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Aging without support is becoming more prevalent for older people in Canada. How can we stem the tide? A look at inclusive aging during Loneliness Awareness Week
“Why was it, she wondered, so difficult to believe that the old had been young, with the strength and the animal beauty of youth, had loved, been loved, laughed and had been full of youth’s unmeditated optimism?” — PD James —
This past winter, my neighbours found one of our older residents wandering around downstairs in the laundry room hallway of our apartment building. She appeared to be lost and confused.
We ended up calling an ambulance once it became clear that she was unwell. She had been living across from me, but I never really knew her. That day, after a brief phone assessment, the dispatcher told us it would be a four-hour wait. Since there wasn’t any food in her fridge, some of us brought snacks and made her a few cups of tea while waiting for the ambulance at her kitchen table. After learning she was 91 and living alone, we asked her about people we might call. But it took a few hours of chatting before she told us that she had no children or siblings. The one exception was a nephew who lived hundreds of kilometers away, who was surprised when we called him, saying they had not spoken in years.
The events that January day were a turning point for her, and for me. She hasn’t been back since being taken to the hospital. I don’t know what ended up happening, and I will never find out because I am not part of her family. Still, later that evening I couldn’t help wondering whether this was what the future might look like for me.
Aging and loss
Aging can bring an accumulation of losses: loved ones, social networks, physical well-being, financial security, purpose, a sense of being part of the wider world, and even a sense of personal identity. These are the kinds of significant losses that “deeply challenge people’s sense of connection to the world around them,” according to Dr. Sam Carr, principal investigator for The Loneliness Project — which qualitatively explored older people’s experiences of loneliness in depth. Many of them spoke to the researchers about how aging presents unique challenges related to loneliness and isolation. The research — now published in Ageing and Society — generated over 130 hours of conversations. One participant’s experience with losing a spouse shows the extent these losses often have: “When he was gone, I didn’t know where I fitted anymore. I didn’t know who I was anymore because I wasn’t [upset]. You just existed. Went shopping, when you needed food. I didn’t want to see people. I didn’t go anywhere.”
In an interview study of older persons’ loss of meaningful connection, researchers at Malmö University in Sweden concluded that profound loneliness in later life can be understood as if the individual “is in a process of letting go of life.” Such an experience also “involves the body, in that the older person is increasingly limited in his/her physical abilities. The older person’s long-term relationships are gradually lost, and finally the process entails the older person’s increasingly withdrawing into him- or herself and turning off the outside world.”
Getting older without kin
In Canada, aging without support is also on the rise. Sometimes called “solo agers,” an increasing number of older adults are kinless, meaning they are without a spouse or living children (or the children live far away). Others who may not be technically kinless may still be isolated. Even though most of them want to age in place, kinlessness can lead older people into long-term care. As a country that already has one of the highest kinless rates in the world, how will Canada support and care for the increasing number of people in this group?
In the U.K., the issue is connected to a larger theme: loneliness as a growing health threat. In 2018, Prime Minister Theresa May called it “one of the greatest public health challenges of our time” when she established “the world’s first ministerial lead” to tackle loneliness. Japan’s Prime Minister Yoshihide Suga followed suit in early 2021, adding a new minister of loneliness to his cabinet. Its initial appointee, Tetsushi Sakamoto, was tasked with preventing and reducing widespread loneliness, social isolation, and the increased suicide rates accelerated by COVID-19 restrictions.
Such measures are grounded in evidence about the health and mental health risks of loneliness. Research has consistently shown that low social support or increased social isolation is one of the major risk factors for depression at all ages,” according to Dr. Keith Dobson, a professor of clinical psychology at the University of Calgary. The U.S. National Institute on Aging ties loneliness and isolation with “poor aging outcomes,” including higher rates of mortality, depression and cognitive decline.
Loneliness in significant numbers also comes with an economic impact. In the U.S., a decades-long increase in loneliness has reached the point where “more than two out of three working adults consider themselves lonely” — something that costs employers about $154 billion each year due to related health problems, productivity losses, and staff turnover. In England, 45 per cent of adults experience some degree of loneliness, which, according to a 2017 New Economics Foundation report, costs U.K. employers £2.5 billion (C$4.2 billion) each year. The data paints a dire picture, especially when you consider that much of it stems from pre-pandemic research.
It’s not the same for everyone
As we might expect, the effects of loneliness and isolation don’t impact everyone equally. Charitable organizations that support older persons witness first-hand how some people bear the brunt of overlapping life challenges. According to Gregor Sneddon, executive director of Ottawa-based HelpAge Canada, we know that “as people age and experience physical and cognitive impairments, their exposure to the world shrinks, as does their exposure to other people and they ‘bear the fruit of isolation.’ Add in a global pandemic that locks people in their homes, takes away their means of participating in the community and belonging, and disconnects them from family and friends, and the result is critical health effects.” But it is definitely “worse for those with little money. . . . Those who don’t have options are the most susceptible to loneliness, which we know, can be fatal.”
Does Canada need a minister of loneliness?
CARP interim chief policy officer Bill VanGorder understands that “loneliness and isolation doesn’t only affect people who may be considered a senior.” But he’s all for having a minister of loneliness in Canada “if that’s what it takes to address the impact of isolation and loneliness on Canadians. A minister would make sure that programs are in place to ease these issues, other parts of the government would be accountable to them, and maybe, finally, we could change the way we care for older Canadians.” In societies like ours that favour independence and individualism, we tend to let people sort out and manage their own challenges. But if you are unwell, isolated, and lacking support, that’s much harder to do.
