Structural stigma: The health-care crisis hiding in plain sight

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.”