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The CatalystConversations on Mental Health

In conversation with Dr. Thomas Ungar, the first in a series

When Thomas Ungar, psychiatrist-in-chief at St. Michael’s Hospital and associate professor at the University of Toronto, was asked to describe the structural stigma that spells poorer health outcomes for people living with mental illness and substance use disorders, he responded in a most unusual way.

“Perhaps I should tell you about the silly garbage cans,” he said from his office in Toronto, where he engages in a daily campaign to help his peers and colleagues in other specialties better understand the complex nature of mental illness.

A hospital where he once worked brought in some “efficiency people” to tighten the budget. At one point, they determined that garbage receptacles in clinical spaces would be emptied daily while those in “administrative” or “non-clinical spaces” would only be done every two weeks.

“I don’t see patients in rooms with sinks,” Ungar explained. “And the litmus test for “clinical space” by the powers that be was, you guessed it, whether or not it had a sink.”

For Ungar, the implicit bias was clear. For “real” medicine, you need to wash your hands. Psychiatric work — the lowest paid specialization in medicine — didn’t make the cut.

Medical versus mental health care needs
Such an example may sound insignificant, but Ungar has dozens, if not hundreds like it. In fact, he collects these small indignities like unwanted mementos. They serve as a constant reminder that providing mental health care remains the poor cousin of practising in the purely physical realm.

Taken as a whole, they add up to an immeasurable inequity.

“There was the time when I went to a meeting to get some equipment I needed for my department,” he recalled. That included new locks, because some doors on his floor had been kicked in, and improved video monitor safety equipment. But these seemingly straightforward requests were quickly brushed aside. “I was told to talk to facility management or IT because, again, my needs weren’t ‘real’ medical needs.”

“And,” added Ungar, “we’re always being left behind. When a hospital moves to a brighter, newer space, the psychiatry department is invariably told we’ll be joining ‘soon.’ Then ‘soon’ becomes months, and in some cases years. We’re left behind in crumbling, run-down buildings because we’re told having a dedicated space for mental health care is better for the patient. Who are we kidding? It’s just more palatable for everyone else.” 

The effects of mental health care inequity
Yet Ungar’s greatest frustration isn’t that his speciality is sidelined. It’s that people suffer as a result.

“When you present to the emergency room, regardless of your mental health history, you should be given an appropriate physical workup. Only in psychiatry would the treating physician refer someone to you directly, without doing such a rudimentary exam. Imagine an ER doctor taking one look at you and saying, ‘Right, I think it’s your heart, off to cardiology you go.’”

This cavalier, and all-too-prevalent, attitude can have dire consequences. Ungar himself is familiar with cases where patients have died of blatant neglect because of “diagnostic over-shadowing.”

“It’s when an assumption is made that physical complaints are not relevant or reliable because someone has an underlying mental illness or substance use disorder,” he explained, “and it’s not acceptable.”

Dealing with structural stigma
Ungar finds himself swimming against the tide in a profession where stigma is so entrenched, and unconscious bias so pervasive, that most of the well-meaning professionals practising within it are totally unaware of its existence.

“It’s not unlike racism,” he explained. “You don’t have to throw around epithets or be blatantly discriminatory to uphold implicitly racist societal norms. Being unaware of something doesn’t make you a bad person, but it doesn’t make you part of the solution either. The same is true for stigma. Just because you don’t use pejorative terms doesn’t mean you aren’t unconsciously dismissing a patient as ‘badly behaved’ or ‘morally corrupt’ because they are presenting in a way that’s uncomfortable or inappropriate.”

While the beauty of not knowing is that it can be fixed, a complete paradigm shift is a generational proposition, and Ungar doesn’t have that kind of time.

“It doesn’t mean I’m not trying,” he laughed, but he also thinks additional strategies are needed. “I’m leveraging quality of care as a central tenet of why we need to address structural stigma,” he said, noting that building certain patient safeguards into hospital policy may be the quickest route to fulfilling the Hippocratic Oath.

A new way forward
“For it to count, we need to measure it,” Ungar noted, “and not just in egregious situations that trigger a coroner’s inquest.” Here, he recounted an instance where a patient died of a pulmonary embolism because concerns about his mental health overshadowed the physical discomfort he was experiencing.

Ungar wants to change the rules of the game, full stop. He wants hospitals to assess structural stigma against qualifiers that effectively dismantle it. “For example, if we require all patients to receive a physical exam within one day of being admitted, suddenly it doesn’t matter whether Dr. Smith thinks it’s necessary. It’s simply required.”

This kind of intervention is what Ungar refers to as a health-care system “hack”: a quick and imperfect shortcut to improve results, while the longer-term work to shift attitudes and behaviours plods along in the background.

To help health-care administrations understand, evaluate, and score structural stigma against a framework that breaks down the barriers putting treating mental illness at a disadvantage, Ungar is working with a team at the Mental Health Commission of Canada (MHCC) to create tools and new standards.

Describing this project, he said, “If we can measure and monitor those barriers and get them on a mandatory dashboard or at-a-glance report card, then a red-light indicator will scream out for attention and require a fix. I won’t have to try and advocate, negotiate, or convince others one provider at a time. I’ve had it with that.”

In fact, Ungar sees this path as a decisive way forward. “The work I’m doing with the MHCC is the most exciting of my professional career. I’m not aware of this kind of work being done anywhere else. It’s the kind of progressive, thoughtful policy shift we’ll look back on in two decades and say, ‘I can’t believe we didn’t do that sooner.’ Our current practices will seem as outmoded to our future selves as bloodletting does to us now.”

Until then, Ungar plans to continue using his considerable influence to call out stigma wherever he finds it. 

“Of course I will,” he said with a laugh, “even if that means telling stories about silly garbage cans.”

Register here for the first webinar on the MHCC’s work to combat mental illness- and substance use- related structural stigma in health care settings — to be held Tuesday, February 9, 12-1:30 p.m. ET — featuring professors Thomas Ungar, Heather Stuart, Jamie Livingston, Javeed Sukhera, and Stephanie Knaak. Participants will increase their understanding of structural stigma, learn about its sources and consequences, and gain insights into how it can be addressed.

Watch this space
In the March Catalyst we’ll be speaking with patient advocate Samaria Nancy Cardinal about the harmful effects of structural stigma users are experiencing in the health-care system.

The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy of the Mental Health Commission of Canada.

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