The U.K. government is taking an integrated approach to this issue, recognizing that more needs to be done and everyone must play a role. Building an effective network of connection and supports requires government involvement as well as that of friends, family, employers, voluntary and community sectors, local authorities, and public health bodies. But that’s just the start. Its loneliness strategy is guided by a framework to improve and connect social services, reimagine community spaces, transportation, housing, and technology, holistic health approaches, and public health campaigns to raise awareness and reduce stigma around loneliness. One example is the government’s 2019 Let’s Talk Loneliness campaign, which challenges this stigma by emphasizing the importance of talking about it.
The program even uses social prescribing, where community connectors, health and well-being advisers, and community navigators support non-clinical needs (including those of people who feel lonely) by connecting people to community groups and services for practical and emotional support.
While the success of the U.K.’s integrated approach is still to be evaluated, regardless of future results, its common-sense principles seem more robust than the current fragmented and disconnected supports available in Canada. While some resources and programs exist, they can be difficult to find, especially if someone is isolated and has no internet access. And yet, the premise could not be simpler: communities benefit when we support the well-being of older people and their families. The same could be said for people who live with chronic illness or disability. A truly inclusive society benefits everyone.
What does the future of inclusive and healthy aging in our country look like? Is it a society that recognizes the value of older people, and the worth and dignity of all, putting aside ableism and prejudice? I hold out hope for a new vision of supportive and inclusive aging where we “create living environments in which these mechanisms of support are embedded and integrated into [our] communities.”
Resources for people in Canada:
Nicole Chevrier
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Future directions for disability inclusion
Disability is often viewed as an issue that affects a small subset of the population. Yet the pandemic has broadened the scope of that definition — think long COVID symptoms — which could also include mental health conditions that affect most people at some point in their lives. In other words, disabilities — short-term and long-term — are likely to be a part of everyone’s life, whether personally or as a caregiver, and policy needs to catch up with that reality. While Canadian disability policy has made great strides in recent years, barriers to inclusion continue.
Making disability normal
As a person with disabilities, I need a variety of workplace accommodations to help reduce my pain and function well, including a flexible schedule, ergonomic workstation, dictation software, and the ability to work remotely.
I have hydrocephalus, cerebral palsy, and chronic pain as well as depression and anxiety, which further limit my ability to function. While chronic pain affects my mental health and I need psychotherapy, I can’t afford it because disability-related expenses like physiotherapy eat into my meagre income. I’ve managed to cut back on some expenses since the pandemic started, but my ability to do so is based on my need for isolation to avoid catching COVID, which would have devastating consequences for me (cerebral palsy affects breathing). On the other side, isolation itself comes with a cost: it leads to more depression, anxiety, and loneliness. Of course, that won’t be a surprise to people with disabilities and chronic conditions. Research shows that those of us who are living with such conditions have had the worst health and employment outcomes during the pandemic.
A wider spectrum to promote inclusion
I share my personal story to try and normalize the conversation around the accommodation process and advocate for a more streamlined approach. To close policy gaps and set a future course for disability inclusion, those with lived experience need to be at the table. As experts on their own lives, people who experience episodic or fluctuating conditions or invisible disabilities, for example, can make their daily challenges known to help inform policies around work, health care, and other systems. To ensure that policy reflects the needs of those it affects, scholars recommend that people with disabilities be included in research and be consulted as subject matter experts. Doing so would reduce barriers to social inclusion and bring policy questions around employment and financial security into the open.
An aging population also raises new questions; for instance, in connection with the decline in functional ability as people age. Shouldn’t disability policy account for the many who may find themselves coping with unexpected or new limitations in their daily lives?
In Canada’s most populous province, the Ontario Disability Support Program (ODSP) currently provides income and employment support along with drug benefits only to people with “substantial physical or mental impairment that is continuous or recurrent and expected to last a year or more.” That narrow definition focuses on permanent disabilities and chronic illnesses with no prospect of improvement — excluding episodic, temporary, or fluctuating disabilities like long COVID, which can include brain fog, shortness of breath, and other debilitating symptoms. While coverage has recently been included in the Ontario Health Insurance Plan, people with long COVID are having challenges navigating the benefits system, since it is considered “invisible and hard to diagnose.”
Closing the gaps
While social assistance programs are essential, functional limitations are central to receiving adequate benefits. In other words, the worse a person’s condition is, the more financial support they qualify for. At the same time, the program makes it hard for people with disabilities to break the cycle of poverty and income support. To get off social assistance, one must be able to work full time (or at least consistently enough to earn a living). But most people on ODSP can’t work, and those who can must often take low-paying jobs (with long hours in front of a computer) that don’t reflect their skill levels (like call centre jobs).
Unfortunately, these kinds of systemic barriers to employment are all too common. In 2019, I applied to the federal government inventory for students with disabilities, an employment initiative for students to work in the public service and gain valuable experience. However, my application was denied because of my part-time student status (the program was only available to full-time students). Although I explained that my disability made it necessary for me to study part time, that was not sufficient to be included in the pool.
Another example is from the Accessible Canada Act, passed in 2019, which aims to remove barriers related to employment, the built environment, communication, information, program delivery, and transportation. In many cases, work adjustments can be minor — a modified schedule, telework, or an ergonomic workstation — but cumbersome approval processes often lead to frustrating delays.
Similarly, the federal government has implemented a public service Accessibility Strategy that seeks to hire 5,000 people with disabilities by 2025. Applicants for these positions must provide medical documentation in each selection process to receive assessment accommodations. That sounds reasonable enough, yet having a centralized service for accommodation documentation would reduce the cost of doctor’s notes for people who often have limited incomes (and may not have access to a family doctor).
