriately, it leaves room for others to step in to respond consumer priorities: access, choice, competitive pricing, user experience. Worldwide, demand for personalized mental health services far outstrips supply.
- The meaning of it all: “We all get lifted when someone believes in us,” said eMHIC executive director, Anil Thapliyal, in his closing comments.
Coming up: The 10th annual congress takes place in Toronto, November 2025. Register your interest and learn more at: https://events.emhicglobal.com/register-your-interest-for-emhic-2025/
Further reading: Tech Support: Online mental health support is breaking down barriers.
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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.