Bringing these barriers to light has been one part of disability advocacy. Other work has led to Bill C-22, the Canada Disability Benefit Act, a monthly amount that aims to reduce poverty for people with disabilities. Within a year after it passes (it is now before the Senate), the bill will provide them with much-needed funds and hope for a better future. Over that 12-month period, C-22 outlines plans to give “persons with disabilities from a range of backgrounds” the chance to collaborate on its regulations, application process, eligibility criteria, and the amount of the benefit. It is my hope that such consultations will lead to an expanded definition of disability and enable equitable access to adequate supports, so people with disabilities in Canada can participate fully in professional and civic life.
Angela Psimenatos
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Sharing your story — about achievements, traumas, truths, and wheel busters — can reinforce feelings of resilience or remorse. Finding the balance between advocating for change and protecting your mental wellness.
Discussing uncomfortable power dynamics, colonialism, and white supremacy are part of the daily discourse when you’re an anti-racism educator – but the recent increase in the volume and volatility of hateful messages and death threats following a public appearance, or a tweet, have had a chilling effect.
“The rise of white supremacy and right-wing extremism and violence is very real,” says Selam Debs, whose anti-racism educational work focuses on dismantling discriminatory systems and speaking truth to power. “It’s essential for us to recognize that.”
Debs closed the storefront portion of her Kitchener business after her family started receiving threats. Although the local media covered the story, their focus on the hate effectively buried the substance of Debs’s teachings and point of view. She and others are often hushed in this way (making the need to have such discussions apparent), but at what cost?
“If you’re doing a cost-benefit analysis on your own mental health and the power of making change, there’s no formula to follow,” says Jesse Wente, Anishinaabe author, commentator, and fellow death threat recipient. “Put social progress in the strainer, and when all the ugly comes out, what’s left?”
Selam Debs
It’s a good question. Taking a quick scroll of the latest Twitter outbursts makes me want to extend the metaphor — some days it seems like the ugly is blocking the colander holes that might let light through.
“If it involves personal threats, and your notifications are on fire, you make a calculation,” Wente says. “You have to think of your family — and of the real progress that is possible. If you have a forum to make change positively — that’s a gain,” he adds, citing past swells of support on social media that have led to name changes for various sports teams over the years.
Such progress is undoubtedly helped by powerful stories. Not only do they stick in your head and help ground common experiences, they often provide insight, comfort — and motivation. Stories can also reduce stigma, which often happens when a person with mental health concerns opens up about their struggles. That’s one of the main reasons the Mental Health Commission of Canada amplifies the voices of lived and living experiences through its magazine and blog. (For those who are feeling ready to do so, its tips on Sharing Your Story Safely are a good place to start.)
Of course, the decision to share a personal story can involve complications. If it’s a family story, is it entirely yours to share? What about future fallout? Once it’s on the internet, you can’t take it back.
In 2006, former Washington Post reporter Pete Earley used a book to tell the story of his son “Mike’s” mental illness, in Crazy: A Father’s Search Through America’s Mental Health Madness. At that time, the relative anonymity felt right. Flash forward to 2022, and “Mike” (now 43) is ready to change that narrative. Appearing in the Ken Burns documentary, Hiding in Plain Sight: Youth Mental Illness, he consciously chooses to own his story, reveal his experience, and make space for others facing stigma by using his full name: Kevin Mike Earley. “If we’re going to say there’s no shame in having a mental illness, how am I going to go around using my middle name?” he asked in a Washington Post article about the film.
Shifting the discourse
“We’ve seen statues come down and school names changed to address colonial history,” Debs says. We are talking about the long game of raising tough topics to get to meaningful change. While questions about power dynamics and privilege have moved from whispers to full-throated discussions, without meaningful change these discussions are simply talk. So why share your story at all?
“I think there is a transformation happening, but there is a ridiculous amount still to do,” she says. In other words, incremental change is still change. Even so, we have to ask why some choose not to speak up.
“We understand why Black, Indigenous, racialized, queer, and disabled folks are not speaking up because there are consequences: you will not get upward mobility, you will be ostracized, you will be seen as aggressive and experience mental and emotional harm,” she says. “I think we need to differentiate between who we need to keep accountable for standing up and those who are not speaking up.”
Those who hold positions of power and benefit from unearned privileges need to do the work to speak up, she says, while making space for Black, Indigenous, racialized, queer, and disabled people to be heard safely, to be compensated for their labour, and to be allowed to lead conversations.
“I remember a time when, if you talked about microaggressions, you were seen as radical, but there’s now social currency within organizations to do this work. I think some are doing it because they know it’s the right thing to do, and some recognize the currency that comes with using terms such as diversity, inclusion, and equity,” she says. “The progress I have seen is the shift in focus from very passive language to addressing how racism, violence, and hate are showing up in the spaces we are in.”
Shifting the language we use can certainly transform the discourse. For example, well-meaning questions such as “How can we help disenfranchised poor people get more opportunity?” can be modified to ask “Who is perpetuating the harm, and what can be changed on a meaningful — as in a systemic — level?”
For Wente, it is also about the medium. He has a “hokey-pokey” relationship with social media, dipping in and out. “Recently I put my toes back in, and I can’t say I liked it. The failures of content moderation are more obvious these days,” he says, noting that his mental health improves when he’s online less. “That doesn’t mean I don’t say things that are meant to move things forward — I’ve just chosen a different venue to say them.”
It’s part of the reason he wrote Unreconciled: Family, Truth, and Indigenous Resistance: to shift the discussion from tweet wars to panels, speeches, and other forms that support more nuanced conversations. “This is my daily work — to change minds and shift things,” he says. “To me, this is a very serious thing, and it’s only effective when you’re also dealing with other serious people. I’ve come to understand that some social media platforms are not the venue for much seriousness at all. I want to see people in a room where we’re actually talking.”
Jesse Wente
Wente cites past online-offline movements like Idle No More as having real-world gains, but much has changed from that more digitally innocent time — cat photos have given way to daily death threats. The death threats he has received online and on his home phone have led him to the uncomfortable realization that change making now comes with this kind of exposure. “Social justice has always required awareness, balance, and risk,” he says. “Threats happen over the internet and in real life, meaning people who make real change are having to face that.”
Yet, normalized violence reflects a terrible state of affairs, and it is becoming more overt and seemingly acceptable.
“As activists and educators in anti-racism, we are constantly met with violence,” Debs says, which leads to constant states of burnout. “There is a need to self-preserve because telling our stories again and again can become a kind of trauma porn. We have to find a balance between educating or sharing parts of ourselves and preserving our own well-being.”
What does Debs offer to others on coping in these spaces? “I don’t think I have advice, other than I think it’s important to understand why it is the way it is,” she says. A focus on equity and healing for Black communities has given her a guiding path, one she speaks about through her teaching.
“Black liberation is the way by which I live my life,” she explains. “And it comes with many different elements: it’s about personal self-reflective examining and recognizing that systems need to change in order to truly access healing,” she adds. “It’s also learning about my culture, foods, and language as a Black Ethiopian woman.”
She says it is also about decolonizing from all the ways she has been conditioned to see herself as inferior, and that happens through sharing knowledge to create that sense of liberation for others. Sharing your story in this way is a long-term investment. “The intergenerational abundance and well-being are about planting trees that we may never fully receive shade from,” she says. “Our children and our children’s children will receive the abundance of what is planted today.”
Wente sees his work as an obligation that occurs in spaces where he is often the only Indigenous person. That standpoint is one of the ways he helps balance the risks and benefits of opening up. “Your perspective is not one that is heard often,” he says, as we talk about changing narratives. His view on sharing one’s story, he admits, may come across as overly idealistic — but he’s sticking with it.
“If everyone shared their story, it would be hard to deny some simple truths,” he says. “The more people share their stories, the safer it will be for others to do the same.”
Inset: Selam Debs, Blue Aspen Photography
Inset: Jesse Wente, Red Works
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A long-time nurse reaches out to other health professionals to foster an open dialogue about stigma around mental health
Busy periods are common in any profession. Think of the morning rush in a local coffee shop, tight project deadlines, and new product launches – they all create stressors and excitement for employees.
However, the constellation of challenges is taken to a whole other level when we talk about the health-care system in Canada. Overcrowded emergency rooms have been pushed to the limit as the effects of COVID-19 continue to put pressure on our already fragile systems. In the face of such pressures, doctors, nurses, and administrative staff have worked hard to maintain service levels despite limited resources. Many still see no end in sight.
A study completed prior to the pandemic brought to light the toll workplace stress has had on the mental well-being of Canada’s nursing workforce — and the results were staggering. One in three nurses screened positive for major depressive disorder, one in four for generalized anxiety disorder, and clinical burnout. But most concerning of all was that 33 per cent reported having suicidal thoughts, and eight per cent said they had attempted suicide at least once in their lifetime.
How did we get here? And how much worse has the situation gotten since the pandemic?
Debbie Phillips, a registered nurse for over 30 years, with most of that time spent in the emergency department as a psychiatric nurse, has witnessed the increasing pressure placed on hospital staff first-hand.
“Because of cuts in funding to the health-care system, we were constantly tasked with doing more work while being given fewer resources. When I first started my career in the emergency department, if a patient needed to be admitted, we had beds available for them. By the end of my career, I was calling hospitals province-wide to find appropriate spaces for our patients to receive care, often waiting five days until beds became available.”
Unfortunately, her experience is not unique. According to The World Bank, the seven hospital beds per 1,000 patients seen in the 1970s and ‘80s now average less than three and is steadily declining. This regression has had a severe impact on the physical and mental well-being of hospital staff and the people they provide care for.
Giving but not receiving
While under their care, health-care professionals are responsible for our safety and well-being when we are most vulnerable. Over 700,000 of them fill these selfless and often thankless roles to make sure our physical and mental health needs are addressed.
Yet, with such a prolonged strain on our systems, the question of who is there to support their health needs can be overlooked.
One might think health-care workers have an acute sense of their physical and mental well-being, given their daily role in providing treatment for others. But that is not the case, Phillips says.
“Nurses often overlook warning signs of their own mental decline,” she notes. “We have the mindset that we know better, and we wouldn’t let ourselves get to that point.”
For those who do recognize these signs, resources can be scarce. Limited staffing means that sick leave requires proof of a physical ailment. There are no days off for feeling burnt out.
This limitation increases the stigma health-care workers face when it comes to their mental health. “You can’t just take a day off and rest,” says Phillips. “When you’re away from work, you feel guilty that you’re not there because you know your team won’t have additional resources to fill your spot. You know that people will be waiting for care, and that weighs on you. It adds more stress to the situation.”
Some are unaware of the stress they are placing on themselves, and others are too stigmatized to seek support, Phillips says. So where do we go from here? What resources are available to help those in need?
Resources for change
According to a paper in Nurse Leader from April 2022, 76 per cent of nurses in the U.S. who experienced workplace burnout did not seek mental health support. And just 42 per cent of health-care employees felt that their workplace valued their mental health.
Based on this and other evidence, the article calls for the transformation of “nurses’ perceptions and the cultural context that serves as a barrier to nurses caring for their well-being and accessing mental health care.”
Making investments to address stigma, it adds, “could also have a secondary benefit of improving nurses’ perceptions about mental health needs and care in their patient population.”
In Phillips’s experience, such investments in workplace mental health-related programs have been inconsistent. Since the funding grants that are periodically available are for one-off programs, she says, they fail to make a lasting impact on her team.
To address this gap, training must both adequately address employee needs and effectively reduce workplace stigma. One program specifically designed for those purposes is The Working Mind Healthcare, an adaptation of The Working Mind from the Mental Health Commission of Canada.
This evidence-based course is designed to shift the way employees think, act, and feel about mental health in the workplace. It aims to reduce the stigma around mental health and foster open dialogue between co-workers. As a facilitator for The Working Mind, Phillips has seen its impact on participants as they took the training.
“You could literally see lightbulbs coming on for people. Whether it was looking at the mental health continuum or the Big 4 coping strategies, you could see the expressions change on peoples’ faces as they were learning. You could tell they were having their eyes opened.”
Having a background in the health-care sector allows Phillips to connect with those she trains on a deeper level. It helps create an environment that promotes dialogue, knowing that everyone in the room has shared similar experiences.
The most frequent feedback she hears after her sessions is participants’ wish that they had taken the course sooner. “I think it should be part of orientation for everyone going to work in a health-care setting,” she says. “Why not set up the next generation for success as soon as they get in?”
Since tackling the stigma around mental health in health-care settings is a long-term challenge, it’s important that we all do our part to be mindful of the stress these workers are under when we encounter them.
Eric Gronke
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Florence K – musician, mother, CBC host, and doctoral candidate – takes the theme of this year’s Mental Health Week and shares her personal story of mental health challenges, wellness, and discovery.
I was 12 when I first heard Forrest Gump share his mother’s view on life from that park bench in Savannah, Georgia: “Life was like a box of chocolates — you never you know what you’re gonna get.” Lots of people have heard the famous movie line. But as I was to find out, it was a perfect description of what life had in store for me.
At first, I saw myself following the path I’d mapped out in my head hundreds of times during my teenage years. It was a dream that I hoped would lead me to a successful singing career, and I did everything in my power to make it a reality. As a teenager and young adult, I auditioned, competed, took advanced classes, accepted contracts in seedy bars, entertained at nightclubs in Atlantic City and Casablanca, sang at masses, and played piano (for years) in an Old Montreal restaurant. No audience, and no stage, was beyond my reach because they guaranteed I was moving closer to my dream.
I wanted to shine on stage, be embraced by the love of others, show what I had to offer, draw everyone’s attention, and transform my raw emotions into notes to bring them out of my being. Without being aware of it, I also probably wanted to fill what I now call my “inner hole.” At the time, the term mental health was certainly not part of the culture, and I had no words to define it. But it felt like a sense of emptiness fueled by negative, sometimes self-destructive, thoughts about myself. While it even led to experiences of suicidal ideation following a break up at age 14, I would never have thought “this is not normal” or “not everyone feels this way” — or that this hole has a name and there are ways to address it.
My solution at the time was to fill the emptiness with parties, alcohol, and drugs. Later, I did so by being on stage, since performing was an outlet for me. But no matter what I did, the emptiness continued to grow, slyly and subtly as I avoided asking myself about its presence. I shrugged it off and focused on my career — at 23, my first album, Bossa Blue, went gold — and the birth of my first daughter. My emptiness was filled during the early years of motherhood by the happiness and presence of my wonderful little girl.
Florence Khoriaty
After my first tour, I quickly went on to record second and third albums, both followed by a series of shows and promotional campaigns. I couldn’t have asked for more: my big dream was now a reality. My team saw international success for me, and my ambitions followed theirs. But at the same time, I felt my inner hole slowly opening again. My relationship with my daughter’s father was crumbling. I wanted to leave him but couldn’t, consumed by guilt at the thought of unravelling the nest we had built. I now had two worlds: one on stage, which was becoming an addiction, and one as a couple, which I was stepping back from. This guilt about a possible break up started engulfing me, sucking me into a spiral of persecutory thoughts. I hated myself, I blamed myself, and I was afraid. Yet I suffered in silence because of what I told myself: it was shameful to feel this way when so many people were living in war-torn countries while I had a full fridge, a healthy daughter, friends, money, and a job I loved. Before long, I began disappearing into my thoughts, losing my ability to concentrate. I also started losing weight, hair, and most of all, sleep. Insomnia was the beginning of the hell that would inhabit my head for the next eight months. I spent whole nights feeling my fingers tremble, looking at the clock in anguish, grabbing my skull, begging it to let in some quiet and let me rest.
People around me also started to worry. I couldn’t take care of my daughter anymore. I’d asked her father to leave, and he took me up on it, disappearing completely from the life of his five-year-old. Thankfully, my father, mother, and sister-in-law began taking care of her. The important thing was giving her a framework that could continue providing her with everything a child needs while her mom tried to get better. At this point, doing it alone was impossible. All I could manage was to put on my best, fake smile to get on stage with what little voice I had left. I was clinging to this part of my life, the only one I was still able to give something to, for 90 minutes, three times a week.
But the emptiness caught up with me.
What followed was a series of suicidal ideations and behaviours, medication trials and errors, and emergency room visits, while my loved ones looked on feeling completely lost. They weren’t equipped to deal with such a whirlwind, and mental health was so poorly understood in 2011 that they did not fully understand what had taken hold of their daughter, sister, and friend. My final admission to the ER came after an ambulance ride, escorted by two police officers.
While the following weeks were very difficult, they were lifesaving. Being in psychiatric care finally made me realize that I was sick — but also that I wasn’t alone: I felt understood and enveloped by the other patients. With an adjustment of my medication and psychotherapy, I began feeling better. Then, in 2017, when I was on the verge of a relapse, a psychiatrist gave me a diagnosis of bipolar II disorder. This diagnosis was a gift. I could finally understand this inner hole I’d been living with since my teenage years. I could put words to it and identify the symptoms, the triggers, and the tools and resources that could help me.
This quest for balance infused me with an enormous fascination for the brain and human behaviour. This passion became the driving force behind my return to university, where I completed a certificate in psychology, a master’s degree in mental health, then, after a bachelor’s degree in psychology I was finally accepted into a doctoral psychology program. My dissertation is inspired by my history, as it focuses on the possible links between creativity and bipolar disorder.
Today I am proud of my journey. It has been tortuous, unexpected, and fraught (I almost lost my life, more than once). But it has also led me to discover treasures hidden deep within myself that I never knew were there. Even though I live with this chronic disorder, my mental health is excellent. I aim for balance in my life, and I have learned to recognize and listen to the warning signs that could lead me into troubled waters. With my husband, two wonderful daughters, and a passion for my field of study, I now feel fulfilled. And if I was to run into Forrest Gump on the street, I would simply say, “Forrest, you were ab-so-lu-te-ly right!”
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Mental illness, homelessness, and a family’s years-long search for their lost brother.
Wendy Hill-Tout doesn’t like being in the spotlight, but that’s where she finds herself these days. With her new documentary, Insanity, she shines a light on families coping with the severe and persistent mental illness of a loved one lost to homelessness. Sharing the camera’s attention are her siblings, who recount their lives with their brother, Bruce, as he struggled with schizophrenia until his disappearance 25 years ago.
Wherever the Canadian filmmaker’s North American travels take her, she searches the faces of unhoused people, looking for her brother. The photos she carries, bearded and clean-shaven, are shown to anyone who might recognize him. Her quest brings her to the alleys and tent cities that have become points of refuge for those the system has failed. The various homeless encampments the film documents show the scale of the problem and make it clear that Bruce’s face is just one among so many others.
Insanity shares the stories of families caught up in a system that doesn’t support individuals who are either not sick enough to get help or unable to access support while they are housed. In one example, Shirley Chan, a board member for the Pathways Serious Mental Illness Society, has desperately been trying to find the right support for her daughter. After being told that she was “too high functioning” to qualify for housing with the 24-hour support she needed, Chan discovered that the only way to obtain it was to refuse to bring her home the next time she was discharged from the hospital. Her daughter had to be homeless to become a priority.
Another instance shows Tyler, the youngest brother of Kristin Booth, a colleague Hill-Tout met while working on a different film. Tyler had been living on the street in Ontario when he was arrested after suffering a manic episode. Six weeks later, while on probation and living on his mother’s property, Booth recounts the trauma of lying to her brother to keep him on the premises so the Toronto police could collect him. Her voice cracks as she recounts the guilt of having to watch him be cuffed and taken away, breaking down at the impossible situation she found herself in. Even with the support of a lawyer and physician, she still couldn’t get Tyler the help he needed.
“What do other families do?” Karen Booth, Kristin’s mother, asks. Her doctor, who can find no other solution, tells her, “Mrs. Booth, if it wasn’t for you, Tyler would be either be dead or under a bridge — or in prison. That’s just the way it is.” But she refuses to accept that.
Hill-Tout delicately weaves these stories into the film to illustrate how easy it is for someone living with mental illness to end up on the street or get caught up in the criminal justice system. As she says during our Zoom interview while in Calgary, it is unacceptable that so many people are without help in a wealthy nation like Canada.
Wendy Hill-Tout
“Our system needs a major overhaul,” she says. “The first step would be to increase mental health care spending from where it’s at [seven per cent of total health-care spending] to 10 per cent like in European countries. We need to create more community mental health services to help people with mental health concerns before they’re in crisis. Imagine if we had specialized mental health clinics, so people would have somewhere they knew they could go and speak with specially trained doctors and nurses to connect them with appropriate services. Why is it the default to go straight to the hospital or ask someone in crisis to wait six months for services?” she asks.
Other issues to address include the lack of psychologists and psychiatrists, supportive housing, and access to services, Hill-Tout notes, adding that Canada needs to start somewhere, and increasing mental health funding is a good place to get the ball rolling.
What shocked her most during the project was how much more pronounced the problem became in a short time. “When we began filming in 2019, we would go to a city and hope to find someone on the street to show Bruce’s photo to. But before long, we were being confronted with tent cities — and it was happening everywhere — not just in Vancouver’s Downtown Eastside. The number of people on the street increased in both big and smaller cities.
“We need to do something urgently because we can change this,” she says with quiet conviction. “Instead of spending money on policing the problem, we should prevent it. So many people with mental illness are one breakdown from becoming homeless. How do you get back into housing once you’ve lost it? We need more community services along the way to prevent this from happening in the first place.”
She hopes that her documentary reaches the right people in government who have the power to enact the needed change, whether they’re municipal, provincial, or federal officials. This issue impacts more than one in five people who will experience a mental health problem during their life. It also spreads out across friends and families, and they’re the reason she made this film.
“It still surprises me how raw it is to talk about Bruce even after 25 years,” Hill-Tout says, toward the end of our time together. That emotion is also apparent in the film as her siblings share touching stories about their brother. They laugh together, but their memories have an undercurrent of sadness. And through their accounts, we learn that Bruce was the eldest of four children, thoughtful, funny, and warm-hearted, as well as being an artist and a bit of a daredevil at times.
“Bruce was the best person I’ve ever known,” her brother David said, “He was a really great big brother, and he’s worth fighting for.”
As hard as it is to revisit what led to Bruce’s disappearance, it’s important to put a name and face to the problem. Once society sees the people the system has failed as individuals loved and missed by their families, they are more inclined to push for change. Society is more likely to care for them.
It’s not all bad, though, as Hill-Tout points out. Some things give her hope for the future. For one, a greater general awareness of mental health and illnesses exists. The press now reports on people experiencing homelessness and how cities are handling the issue. There are also more police officers and first responders taking training on how to handle mental health calls. As well, there are more mobile mental health crisis units like Car 87 in British Columbia (compared to 10 years ago) — although these units cannot keep up with the current demand, so increased funding is still needed.
In the meantime, Hill-Tout and her family remain hopeful that they’ll find Bruce. She continues to search faces for one she’ll recognize after so many years. Maybe an audience member will recognize him after watching the documentary. Either way, her final message to me is the same one repeated in the film.
“Bruce, you are loved.”
Insanity will play at select screens in theatres nationwide starting May 11, 2023, with Q&As from Hill-Tout and other families featured in the documentary. Get more information and find out if it’s coming to a theatre near you at www.insanitydoc.com.
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It’s also around you: storms, fires, catastrophe — the intersections between climate and mental health — and what you can do about it.
In March, a small group gathered along the Rideau Canal in an act of collective mourning. It hadn’t been cold enough to keep the eight kilometre stretch frozen, so the iconic skateway would stay closed for the year. The vigil — organized by the Ecology Ottawa non-profit — gave people a chance to come together and animate discussions on climate change and loss. They would meet on the canal edge, frozen in time on so many postcards and in travelogues, to “be with our uncertainty, not knowing what will happen in the years to come,” as the e-vite put it.
Bringing the global reality of a changing climate close to home — and realizing some of the things we may no longer be able to do — helps us to ground a head-spinning catastrophic concept that can bring up feelings of grief, anxiety, and uncertainty.
But as opinion writer Trish Audette-Longo asked in Canada’s National Observer, could it also be a call to action? “On a scale of climate disasters, in which our collective attention necessarily focuses on the uneven impacts of wildfires, floods, and a range of other losses, one missed season on the Rideau Canal Skateway can register as a footnote for the history books,” she wrote, noting that an apocalyptic focus can eclipse the potential to envision alternative futures.
In other words, instead of imagining far-off idealized or end-of-time scenarios, what can we do right now?
Putting the mental in environmental
The umbrella term eco-anxiety is used to describe a number of emotional and mental states linked to a heightened awareness of climate change and concurrent distress in the face of its threatening implications for the future.
Defined by the American Psychological Association as a “chronic fear of environmental doom,” it manifests as anger, exhaustion, phobia, and despair. It can show up as flash-forwards, nightmares, and even “climate orthorexia,” which Britt Wray describes in Generation Dread: Finding Purpose in an Age of Climate Crisis as “an obsession with eating ‘clean’ for the sake of the environment.”
People in regions plagued by extreme weather usually experience elevated levels of climate-related fear and sadness (as will those living with the consequences for years to come). Two out of three respondents in a landmark Nature survey (10,000 people, ages 16 to 25, across 10 countries) reported having such experiences. Meanwhile, the Intergovernmental Panel on Climate Change included mental health consequences arising out of environmental catastrophes as part of its 2022 assessment report.
While eco-anxiety is not a term listed in the DSM-5, there is plenty of developing research in the field, nicely summarized by the headline in a University of Helsinki article — “Understanding the Mental in Environmental” — featuring the work of Panu Pihkala, an adjunct professor of eco-theology. Pihkala refers to one clinical intervention as “binocular vision;” meaning therapists help clients see that numerous bad and good things can co-exist (instead of black-and-white catastrophizing).
Fostering this sense of inner resilience was among five themes that emerged from a 2021 scoping review by Pauline Baudon and Liza Jachens on the treatment of eco-anxiety. The study appeared in a special issue of the International Journal of Environmental Research and Public Health about the psychological impacts of climate change. Apart from practitioners’ inner work and education, the other themes included encouraging clients to take action, connecting them with nature, and helping them find social connection and emotional support by joining groups.
After looking at various schools of thought, the review found that all approaches emphasized the value of group work as a way to support emotional processing and the ability to connect one’s inner experience of eco-anxiety to that of others and to broader social themes.
Gallows humour?
One form of group therapy involves taking an unfunny topic and giving it a lighter touch. In a March Guardian article called “How Do You Laugh About Death?” for instance, comedians tackle climate change as a gateway to address heavy themes or to try to bridge political polarities or talk to deniers. Participants in the Climate Comedy Cohort, a nine-month fellowship from American University’s Center for Media and Social Impact and the non-profit Generation180, develop shorts and pitch ideas to TV networks on intersecting issues about race and labour. The goal is to talk about climate — even irreverently — to boost civic engagement — something that, for many, can be a more motivating force for change than doom. For those not at the ha-ha stage, Carbon Conversations (in cities around the world) help people face their worries about climate change and stay engaged and ecologically motivated to act and make enduring lifestyle changes.
Perhaps you’ve made yours — say, with reusable bags and portable water bottles. While these have their place, such small lifestyle changes make me think about cruel optimism, a concept coined by University of Chicago cultural theorist Lauren Berlant. It means taking systemic problems with deep-rooted causes, like depression or obesity, and offering people a simplistic individual solution, usually in peppy language. While it sounds lovely because you’re telling them this massive issue can be solved, it is in fact cruel because the solution conceals deeper causes through neoliberal self-control narratives like engaging in healthy lifestyles or taking out gym memberships, which actually direct people’s attention away from the main concern and delay potential answers. To have effective solutions on global warming, we need our conversation and actions to move in time with the ticking climate clock.
Collectivist approaches
While those individual choices can add up — the neoliberal-only view can mean missing the forest for the trees.
As University of Toronto political science professor and Munk School environmental lab co-director Matt Hoffman told the Toronto Star, there needs to be a societal shift to make climate change an issue across party lines. Individuals can take their concerns to elected officials, the ballot box, and the bank (to encourage fossil fuel free investing, for example). These are things that individuals can do to apply pressure upward and achieve more systemic changes.
A way of combining hope and action can be seen in the Solutions section in The Narwhal, a Canadian non-profit environmental news outlet. The series profiles people and communities who are responding in real time to “broken regulatory systems [by] generating ideas for cleaner communities, and re-envisioning natural resource development.” The stories aim to inspire by looking at root problems and what is being done to fix them. Topics include renewable energy, the revitalization of Canada’s environmental laws, and ideas on daily living.
There is also a role for grief as we all face the results of a changing climate. What we choose to grieve can illuminate our fundamental dependency on healthy and thriving ecosystems — as well as the political and ethical responsibilities we have to such systems, to each other, and to our need to act. This was one finding from a 2020 article, called “You Can Never Replace the Caribou: Inuit Experiences of Ecological Grief From Caribou Declines.” In it, lead author Ashlee Cunsolo points to collectivist approaches — a “we-creating capacity” — that recalls our connections to others and our responsibility to mitigate human-induced environmental degradation.
Fateema Sayani
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How compassionate health care can alter the trajectories of people who use substances.
Jes Besharah doesn’t remember how long they’d been living on the street and using opioids by the time they sought medical care, but they remember being in bad shape.
“I was sick, I was hurt, I was crying, I had abscesses and wounds all over my body. I had many needs that needed to be addressed,” they say. But when the nurse came in and looked Besharah up and down, all she saw was a drug user.
“We didn’t take care of anything at all. She told me she would pray for me, and that was the best she could do.”
For Besharah, it was a crushing response. “It just makes it seem like there’s no point in trying when that’s the answer that you’re met with.”
Unfortunately, Besharah isn’t alone. People who use opioids and other substances often encounter stigmatizing attitudes and discrimination, including from the health-care workers they turn to for care.
The Mental Health Commission of Canada (MHCC) invited Besharah to share their experiences of stigma and its impact in a video called Use Your Voice — Reducing Stigma Toward People Who Use Substances.
“For people who use opioids and other substances, stigma can be a powerful barrier to seeking and receiving quality care,” says Julia Armstrong, manager of MHCC’s mental health and substance use health team. “We created this video (and discussion guide) to start important conversations about stigma in health-care settings — the kind of conversations that lead to better understanding and a higher standard of care for these individuals.”
The video also features the nurse that helped change Besharah’s life — Melinda Billett.
As a primary care nurse practitioner, Billett has had years of experience supporting people who use substances. She has also seen first-hand how small choices can have a powerful ripple effect.
“In health care we can make the choice to treat people with respect,” she says, for example in the notes providers make in a patient’s file. “That’s my voice that someone else is going to read. So, I can choose to say that this person is a drug addict, or I can choose to say this is a person who uses substances.”
In making that small change, Billett is drawing on the power of person-first language, which can help distinguish who someone is from the substances they use or the mental illness they live with.
While both describe other changes that health-care workers — and anyone interacting with people who use substances — can make to help curb stigma, every example comes back to one overarching message: treat individuals who use substances as people, not problems.
Besharah credits the compassion they received from Billett and others for the life they lead today, working as a community harm reduction support navigator and peer support worker. “Part of the reason that I do it is because, when I was on the streets, there were people doing outreach that didn’t judge me, that cared about me, that would go out of their way to make sure that I was still around,” they explain. “That made a huge difference in me wanting to take back control of my life.”
Billett emphasizes that people who use substances have a great deal of inner resilience, and it’s up to health-care providers at every level to recognize it. “If we can tap into that, and be kind to them, and care for them and meet them where they’re at . . . then those things together is what can help change the trajectory of someone’s path.”
Amber St. Louis
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Putting substance use on a spectrum creates a space for more open conversations about safer, healthier, more manageable consumption.
Part of the Mental Health Commission of Canada’s work involves education on the distinction between mental health and mental illness. Mental health — an aspect of overall health — exists on a spectrum we all share. One end of the spectrum reflects optimal mental health, while the other shows where mental illness or mental health problems occur. A spectrum model is also helpful when we talk about substance use.
What it means
Toward one end of the substance use health spectrum, a person might abstain entirely or engage in sporadic use without any adverse consequences. At the other end are substance use disorders with far-reaching effects on overall health and well-being. Depending on the circumstances and a multitude of factors, anyone can move along the spectrum at any time.
Why it matters
Due in part to a long history of criminalization and secrecy around drugs and alcohol, a negative undertone persists. This way of thinking may lead people to see all substance use as problematic. On the other hand, putting substance use on a sliding scale helps create a space for more open conversations about safer, healthier, more manageable consumption — whatever that looks like for each individual.
Reducing stigma around substance use is also an important part of fostering recovery. The less negatively we judge substance use, the more comfortable a person might be about disclosing a concern about their own or someone else’s situation. For someone struggling with substance use, understanding that they can achieve safer, healthier consumption without (or before) complete abstention can help instil hope when they need it most.
How you can use it
Adopting the term substance use health can challenge personal biases and binary thinking. Substance use isn’t black and white. It’s not about being addicted or abstaining entirely. There’s a wide, grey area of movement, nuance, and individual circumstances in between. As with all mental health, the way we think and talk about substance use matters. The better we understand the substance use health spectrum, the better we can support people through every stage of recovery.
